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Giordano T, Durkin A, Simi A, Shannon M, Dailey J, Facey H, Ballester L, Wetmore RF, Germiller JA. High-Dose Celecoxib for Pain After Pediatric Tonsillectomy: A Randomized Controlled Trial. Otolaryngol Head Neck Surg 2023; 168:218-226. [PMID: 35412873 DOI: 10.1177/01945998221091695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Pediatric tonsillectomy causes significant postoperative pain. Newer nonsteroidal anti-inflammatory drugs such as celecoxib control pain without increasing bleeding risk, but in prior studies provided only modest pain reduction at standard doses. We aimed to determine if high-dose celecoxib (double the usual pediatric dose) is effective for pain, without increasing bleeding or other risks. STUDY DESIGN Randomized double-blind trial. SETTING Pediatric tertiary center. METHODS Children aged 3 to 11 years undergoing total tonsillectomy were randomized to receive celecoxib (6 mg/kg/dose) or placebo, twice daily, for up to 10 days. All cases were supplemented with acetaminophen and oxycodone as needed. All participants and personnel were blinded to treatment group. Subjects recorded coanalgesic consumption, pain, diet, and activity. RESULTS The celecoxib group (n = 68) consumed 0.72 mg/kg of oxycodone, as compared with 1.12 mg/kg in the placebo group (n = 62), a 36% difference that was not significant. However, multivariate analysis by treatment group, separate from pain levels, confirmed that this reduction was due to celecoxib treatment (P = .03). In subjects with more prolonged pain (n = 88), celecoxib reduced consumption by 52% (P = .02). Celecoxib showed greater benefit for subjects in the prolonged pain group than for those in the lesser pain group (P = .006). Incidence of adverse events was similar between groups. Minor hemorrhage occurred in 4.6% (5 placebo, 3 celecoxib). CONCLUSION High-dose celecoxib is effective in controlling pain after tonsillectomy, with no adverse effects in this relatively small sample. It reduces narcotic consumption, and its impact appears greater in children with higher degrees of pain. Celecoxib can be considered an effective alternative to ibuprofen after tonsillectomy. This trial was registered at ClinicalTrials.gov: NCT02934191.
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Affiliation(s)
- Teresa Giordano
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexandra Durkin
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrea Simi
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Megan Shannon
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia Dailey
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hannah Facey
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ralph F Wetmore
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John A Germiller
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cook-Sather SD, Castella G, Zhang B, Mensinger JL, Galvez J, Wetmore RF. Principal Factors Associated With Ketorolac-Refractory Pain Behavior After Pediatric Myringotomy and Pressure Equalization Tube Placement: A Retrospective Cohort Study. Anesth Analg 2020; 130:730-739. [PMID: 31082971 DOI: 10.1213/ane.0000000000004226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prophylactic analgesic administration reduces pain behavior after pediatric bilateral myringotomy and pressure equalization tube placement (BMT). We hypothesized that postoperative pain in children treated with intraoperative ketorolac would, among several exposures of interest, be strongly associated with ear condition. METHODS We conducted a retrospective cohort study of healthy children (9 months to 7 years) who underwent BMT at the Children's Hospital of Philadelphia or its ambulatory surgery centers from 2013 to 2016. Anesthetic care included preoperative oral midazolam, sevoflurane/nitrous oxide (N2O)/air/oxygen (O2) by mask, and intramuscular ketorolac. Demographic and procedural information included left and right tympanic membrane (normal, retracted, or bulging) and middle ear (normal/no, serous, mucoid, or purulent effusion) conditions. Because tympanic membrane and middle ear conditions were highly concordant and mean maximum Face, Legs, Activity, Cry and Consolability (FLACC) scores (0-10) were not different across the array of abnormal findings, we categorized each ear as normal or abnormal based on middle ear effusion alone. We then defined the ear condition of each child (primary exposure) using bilateral findings: normal/normal, normal/abnormal, and abnormal/abnormal. Secondary exposures included age, BMT history, procedure duration, facility location, and attending surgeon/anesthesiologist pair. The primary outcome was maximum postanesthesia care unit FLACC score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed models with random intercepts accounting for the clustering effect of provider pairs. Adjusting for multiple comparisons, significance level was set at P = .004. RESULTS Excluding recurrent cases, 1922 unique evaluable subjects remained. The probability of moderate-to-severe pain behavior (FLACC, 4-10) was 52.4% (95% confidence interval [CI], 50.2-54.6) overall. In a confounder-adjusted model, ear condition was significantly associated with moderate-to-severe pain: compared to bilateral abnormal (effusions), odds ratio (OR) (95% CI) for bilateral normal was 2.2 (1.6-2.9), P < .0001. Younger age (OR, 1.1 [1.1-1.2] per year; P = .001) and longer procedure duration (OR, 1.1 [1.0-1.2] per minute; P = .0008) were likewise related to higher pain. With surgeon added to the model, variance explained by provider pairs decreased from 9.60% to 1.05%. Two secondary outcome associations also emerged: comparing bilateral normal to abnormal ears, ORs were 1.7 (1.3-2.2), P = .0001, for rescue oxycodone and 2.0 (1.2-3.3), P = .008, for emergence agitation. CONCLUSIONS Pain behavior after BMT varies by surgeon and is strongly associated with ear condition. Ketorolac as a single prophylactic analgesic appears less effective in younger children with normal middle ear findings.
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Affiliation(s)
- Scott D Cook-Sather
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gabrielle Castella
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bingqing Zhang
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Janell L Mensinger
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Jorge Galvez
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ralph F Wetmore
- Department of Otorhinolaryngology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Chan KH, Dinwiddie JK, Ahuja GS, Bennett EC, Brigger MT, Chi DH, Choo DI, Cunningham MJ, Elluru RG, Giannoni CM, Goudy SL, Koempel JA, MacArthur CJ, Malone B, Messner AH, Mitchell RB, Park AH, Richter GT, Rosbe KW, Shah UK, Sie KCY, Smith RJ, Sulman CG, Thompson JW, Thorne MC, Wei JL, Wetmore RF, White DR, Zalzal GH, Schoem SR. Advanced practice providers and children's hospital-based pediatric otolarynology practices. Int J Pediatr Otorhinolaryngol 2020; 129:109770. [PMID: 31733596 DOI: 10.1016/j.ijporl.2019.109770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.
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Affiliation(s)
- Kenny H Chan
- Children's Hospital Colorado, Aurora, CO, USA; Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jordyn K Dinwiddie
- Children's Hospital Colorado, Aurora, CO, USA; Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gurpreet S Ahuja
- CHOC Children's Hospital, Orange, CA, USA; Department of Otolaryngology - Head and Neck Surgery, University of California Irvine, Orange, CA, USA
| | - Erica C Bennett
- Division of Otolaryngology - Head and Neck Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Matthew T Brigger
- Rady Children's Hospital, San Diego, CA, USA; Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA, USA
| | - David H Chi
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA; Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Daniel I Choo
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael J Cunningham
- Boston Children's Hospital, Boston, MA, USA; Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
| | - Ravindhra G Elluru
- Department of Otolaryngology, Dayton Children's Hospital, Dayton, OH, USA
| | - Carla M Giannoni
- Texas Children's Hospital, Houston, TX, USA; Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Steven L Goudy
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Otolaryngology - Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey A Koempel
- Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Carol J MacArthur
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Anna H Messner
- Lucille Packard Children's Hospital, Palo Alto, CA, USA; Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Ron B Mitchell
- Children's Health, Dallas, TX, USA; Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Albert H Park
- Primary Children's Hospital, Salt Lake City, UT, USA; Division of Otolaryngology - Head and Neck Surgery, University of Utah, Salt Lake City, UT, USA
| | - Gresham T Richter
- Arkansa Children's Hospital, Little Rock, AR, USA; Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kristina W Rosbe
- Benioff Children's Hospital, San Francisco, CA, USA; Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA
| | - Udayan K Shah
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA; Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kathy C Y Sie
- Seattle Children's, Seattle, WA, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Richard J Smith
- Molecular Otolaryngology and Renal Research Laboratories, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cecille G Sulman
- Children's Hospital of Wisconsin, Milwaukee, WI, USA; Department of Otolaryngology and Communication Sciences, Division of Pediatric Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jerome W Thompson
- LeBonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Marc C Thorne
- C.S. Mott Children's Hospital, Ann Arbor, MI, USA; Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Julie L Wei
- Nemours Children's Hospital, Orlando, FL, USA; Department of Otolaryngology - Head and Neck Surgery, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Ralph F Wetmore
- Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Otolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David R White
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - George H Zalzal
- Children's National Health System, Washington, DC, USA; Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Scott R Schoem
- Connecticut Children's Medical Center, Hartford, CT, USA; Department of Otolaryngology - Head and Neck Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
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Wetmore RF. Surgical management of the tonsillectomy and adenoidectomy patient. World J Otorhinolaryngol Head Neck Surg 2017; 3:176-182. [PMID: 29516064 PMCID: PMC5829294 DOI: 10.1016/j.wjorl.2017.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/03/2017] [Accepted: 01/17/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ralph F. Wetmore
- E. Mortimer Newlin Professor of Pediatric Otolaryngology, The Children’s Hospital of Philadelphia, Dept. of Otorhinolaryngology, Civic Center Boulevard, Philadelphia, PA 19104, USA
- Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Mudd PA, Thottathil P, Giordano T, Wetmore RF, Elden L, Jawad AF, Ahumada L, Gálvez JA. Association Between Ibuprofen Use and Severity of Surgically Managed Posttonsillectomy Hemorrhage. JAMA Otolaryngol Head Neck Surg 2017; 143:712-717. [PMID: 28472239 DOI: 10.1001/jamaoto.2016.3839] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to quantify but may be a more important outcome to measure. Objective To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity. Design, Setting, and Participants This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children's Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query. Main Outcomes and Measures Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion. Results Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256 female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater. Conclusions and Relevance The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.
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Affiliation(s)
- Pamela A Mudd
- School of Medicine and Health Sciences, George Washington University, Washington, DC2Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, DC
| | - Princy Thottathil
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania4Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Terri Giordano
- Division of Otolaryngology (Ear, Nose, and Throat), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ralph F Wetmore
- Division of Otolaryngology (Ear, Nose, and Throat), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania6Department of Otorhinolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa Elden
- Division of Otolaryngology (Ear, Nose, and Throat), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania6Department of Otorhinolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Abbas F Jawad
- Department of Biostatistics in Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Luis Ahumada
- Enterprise Reporting and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 9Section of Biomedical Informatics, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania4Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia9Section of Biomedical Informatics, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 10Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Affiliation(s)
- Steven E Sobol
- Division of Pediatric Otolaryngology, The Children's Hospital of Philadelphia, Richard D. Wood Center, Philadelphia, PA 19104-4399 USA
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Wenger TL, Bhoj EJ, Wetmore RF, Mennuti MT, Bartlett SP, Mollen TJ, McDonald-McGinn DM, Zackai EH. Beare-Stevenson syndrome: Two new patients, including a novel finding of tracheal cartilaginous sleeve. Am J Med Genet A 2015; 167A:852-7. [DOI: 10.1002/ajmg.a.36985] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/22/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Tara L. Wenger
- Division of Craniofacial Medicine; Seattle Children's Hospital; Seattle Washington
| | - Elizabeth J. Bhoj
- Division of Human Genetics and Molecular Biology; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Ralph F. Wetmore
- Division of Otolaryngology; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Michael T. Mennuti
- Division of Obstetrics and Gynecology; University of Pennsylvania; Philadelphia Pennsylvania
| | - Scott P. Bartlett
- Division of Plastic and Reconstructive Surgery; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Thomas J. Mollen
- Division of Neonatology; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Donna M. McDonald-McGinn
- Division of Human Genetics and Molecular Biology; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Elaine H. Zackai
- Division of Human Genetics and Molecular Biology; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
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Abstract
Objectives: Based on an interpretation of a recent Joint Commission protocol to sterilize instruments coming into contact with mucous membranes, there has been institutional interest in sterile packaging of cerumen curettes used for manual cerumen removal. To date, there are no studies that have assessed the risk of otitis externa (OE) following cerumen removal and the utility of sterile packaging is questionable. The objective of this study is to assess the incidence of OE following cerumen disimpaction prior to the implementation of sterile packaging at our institution. Methods: This was a retrospective chart review. Over a 1-year period, 1457 episodes of manual cerumen removal took place in the otolaryngology clinic. Charts were assessed for signs or symptoms of OE within 2 weeks of the procedure through follow-up phone calls and clinic visits in the otolaryngology division. Results: There were no patients who followed up with symptoms or signs suggestive of OE in the 2-week postprocedure period. Conclusion: There is no evidence that OE is a complication of manual cerumen removal when performed by otolaryngologists using clean technique. Unnecessary sterilization of tools leads to increased cost and time for this common outpatient procedure performed by the otolaryngologist.
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Affiliation(s)
- Jessica L. Guidi
- Division of Otolaryngology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ralph F. Wetmore
- Division of Otolaryngology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Steven E. Sobol
- Division of Otolaryngology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Affiliation(s)
- Natalie E Cusano
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
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Sobol SE, Wetmore RF, Marsh RR, Stow J, Jacobs IN. Postoperative Recovery After Microdebrider Intracapsular or Monopolar Electrocautery Tonsillectomy. ACTA ACUST UNITED AC 2006; 132:270-4. [PMID: 16549747 DOI: 10.1001/archotol.132.3.270] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To prospectively assess the postoperative recovery in patients randomly selected to receive either microdebrider intracapsular tonsillectomy (MT) or monopolar electrocautery tonsillectomy (ET). DESIGN A prospective, randomized, single-blinded study. SETTING Tertiary care children's hospital. PATIENTS A total of 74 patients between the ages of 3 and 7 years undergoing adenotonsillectomy for obstruction were randomly assigned to the MT and ET groups. MAIN OUTCOME MEASURES Families were blinded to the technique used and given a checklist to fill out daily quantifying pain, activity, diet, and the number of doses of pain medication given over a 10-day period. Other variables assessed included the time of surgery and intraoperative blood loss. RESULTS The average time of surgery was 16.9 minutes for ET compared with 20.9 minutes for MT (P<.001). The average blood loss was 30 mL for ET compared with 45 mL for MT (P = .01). Resumption of near-normal dietary intake was achieved 1.7 days earlier in patients receiving MT compared with ET (P = .04). There was no significant difference in the number of days taken for the resolution of pain or resumption of normal activity between the 2 groups. CONCLUSIONS Microdebrider tonsillectomy takes over 4 minutes longer to perform compared with ET and has slightly higher intraoperative blood loss. There appears to be a slight advantage in the resumption of normal dietary intake with MT but no significant difference in the number of days taken for the resolution of pain or resumption of normal activity.
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Affiliation(s)
- Steven E Sobol
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Potsic WP, Wetmore RF. Otolaryngologic Disorders. Pediatric Surgery 2006. [PMCID: PMC7158348 DOI: 10.1016/b978-0-323-02842-4.50055-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sobol SE, Elden LM, Wetmore RF. Management of Lateral Sinus Thrombosis in Children. Otolaryngol Head Neck Surg 2004. [DOI: 10.1016/j.otohns.2004.06.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Lisa M Elden
- Philadelphia PA; Philadelphia PA; Philadelphia PA
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Sobol SE, Jacobs IN, Levin L, Wetmore RF. Pistachio nutshell foreign body of the oral cavity in two children. Int J Pediatr Otorhinolaryngol 2004; 68:1101-4. [PMID: 15236901 DOI: 10.1016/j.ijporl.2004.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Revised: 03/15/2004] [Accepted: 03/18/2004] [Indexed: 10/26/2022]
Abstract
Pistachio nutshell foreign bodies have been documented in the literature, occurring most commonly in the bronchi. The objective of this study is to report on two cases of oral cavity lesions, which were subsequently found to be pistachio nutshell foreign bodies. The first patient is a 9-month-old male who presented with a hard palate mass measuring 1.5 cm. The patient was evaluated in the operating room, and found to have a submucosal pistachio nutshell foreign body. The second patient is a 17-month-old female who presented with a firm, fixed midline hard palate mass. The lesion was subsequently noted to dislodge from the palate, and was identified as a pistachio nutshell.
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Affiliation(s)
- Steven E Sobol
- Division of Pediatric Otolaryngology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Richard D. Wood Center, 1st Floor, 34th and Civic Center Blvd., Philadelphia, PA 19104-4399, USA
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Sobol SE, Samadi DS, Wetmore RF. Actinomycosis of the temporal bone: a report of a case. Ear Nose Throat J 2004; 83:327-9. [PMID: 15195879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Actinomycosis is a chronic suppurative infection of the cervicofacial region caused by Actinomyces species, which are anaerobic, gram-positive filamentous bacteria. Although actinomycosis has a propensity for involving the oral cavity, rare cases of actinomycosis involving the temporal bone have been published. We report the case of a 14-year-old girl who presented with clinical, audiometric, and radiologic findings consistent with right chronic suppurative otitis media that persisted despite tympanomastoidectomy. Findings on histologic evaluation of a specimen obtained during revision surgery were consistent with a diagnosis of actinomycosis. Although actinomycosis of the temporal bone is rare, it should be considered in the differential diagnosis of chronic suppurative temporal bone infections that are resistant to standard therapy.
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MESH Headings
- Actinomycosis/diagnosis
- Actinomycosis/physiopathology
- Actinomycosis/therapy
- Adolescent
- Audiometry
- Diagnosis, Differential
- Ear, Middle/diagnostic imaging
- Ear, Middle/pathology
- Ear, Middle/surgery
- Female
- Granulation Tissue/pathology
- Hearing Loss, Conductive/diagnosis
- Hearing Loss, Conductive/etiology
- Humans
- Mastoid/diagnostic imaging
- Mastoid/pathology
- Mastoid/surgery
- Mastoiditis/diagnosis
- Mastoiditis/microbiology
- Mastoiditis/therapy
- Otitis Media, Suppurative/diagnosis
- Otitis Media, Suppurative/microbiology
- Otitis Media, Suppurative/therapy
- Otologic Surgical Procedures/methods
- Penicillins/therapeutic use
- Tomography, X-Ray Computed
- Tympanic Membrane/surgery
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Affiliation(s)
- Steven E Sobol
- Division of Otolaryngology, Department of Surgery, The Children's Hospital of Philadelphia, PA 19104-4399, USA
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16
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Abstract
Actinomycosis is a chronic suppurative infection of the cervicofacial region caused by Actinomyces species, which are anaerobic, gram-positive filamentous bacteria. Although actinomycosis has a propensity for involving the oral cavity, rare cases of actinomycosis involving the temporal bone have been published. We report the case of a 14-year-old girl who presented with clinical, audiometric, and radiologic findings consistent with right chronic suppurative otitis media that persisted despite tympanomastoidectomy. Findings on histologic evaluation of a specimen obtained during revision surgery were consistent with a diagnosis of actinomycosis. Although actinomycosis of the temporal bone is rare, it should be considered in the differential diagnosis of chronic suppurative temporal bone infections that are resistant to standard therapy.
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Affiliation(s)
- Steven E. Sobol
- From the Division of Otolaryngology, Department of Surgery, The Children's Hospital of Philadelphia, and the Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Daniel S. Samadi
- From the Division of Otolaryngology, Department of Surgery, The Children's Hospital of Philadelphia, and the Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Ralph F. Wetmore
- From the Division of Otolaryngology, Department of Surgery, The Children's Hospital of Philadelphia, and the Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia
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Abstract
BACKGROUND The purpose of this study was to evaluate the surgical results of pediatric submandibular triangle masses, with specific attention to neoplastic processes. METHODS We retrospectively reviewed the medical records of 105 patients aged 6 months to 21 years who underwent surgery in the submandibular triangle at a major pediatric tertiary care hospital from 1987 to 2001. RESULTS One hundred five patients who underwent surgery in the submandibular triangle were included in the study. Twenty patients had neoplastic processes, six of which were of primary salivary origin (two mucoepidermoid carcinomas and four pleomorphic adenomas). Twenty-four patients underwent excision of inflamed or infected lymph nodes, and 23 patients underwent excision of inflamed or infected submandibular glands. Thirty-eight patients were included who underwent surgery for sialorrhea or to gain access for another surgical procedure. Complications included tumor recurrence, transient and permanent marginal mandibular nerve weakness, ranula, postoperative fluid collection, and cellulitis. Duration of follow-up ranged from no follow-up to 11 years. CONCLUSION Surgical excision of submandibular triangle masses is uncommon. We present our experience with these lesions, with a discussion of diagnosis, surgical indications, and surgical complications.
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Affiliation(s)
- Neil G Hockstein
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, One Wood Building Philadelphia, Pennsylvania, USA
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18
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Abstract
OBJECTIVE Heterotopic gastric mucosa found within the oral cavity has been reported as a rare occurrence with less than 30 cases in the English literature. We propose that this entity may not be as rare as originally described. METHOD Five cases of heterotopic gastric mucosa in the oral cavity were collected from three institutions. RESULTS Five new cases of heterotopic gastric mucosa in the oral cavity were confirmed. CONCLUSIONS Heterotopic gastric mucosa of the oral cavity may not be as rare as originally thought.
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Affiliation(s)
- Ralph F Wetmore
- Department of Pediatric Otolaryngology, Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, 34th Street and Civic Center Bluiding, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVE To develop a staging system for congenital cholesteatoma in predicting the likelihood of residual disease. DESIGN Retrospective analysis of data from a case series, to identify predictors of residual disease. SETTING Tertiary care pediatric hospital. PARTICIPANTS Children undergoing surgical removal of congenital cholesteatoma. There were 156 patients, with 160 cholesteatomas; 4 children had bilateral disease. INTERVENTIONS Each case was scored as to quadrants of the middle ear involved, ossicular involvement, and mastoid extension. MAIN OUTCOME MEASURE Surgically confirmed residual disease at any time after the initial procedure. RESULTS Four stages were defined as follows: stage I, disease confined to a single quadrant; stage II, cholesteatoma in multiple quadrants, but without ossicular involvement or mastoid extension; stage III, ossicular involvement without mastoid extension; and stage IV, mastoid disease. There was a strong association between stage and residual disease, ranging from a 13% risk in stage I to 67% in stage IV. CONCLUSIONS This simple staging system may be particularly useful in standardizing the reporting of congenital cholesteatoma and in adjusting for severity in evaluating outcomes. It also provides information that is useful in counseling parents.
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Affiliation(s)
- William P Potsic
- Division of Pediatric Otolaryngology, 1 Wood Bldg, The Children's Hospital of Philadelphia, 324 S 34th St, Philadelphia, PA 19104, USA.
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Potsic WP, Korman SB, Samadi DS, Wetmore RF. Congenital cholesteatoma: 20 years' experience at The Children's Hospital of Philadelphia. Otolaryngol Head Neck Surg 2002; 126:409-14. [PMID: 11997782 DOI: 10.1067/mhn.2002.123446] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We report our experience with congenital cholesteatoma over a span of 20 years with an emphasis on presenting characteristics and predictors of outcome. METHODS We conducted a retrospective review from 1981 through 2000. RESULTS One hundred seventy-two congenital cases were identified in 167 patients. Five patients had bilateral disease. The majority (72%) were found in boys, with an average age of 5.0 years. Hearing loss was slight to moderate. When confined to 1 quadrant, cholesteatoma was anterosuperior in 82% of cases; 47% had cholesteatoma in 2 or more quadrants. Ossicular chain involvement was found in 43% of all cases, and mastoid extension was evident in 23%. The rate of recurrent disease was directly related to the extent and number of quadrants involved. CONCLUSION To our knowledge, this is the largest series of congenital cholesteatomas to be reported. This review confirms the male predominance and predilection for the anterosuperior quadrant. The extent of cholesteatoma and its relation to residual disease should be used as a guide for planning a second-look procedure.
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Affiliation(s)
- William P Potsic
- The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, 19104, USA.
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Affiliation(s)
- R F Wetmore
- Department of Pediatric Otolaryngology, Children's Hospital of Philadelphia, PA 19104, USA
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22
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Abstract
In 1982, the experience with tracheostomy at The Children's Hospital of Philadelphia was reported for 1971 through 1980. We have now reviewed 450 cases for the period from 1981 through 1992, and compared the characteristics of these cases with those in the previous review. Long-term follow-up was available on 83% of cases, and the median follow-up was 2.96 years. Patients received a tracheostomy for airway obstruction (38%), chronic ventilation (53%), or multiple indications (9%). The mean duration of tracheotomy (adjusted for death and loss to follow-up) was 2.13 years. The tracheostomy-related mortality was 0.5%, and the nontracheostomy-related mortality was 22%. Nineteen percent of patients had complications in the first postoperative week, and 58% had 1 or more late complications. In comparison with the previous study from our institution, there was a great increase in long-term tracheostomy and a continuing trend away from tracheostomy for short-term airway management. Better monitoring and improvements in parental teaching may have contributed to a decrease in tracheostomy-related mortality.
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Affiliation(s)
- R F Wetmore
- Department of Pediatric Otolaryngology, The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, 19104, USA
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Abstract
OBJECTIVE To determine the cause of congenital airway abnormalities in pediatric patients requiring hospitalization for their respiratory status. DESIGN AND SETTING Case series in a tertiary care center. PATIENTS A 5-year retrospective chart review was conducted at our institution. A total of 174 patients were identified who required hospitalization for their respiratory status as a result of a congenital airway abnormality. RESULTS Of the 174 patients, 114 (65.5%) were male and 60 (34.5%) were female. Eighty patients (47%) presented within the first 3 months of life. Forty-six patients (26%) were born prematurely, and 49 patients (28%) were diagnosed as having gastroesophageal reflux. The majority of patients (139 [80%]) had multiple presenting symptoms or signs. Stridor was the most common (129 [74%]), followed by accessory respiratory effort, cyanosis, apnea, and failure to thrive. Diagnosis was made at the time of surgical evaluation in 91% of the patients, with the remaining diagnoses made using radiological findings and/or clinical evaluation. Sixty-five patients (37%) had multiple sites of airway abnormalities; laryngeal abnormalities were noted almost 3 times as often as tracheal abnormalities (161 vs 62, respectively). Of the laryngeal abnormalities, laryngomalacia was the most common, followed by glottic web, subglottic stenosis, vocal-cord paralysis, and subglottic hemangioma. Tracheomalacia was the most common tracheal abnormality, followed by external compression and tracheal stenosis. Thirty-three patients (19%) required tracheotomy for management of recurrent respiratory decompensation. CONCLUSIONS While congenital airway abnormalities are usually self-limited, those patients requiring hospitalization represent a group with a more severe respiratory status who have a greater chance of requiring tracheotomy. The recognizable percentage of patients with gastroesophageal reflux and prematurity accounts for comorbid factors in the need for hospitalization for respiratory issues related to congenital airway abnormalities.
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Affiliation(s)
- K W Altman
- Department of Otolaryngology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, 19104, USA
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24
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Affiliation(s)
- J L Keller
- Division of Otolaryngology, Children's Hospital of Philadelphia, PA 19104, USA
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25
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Abstract
OBJECTIVES/HYPOTHESIS To review the clinical presentation and diagnostic evaluation of patients with symptomatic congenital vascular anomalies causing tracheobronchial compression and to establish the short- and long-term results of surgical intervention with respect to postoperative complications, persistent symptoms, and ventilator and tracheostomy dependence. STUDY DESIGN Retrospective review. METHODS Chart review and telephone follow-up. RESULTS Between 1987 and 1996, 35 children underwent surgical intervention to relieve symptomatic tracheobronchial compression resulting from a congenital vascular anomaly. Historically, the onset of symptoms occurs within the first months of life; however, only 12 (34%) of patients were diagnosed by 6 months of age and 13 (37%) were diagnosed at greater than 1 year of age. Excluding anomalous innominate artery, chest radiography or barium swallow was suggestive of a congenital vascular anomaly in 30 (94%) of the patients. Magnetic resonance imaging correctly delineated the anatomy of the vascular anomaly in 29 patients. Bronchoscopy was diagnostic in all three patients with anomalous innominate arteries causing tracheal compression. Postoperative follow-up was obtained in 32 (91%) of patients; 25 (78%) of these were asymptomatic at the time of their most recent examination. The remaining patients had persistent stridor, recurrent respiratory tract infections, and/or chronic cough. In all three patients who underwent postoperative bronchoscopy for persistent symptoms, tracheomalacia was demonstrated in the region of previous compression. CONCLUSIONS Tracheobronchial compression from congenital vascular anomalies is a rare but treatable cause of respiratory symptoms. Early diagnosis requires a prompt, thorough clinical and radiologic evaluation. Surgery affords excellent long-term resolution of symptoms.
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Affiliation(s)
- R B McLaughlin
- Department of Otorhinolaryngology--Head and Neck Surgery, The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, 19104, USA
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26
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Abstract
In children, infections involving both the superficial and deep neck spaces are common. Children so affected typically present with fever, neck mass, neck stiffness, and, occasionally, airway compromise. Radiologic modalities used in the evaluation of neck infections include plain lateral neck radiography, ultrasound, computed tomography, and magnetic resonance imaging. All these modalities have proved useful in the treatment of such infections, specifically the decision to perform incision and drainage. The charts of 66 patients-33 with superficial and 33 with deep neck infections-were analyzed with respect to symptoms, signs, computed tomography findings, and need for surgical intervention. Computed tomography was not particularly helpful in superficial neck infections with regard to the decision to perform surgical drainage; however, it did localize and demonstrate the extent of infection. In deep neck infections we found a 92% correlation between computed tomographic evidence of an abscess and surgical confirmation of one. Contrast-enhanced computed tomography remains an excellent tool in the treatment of neck infections in children.
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Affiliation(s)
- R F Wetmore
- Department of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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27
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Abstract
Laryngomalacia is a common cause of stridor in children. The disorder has a heterogenous presentation, from the mildest form, which resolves with maturation, to the most severe form, requiring tracheotomy. While there is a vast literature on the subject, there is neither stratification nor correlation of clinical presentation, endoscopic appearance, treatment and outcome. In order to statistically evaluate the choice of treatment based upon presentation, patients must first be classified by relevant predictors of disease severity. A form is proposed to classify the clinical presentation of laryngomalacia by recording relevant historical and anatomic factors. Historical factors are classified by (1) severity of stridor; (2) weight gain; (3) age at presentation; and (4) neurologic status, forming the mnemonic SWAN. The principal anatomic site of collapse is recorded as: (1) postero-lateral; (2) posterior; or (3) anterior. Endoscopic findings consistent with gastroesophageal reflux disease (GERD) or gross aspiration are noted. Photographic and/or video documentation is performed when possible. A pilot study was undertaken to determine the ease of use of this instrument. Ten children, four boys and six girls, were classified. Ages ranged from 1-day-old to 19 months, with a mean of 9 months. Five children were examined in the clinic and five in the operating room. The form was readily and easily applied, and allowed the heterogeneity of the disorder to be organized. Wider application of this form across institutions, with classification of patients with laryngomalacia by historical and anatomic factors, should allow the accumulation of sufficient numbers of patients to allow statistical analyses of treatment and outcome as they relate to the initial presentation of this disorder of airway dynamics.
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Affiliation(s)
- U K Shah
- Division of Pediatric Otolaryngology, The Children's Hospital of Philadelphia, PA 19104-4399, USA.
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28
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Affiliation(s)
- R B McLaughlin
- Division of Pediatric Otolaryngology, The Children's Hospital of Philadelphia, PA 19104, USA
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29
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Altman KW, Wetmore RF, Mahboubi S. Comparison of endoscopy and radiographic fluoroscopy in the evaluation of pediatric congenital airway abnormalities. Int J Pediatr Otorhinolaryngol 1998; 44:43-6. [PMID: 9720679 DOI: 10.1016/s0165-5876(98)00042-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In order to assess the accuracy of conventional dynamic radiographic studies compared to endoscopy in the diagnosis of congenital airway abnormalities, we performed a retrospective chart review for the period between July 1991 to June 1996. A total of 186 patients were identified who required hospitalization for their respiratory status as a result of a congenital airway abnormality. Of these, 19% had both endoscopy and conventional dynamic radiographic evaluation (airway fluoroscopy, barium esophagography, or both). Eleven percent had fluoroscopy only, 62% had endoscopy only, and 9% had neither. In those patients who underwent both endoscopic and conventional dynamic radiographic evaluation, endoscopy was considered to be the definitive procedure for diagnosis. Laryngomalacia was present in 94% of these patients. Thirteen patients had multiple sites of airway abnormalities on endoscopy, and a total of 51 abnormalities were identified. Dynamic radiographic evaluation was correct in four, was suggestive of the abnormality in 12, did not recognize an abnormality in 33, and suggested a different diagnosis (not corresponding to endoscopy) in two. Thus, airway fluoroscopy and/or barium esophagography were correct or suggestive in 16 of 51 abnormalities (31%). We conclude that endoscopy is required in the majority of hospitalized patients for the precise diagnosis of a congenital airway abnormality. Conventional dynamic radiographic studies are helpful to confirm a suspected diagnosis in patients with a strong clinical history and physical examination. When the diagnosis is not clear based on the patient presentation, endoscopy is more definitive than conventional dynamic radiography in identifying pediatric congenital airway abnormalities.
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Affiliation(s)
- K W Altman
- Department of Otolaryngology, The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, 19104, USA
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30
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Altman KW, Wetmore RF, Marsh RR. Congenital airway abnormalities requiring tracheotomy: a profile of 56 patients and their diagnoses over a 9 year period. Int J Pediatr Otorhinolaryngol 1997; 41:199-206. [PMID: 9306176 DOI: 10.1016/s0165-5876(97)00089-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We reviewed the 9 year experience at the Children's Hospital of Philadelphia with patients requiring tracheotomy for a diagnosis of congenital airway abnormalities. Of the 56 patients, 28 (50%) had cardiovascular, or chromosomal abnormalities, neurologic conditions, or congenital syndromes, 24 (43%) were born prematurely, and 13 (23%) were found to have gastroesophageal reflux. Only 18 (32%) went on to eventual decannulation of their tracheotomy with a mean tracheotomy duration of 1.75 years. The majority of patients (75%) had multiple presenting signs. Stridor was the most common (54%), followed by accessory respiratory effort (39%), cyanosis (30%), apnea (29%), and failure to thrive (23%). Twenty eight patients (50%) had multiple airway abnormalities contributing to their need of a tracheotomy for airway protection orr ventilator dependence. Laryngeal abnormalities were found in 71% of patients, tracheal abnormalities in 48% of patients, bronchial abnormalities in 11%, and upper airway obstruction in 14%. Of the laryngeal abnormalities, laryngomalacia was the most common, followed by subglottic stenosis, glottic web, and vocal cord paralysis. Tracheomalacia was the most common tracheal abnormality. The relatively large percentage of patients with cardiovascular or other major malformations, and prematurity, accounts for comorbid factors in the need for prolonged tracheotomy (and low early decannulation rate). Although gastroesophageal reflux was found in a recognizable portion off the patients, it is unclear whether this represents a comorbid condition.
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Affiliation(s)
- K W Altman
- Department of Otolaryngology, Children's Hospital of Philadelphia, PA 19104, USA
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31
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Abstract
Periauricular cysts, sinuses, and fistulas occur commonly in the pediatric population. They arise from developmental defects of the first branchial cleft and first branchial arch. In most instances the diagnosis and management of these conditions are straightforward, but exceptional presentations sometimes occur. Failure to recognize these unusual cases may result in inadequate treatment and subsequent recurrence, and even if the correct diagnosis is made, surgical management of these lesions may be complicated. A series of 15 cases of periauricular congenital lesions is reviewed, of which three cases illustrating a diagnostic or surgical challenge are presented. The embryology, presentation, and management of these anomalies are discussed. This is one of the largest series of first branchial cleft anomalies reported in the literature, and our paper uniquely discusses first branchial cleft anomalies and preauricular sinuses together, with an emphasis on the surgical management of facial nerve, external ear, and middle ear involvement.
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Affiliation(s)
- Y C Nofsinger
- Division of Otolaryngology, The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, 19104, USA
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32
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Abstract
Granulomatous inflammation is a common finding in pathologic evaluation of surgically excised chronic lymphadenopathy in children. Confusion exists regarding diagnosis and management of these lesions. Over a 10-year period at The Children's Hospital of Philadelphia, a total of 81 children were identified with biopsy-confirmed granulomatous lesions of the head and neck, with nontuberculous mycobacteria (NTM) accounting for 67 of the cases. The typical presentation was that of a nontender mass in the cervicofacial area present for weeks to months, unresponsive to antimicrobials. All underwent surgical excision, which was curative in 54 patients; 13 children required additional procedures. This paper reviews NTM, its typical clinical presentation, difficulty in diagnosis, and the methods of treatment.
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Affiliation(s)
- D L Suskind
- Division of Otolaryngology, Children's Hospital of Philadelphia, PA 19104, USA
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33
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Abstract
Controversy exists regarding the management of the middle meatus after pediatric functional endoscopic sinus surgery (FESS). To prevent adhesions following pediatric FESS, gelatin film stenting of the middle meatus has been recommended. The effects of stenting, however, have not been established. Fifty-one children with similar degrees of bilateral sinus disease had a gelatin film stent placed in one middle meatus on completion of FESS, while the opposite meatus was not stented. Two to three weeks later at the time of a second, staged procedure, the sides were compared for the presence of the stent, adhesions, granulaion tissue, and patency of the maxillary sinus ostia. In 11 children the postoperative findings were more severe in the side without the stent, whereas in 29 children they were more severe in the stented side. There was no difference between the sides in 11 children. Although gelatin film stenting benefits some children, it should not be used routinely following pediatric FESS but should be reserved for children who are predisposed to develop adhesions or have poor prognostic factors, such as immunodeficiency and ciliary dyskinesia.
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Affiliation(s)
- L W Tom
- Division of Otolaryngology, Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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34
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Abstract
Sternocleidomastoid tumor of infancy (STOI) is a benign, firm, fibrous swelling predominantly involving the middle or inferior third of the sternocleidomastoid muscle. Patients may present simultaneously with, or progress to the development of, congenital, muscular torticollis (CMT) during childhood. This pseudotumor affects infants in their first few weeks of life with the vast majority showing complete regression over the ensuing few months. Multiple postulates have been presented as to the exact etiology of STOI; however, the cause is still unknown. Two siblings, both requiring vacuum extraction during delivery, presented at 4 weeks of age to the Children's Hospital of Philadelphia (CHOP) with STOI. The possible genetic predisposition of these siblings to develop STOI is hypothesized. Familial cases of CMT have been reported along with the possible genetic or peripartum factors that could play a role in its development. We reviewed these same mechanisms that could also predispose to familial STOI. Currently, magnetic resonance imaging is the diagnostic modality of choice. Fortunately, the majority of STOI responds to conservative measures with aggressive physical therapy, thus avoiding the need for operative intervention.
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Affiliation(s)
- M A Tavill
- Department of Otolaryngology, Children's Hospital of Philadelphia, PA, USA
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35
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McLaughlin RB, Keller JL, Wetmore RF, Tom LWC. 131: Kawaski Disease: A Diagnostic Dilemma. Otolaryngol Head Neck Surg 1996. [DOI: 10.1016/s0194-5998(96)80993-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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36
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Abstract
Cerebrospinal fluid (CSF) rhinorrhea typically results from trauma to the skull base, producing leaks through either the cribiform plate region or the sphenoid bone. Traditional approaches to the repair of such leaks include a frontal craniotomy or external ethmoidectomy. An endoscopic approach through the nose has also proven to be successful. A 7-year-old male suffered traumatic CSF rhinorrhea and development of a meningocele in the region of the cribiform plate. After demonstrating the site of the leak with fluorescein dye, the defect was repaired via a transnasal endoscopic approach. The evaluation of the child with CSF rhinorrhea, including the presenting symptoms and signs and the radiographic assessment, is presented. The variety of approaches, types of repair and post-operative care are also discussed.
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Affiliation(s)
- R F Wetmore
- Department of Otolaryngology, Children's Hospital of Philadelphia, PA 19104, USA
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37
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Tavill MA, Wetmore RF. 181 A Case of Familial Sternocleidomastoid Tumor of Infancy. Otolaryngol Head Neck Surg 1995. [DOI: 10.1016/s0194-5998(05)81056-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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38
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Affiliation(s)
- M A Tavill
- Division of Otolaryngology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, USA
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39
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Abstract
Unilateral vocal cord paralysis (UVCP) in children is uncommon and rarely leads to serious sequelae. However, on rare occasions, it can present with severe aspiration and dysphonia. Several therapeutic techniques have been used in adults with UVCP, but the reported alternatives in children have been much more limited. Observation and speech therapy are the standard treatment. We describe three children with UVCP and severe aspiration who were treated with vocal cord injection. The treatment indications, clinical courses, and outcomes of the three cases are detailed. The injection of vocal cords in children is discussed, with an emphasis on those aspects unique to the management of UVCP in pediatric patients. Alternative surgical treatment modalities are also presented. Vocal cord injection is an effective and viable therapeutic option for the management of UVCP in certain pediatric patients with severe aspiration and dysphonia.
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Affiliation(s)
- B A Levine
- Department of Otorhinolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Pa
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40
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Abstract
Congenital tracheal stenosis is a rare congenital anomaly, with less than 70 reported cases in the literature. The presenting signs and symptoms of stridor, recurrent pneumonia, and respiratory distress are commonly seen in other conditions. The rarity of congenital tracheal stenosis and the diverse presentations make accurate early diagnosis difficult and frequently lead to inappropriate treatment. We treated three patients with congenital tracheal stenosis who presented with different sites of stenosis. Each patient displayed different symptoms and required individualized management. The treatment of congenital tracheal stenosis depends on identifying the site and extent of the stenosis. We reviewed the embryogenesis and treatment of this abnormality and developed a new classification system that will aid in the management of congenital tracheal stenosis.
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Affiliation(s)
- M E Hoffer
- Division of Otolaryngology, Children's Hospital of Philadelphia, Pa
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41
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Abstract
Tracheobronchomalacia (TBM) is an important cause of airway distress during infancy, but it generally resolves as the airway enlarges. To assess the origin and natural history of TBM, a chart review and telephone survey were conducted for 50 patients with TBM at the Children's Hospital of Philadelphia (Pa). This study revealed that TBM is a relatively common airway abnormality and is found on 15% of all diagnostic bronchoscopies. Prematurity, low birth weight, bronchopulmonary dysplasia, and prolonged ventilation predispose patients to the most severe symptoms. In our study, a tracheotomy with continuous positive airway pressure was required by 75% of the premature infants and 25% of the full-term infants with TBM. Seventy-one percent of all patients underwent decannulation without any other surgical intervention and remained nearly asymptomatic. Some patients could not undergo decannulation because of other airway lesions. In most instances, TBM is a self-limited disease that resolves without surgery.
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Affiliation(s)
- I N Jacobs
- Department of Otolaryngology, Children's Hospital of Philadelphia, Pa
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42
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Abstract
Sudden infant death syndrome (SIDS) has been shown to result from a variety of causes. One group of neonates at high risk for SIDS includes those who develop apnea secondary to gastroesophageal reflux (GER). Reflux has been shown to produce apnea in infants, and aggressive treatment results in significant improvement in symptoms. Because it is a site of resistance in the airway, the larynx plays an important role in the development of apnea. Through its sensory innervation, the larynx also serves as the afferent limb for reflexes that regulate respiration. In order to investigate the relationship between obstructive apnea and central apnea induced by the instillation of acid on the larynx, simulating GER, a rabbit model was developed. Maturing rabbits at 15-day intervals up to 60 days of age were studied using saline and acid solutions. Acid solutions produced obstructive apnea in all age groups. With acid solutions, central apnea occurred in all age groups but had a peak incidence at 45 days. Gasping respirations were seen in all groups but were most common at 30 days of age. Although obstructive and central apnea occurred together as mixed apnea, both types of apnea were seen independently of each other. Acid instilled on the larynx of maturing rabbits resulted in significant obstructive, central, and mixed apnea. Gasping respirations and frequent swallowing were frequent associated symptoms. Acid-induced obstructive apnea in rabbits mirrors symptoms seen in human infants with GER. Central apnea in infants with GER is seen less commonly; however, central apnea as the result of laryngeal stimulation has been demonstrated repeatedly in several animal models. Central apnea, culminating in fatal asphyxia, has been described in several animal models. The larynx appears to play a pivotal role in the development of apnea in susceptible infants with GER.
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Affiliation(s)
- R F Wetmore
- Department of Pediatric Otolaryngology, Children's Hospital of Philadelphia, PA 19104
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43
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Abstract
OBJECTIVE To quantify the intensity, spectral content, and duration of exposure for suction noise created during aspiration of middle ear fluid following myringotomy. DESIGN Case series. SETTING Tertiary care center. PATIENTS OR OTHER PARTICIPANTS Convenience sample of 245 myringotomies performed on 124 patients ranging in age from 6 months to 14 years (mean age, 2 years 8 months). MAIN OUTCOME MEASURES Intensity, spectral content, and duration of exposure associated with suction noise were defined by electroacoustic analysis of high-fidelity tape recordings of the noise created during suctioning middle ear fluid. RESULTS The intensity of suction noise ranged from 74 to 117 dB; most acoustic energy was concentrated in the frequency range between 1.7 and 6.0 kHz, and the duration of exposure varied from 4 to 23 seconds.
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Affiliation(s)
- R F Wetmore
- Department of Otorhinolaryngology and Human Communication, Children's Hospital of Philadelphia
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44
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Abstract
Pediatric tracheotomy is a safe procedure, and the tube can be maintained for a prolonged period. There are, however, few guidelines regarding the endoscopic assessment of the airway following tracheotomy. From January 1988 through December 1989, the Division of Otolaryngology of The Children's Hospital of Philadelphia (Pa) performed tracheotomies on 81 patients. Thirty-two children had direct laryngoscopy and bronchoscopy at the time of the procedure, 1 week later, and at 6-month intervals for a minimum of 18 months. Four children had normal airways while 21 had intraluminal stomal granulomas, 16 had development of subglottic stenosis, nine had collapse of the anterior tracheal wall, and three had development of distal tracheal granulations. Sixteen children had multiple lesions. Anatomic changes occur in the airways of the majority of children with long-term tracheotomies, and endoscopic evaluation is an essential part of their care.
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Affiliation(s)
- L W Tom
- Division of Otolaryngology, Children's Hospital of Philadelphia, PA 19104
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45
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Abstract
Fifty-five cases of acute epiglottitis were diagnosed and treated at the Children's Hospital of Philadelphia between 1985 and 1991. To evaluate the changing patterns of the disease over recent years, we compared the current results with those obtained from an earlier study reported at our institution in 1979. The overall annual incidence was higher in recent years than in the earlier study, with a sharp decline in new cases over the last two years. Thirty-six percent of the Hemophilus influenzae type B (HIB) infections were ampicillin-resistant in recent years, while no resistance had been found in the past. Twenty-seven percent of the cases were vaccine failures, all before 1990. Endotracheal intubation was the sole method for upper airway maintenance, while in the past 31% of the children underwent a tracheotomy. No mortality or long-term complications were found in either study.
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Affiliation(s)
- A Kessler
- Department of Pediatric Otolaryngology, Children's Hospital of Philadelphia, PA 19104
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46
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Potsic WP, Wetmore RF. Practical aspects of managing the child with apnea. J Otolaryngol 1992; 21:429-33. [PMID: 1494186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Sleep apnea is a common problem in children and probably more common than currently realized. Apnea in children may be central, obstructive or mixed. Otolaryngologists are called upon to diagnose and treat obstructive apnea. The most common cause of obstructive apnea in children is adenotonsillar hyperplasia, and several conditions predispose children to sleep apnea. The most severe, and occasionally only, signs occur during sleep. The majority of children can be diagnosed by a careful history from parents or caretakers. However, sleep sonography, pulse oximetry and polysomnography may be needed to assist in diagnosis. The treatment of apnea in children may include medications, but the most common procedure employed to resolve obstructive apnea in children is adenotonsillectomy.
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Affiliation(s)
- W P Potsic
- Children's Hospital of Philadelphia, Pa. 19104
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47
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48
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Abstract
The external nose is a structure that provides prominence to the face. The internal nose is a paired nasal cavity that extends from the face to the pharynx. Turbinates are major structures within the lateral walls of the nose. They perform the major functions of the nose that include respiration, humidification, temperature regulation, and filtration of the inspired air. Conditions that obstruct the nose interfere with its optimal function. These range from acute or chronic infection to enlarged tonsils and adenoid tissue to nasal septal deviation. Surgeons caring for patients with clefts must have familiarity with nasal anatomy and function and conditions that alter them. Correction of these conditions may require medical and/or surgical treatment.
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Affiliation(s)
- R F Wetmore
- Department of Otolaryngology, Children's Hospital of Philadelphia, PA 19104
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49
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Abstract
A retrospective analysis identified 29 children with nasopharyngeal malignancies who were evaluated at the Children's Hospital of Philadelphia from 1970 through 1989. Rhabdomyosarcoma (15) and carcinoma (9) were the most common tumor types, and there were distinct differences in the clinical presentations of these two malignancies. Patients with rhabdomyosarcoma were generally younger than those with carcinoma and enjoyed longer survival. Six (67%) of the children with carcinoma were black; all of the patients with rhabdomyosarcoma were white. Patients with carcinoma were also more likely to present with cervical metastases. The presentation, evaluation, and methods of treatment for pediatric nasopharyngeal malignancies are discussed.
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Affiliation(s)
- L W Tom
- Department of Otolaryngology, Children's Hospital of Philadelphia, PA 19104
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50
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Pribitkin EA, Handler SD, Tom LW, Potsic WP, Wetmore RF. Ventilation tube removal. Indications for paper patch myringoplasty. Arch Otolaryngol Head Neck Surg 1992; 118:495-7. [PMID: 1571120 DOI: 10.1001/archotol.1992.01880050041010] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Paper patch myringoplasties are commonly performed in children at the time of ventilation tube removal, yet no series documenting their efficacy appears in the otolaryngology literature. Over an 18-month period at the Children's Hospital of Philadelphia (Pa), 163 ventilation tube removals were performed on 131 children aged 1 to 18 years. In 95 of these ears, a paper patch myringoplasty was performed after tube removal. No significant difference (87% vs 85%) in the overall healing rate at 6 months was shown between these two groups. An analysis of the variables potentially affecting outcome revealed that healing following simple tube removal was influenced by the frequency of tube placement and by tube size. Paper patch myringoplasty significantly improved outcome (93% vs 61%) in ears with more than three previous tube placements.
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Affiliation(s)
- E A Pribitkin
- Division of Otolaryngology, Children's Hospital of Philadelphia, PA 19104
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