Examining the life-cycle of the Coblator II device: Increases in paediatric post-tonsillectomy haemorrhage after six years of use

All paediatric tonsillectomies were examined from 2012 – 2019 at a single tertiary-referral institution, and all were performed by one of two paediatric otolaryngologists. One exclusively used the diathermy, the other exclusively used the Coblator II. Two Coblator units were purchased simultaneously in 2012 and not replaced. There was no significant difference in number of tonsillectomies performed (1298 via diathermy, 1221 via Coblator), nor in postoperative day of bleed, patient age, indication for procedure, and no patient had an underlying coagulopathy. The most common indication for tonsillectomy in both groups was sleep-disordered breathing. There was no significant difference in postoperative haemorrhage rates between groups for the first six years of the study (0%-1.4%/year). Years 7 and 8 saw the Coblator group haemorrhage rate significantly increase (0%-0.6% diathermy group vs 2%-3% Coblator group), though still fell within accepted rate of postoperative haemorrhage. The devices were then replaced, and the differences in haemorrhage disappeared. There appears to be a significant increase in paediatric post-tonsillectomy haemorrhage when using a Coblator device greater than six years old. This may suggest a useful lifespan for the Coblator II device.

Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children

Importance

The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children.

Objective

To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery.

Design, Setting, and Participants

This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded.

Main Outcomes and Measures

Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding.

Results

Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66).

Conclusions and Relevance

Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.

Adenotonsillectomy for Obstructive Sleep Apnea and Quality of Life: Systematic Review and Meta-analysis

Objective To determine the impact of adenotonsillectomy on the quality of life of pediatric patients with obstructive sleep apnea (OSA) and to identify gaps in the current research. Data Sources The MEDLINE, EMBASE, and Cochrane databases were systematically searched via the Ovid portal on June 18, 2016, for English-language articles. Review Methods Full-text articles were selected that studied boys and girls <18 years of age who underwent adenotonsillectomy for OSA or sleep-disordered breathing and that recorded validated, quantitative quality-of-life outcomes. Studies that lacked such measures, performed adenotonsillectomy for indications other than OSA or sleep-disordered breathing, or grouped adenotonsillectomy with other procedures were excluded. Results Of the 328 articles initially identified, 37 were included for qualitative analysis. The level of evidence was generally low. All studies involving short-term follow-up (≤6 months) showed improvement in quality-of-life scores after adenotonsillectomy as compared with preoperative values. Studies involving long-term follow-up (>6 months) showed mixed results. Modifications to and concurrent procedures with conventional adenotonsillectomy were also identified that showed quality-of-life improvements. Three studies were identified for meta-analysis that compared pre- and postoperative Obstructive Sleep Apnea-18 scores. Short- and long-term follow-up versus preoperative scores showed significant improvement ( P < .001). Short- and long-term scores showed no significant difference. Conclusion This systematic review and meta-analysis demonstrate adenotonsillectomy's effectiveness in improving the quality of life of pediatric patients with OSA. This is well demonstrated in the short term and has strong indications in the long term.

Utility of polysomnography in determination of laryngomalacia severity

OBJECTIVE

To examine the efficacy of polysomnography in determining the severity of laryngomalacia in pediatric patients.

METHODS

Prospective cohort study. Pediatric patients referred to our pediatric otolaryngology department with a polysomnogram already performed for a presumptive diagnosis of laryngomalacia were enrolled in the study. Patients with concurrent airway lesions or neuromuscular disorders were excluded. Patients underwent history, physical exam, and flexible fiberoptic laryngoscopy. These results were used to calculate a total laryngomalacia severity score.

RESULTS

25 pediatric patients (n = 25) with an average age of 3.9 months at time of initial evaluation met criteria for enrollment in our study. 100% of patients had obstructive sleep apnea by definition. 80% of these patients underwent supraglottoplasty. The average AHI of those who underwent surgery (57.26) was not significantly different in those who underwent surgery vs. those that did not (55.43) (p = 0.41). In comparison, the average laryngomalacia severity score based from history, physical exam and flexible laryngoscopy was significantly greater in the patients that required supraglottoplasty (11.16) vs. those who did not (5.33) (p = 0.03). In addition a higher laryngomalacia severity score was not correlated with a higher AHI (p = 0.81, r = 0.08, CI: -0.5197 to 0.6235).

CONCLUSION

In our cohort, polysomnography was not useful in determining the severity of laryngomalacia, did not correlate with the clinical evaluation, and alone was not predictive of the patients that would require surgical intervention. History, physical exam, and endoscopic findings remain reliable predictors of disease severity and need for operative intervention.

Reliability of the Pharyngeal Squeeze Maneuver

Objectives:

Fiberoptic endoscopic evaluation of swallowing with sensory testing has been used to assess the integrity of laryngopharyngeal sensory and motor components. The pharyngeal squeeze is a maneuver used during fiberoptic endoscopic evaluation of swallowing with sensory testing to assess pharyngeal motor function. Although the pharyngeal squeeze manuever has been used in numerous scientific publications, its reliability has not been critically evaluated. Therefore, we sought to evaluate the reliability of the pharyngeal squeeze maneuver.

Methods:

Forty individuals who were undergoing fiberoptic laryngoscopy for various reasons were instructed to perform the pharyngeal squeeze maneuver. Three different clinicians reviewed the videotape on 4 separate occasions. The clinicians were first asked to rate each side of the pharynx as normal, diminished, or absent. They were then instructed to simply rate the maneuver as normal or abnormal. The interobserver and intraobserver reliability of the pharyngeal squeeze maneuver were assessed with the kappa coefficient.

Results:

The mean age of the cohort was 58 years. Fifty-eight percent (23 of 40) were male. When the clinicians were instructed to rate each side of the pharynx as normal, diminished, or absent, the interobserver and intraobserver reliabilities were poor (63% to 68% agreement; kappa = 0.18 to 0.67). When the clinicians were asked to rate the pharyngeal squeeze maneuver as normal or abnormal, both interobserver and intraobserver reliabilities were excellent (85% to 98% agreement; kappa = 0.75 to 0.95).

Conclusions:

The pharyngeal squeeze maneuver displayed poor reliability when motor function was classified into unilateral or bilateral normal, diminished, and absent categories. The pharyngeal squeeze maneuver was very reliable when simply graded as normal or abnormal. Clinicians could not reliably distinguish between diminished and absent pharyngeal motor functions.

A newborn with three cochlear turns: Case report and literature review

Objectives/Hypothesis: The human cochlea is most commonly considered to have two and a half turns. Although the causes of cochlear hypoplasia are well described, cochlear hyperplasia is a rarer entity that is poorly understood. We describe rare anatomic cochlear malformations identified in a 4-month-old male originally referred for evaluation after a failed newborn hearing screening. The full diagnostic evaluation, imaging findings, treatment, and follow-up are described in detail. Cochleae with three turns are an uncommon malformation that is not included in current classifications schemes and may represent a distinct type of anomaly not caused by developmental arrest.

Retropharyngeal phlegmon in Rosai Dorfman disease

Rosai Dorfman disease (RD), also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a benign histiocytic proliferative condition of unsubstantiated etiology that most often presents as bilateral painless cervical lymphadenopathy. Head and neck manifestations of RD are diverse but most commonly present as massive cervical lymphadenopathy. Interestingly, a retropharyngeal fluid collection has never been described as a sequelae of RD. Our objective is to present a novel case of a 9-year old female with RD that suffered from recurrent retropharyngeal phlegmon and to discuss diagnostic and treatment recommendations for this disease process.

Lund-mackay staging system in cystic fibrosis: a prognostic factor for revision surgery?

BACKGROUND

Cystic fibrosis (CF) is an autosomal recessive genetic disease that affects approximately 30,000 people in the United States. Mucus in CF patients can be exceptionally viscous, leading to progressive cycles of inflammation and infection. The most widely accepted staging system used to score sinus computed tomography (CT) scans is the Lund-Mackay Score (LMS).

METHODS

To determine if a significant correlation exists between LMS and the need for revision sinus surgery in a patient population with CF, we performed a retrospective review of 32 patients with CF who were referred to the Tulane Otolaryngology Clinic from 2005 to 2011 and received a CT scan of the paranasal sinuses. CT scans were graded in a blinded manner by the institution's neuroradiologist using the LMS system.

RESULTS

We found no statistically significant difference in the raw or scaled LMSs between patients receiving revision surgery (n=9) and patients receiving a single surgery (n=23).

CONCLUSIONS

CT scans are vital for preoperative planning, but they are not a useful tool for risk stratification. More specifically, application of the LMS is not relevant in identifying which CF patients with chronic rhinosinusitis will be at risk for revision surgeries.

An unusual presentation of Gaucher disease in an infant with progressive dyspnea

BACKGROUND

The most common lysosomal storage disorder, Gaucher disease, represents a collection of 3 clinical syndromes associated with disrupted glucocerebroside catabolism. Despite the common occurrence of dyspnea in advanced Gaucher, dyspnea is rarely reported as a presenting symptom of the disease.

CASE REPORT

A 10-month-old male was referred to the Otolaryngology Clinic for evaluation of progressive dyspnea. Physical examination was significant for cervical adenopathy, inspiratory stridor, and developmental delay. A complete evaluation for failure to thrive and lymphadenopathy was performed, with subsequent lymph node biopsy and enzyme assay confirming the presence of Gaucher disease.

CONCLUSION

A high level of suspicion is required to make an early diagnosis of Gaucher disease, but it should be considered in patients presenting with failure to thrive, generalized lymphadenopathy, and respiratory or neurologic findings. Initiation of early treatment is paramount for the prevention of irreversible disease.

Obstructive lesions of the pediatric subglottis

PURPOSE

To compile information regarding obstructive subglottic lesions in children, including anatomy, pathogenesis, prevention, evaluation, and treatment options, required for implementation of a multi-faceted treatment plan.

METHOD

Review of the literature.

CONCLUSIONS

Although they are infrequent, obstructive subglottic lesions pose significant challenges to treating physicians, from airway management and injury prevention to decannulation and voice rehabilitation. Most patients with these lesions require multidisciplinary care and long-term treatment and can nearly always be treated successfully.

Pleomorphic adenoma of the parotid gland in children

OBJECTIVE

To evaluate the presentation, imaging characteristics and treatment outcome of pleomorphic adenoma of the parotid in the pediatric population.

DESIGN

Retrospective study with institutional review board approval.

SETTING

Tertiary care pediatric medical center.

METHODS

An extensive review of medical records with regard to presentation, imaging, histopathology, complication, recurrence and prognosis on patients 18 years or younger presenting from 1983 to 2005.

RESULTS

Eleven patients (six females, five males) were identified. The most common presentation was an asymptomatic mass. Preoperative imaging was done on nine patients: MRI (N=6), CT (N=3), ultrasound (N=2), and sialogram (N=1). Initial treatments included: superficial parotidectomy (N=5), total parotidectomy (N=3), excisional biopsy followed by superficial parotidectomy (N=2), and excisional biopsy (N=1). There were two recurrences (18%); one presenting 7 months following excisional biopsy who underwent superficial parotidectomy and one occurred 3 years following total parotidectomy requiring revision parotidectomy and radiation. Other complications included: transient facial nerve paresis (N=5; 45%) and permanent weakness (N=1; 9%). The patients were followed an average of 18 months.

CONCLUSIONS

Pleomorphic adenoma is one of the most common tumors of the parotid in children. The most common presentation is an asymptomatic mass. A preoperative evaluation with MRI or CT scan can be helpful in determining the extent of the lesion and surgical planning. Complete excision via superficial or total parotidectomy with preservation of facial nerve is the treatment of choice. Long-term follow up is recommended, though was difficult in a tertiary care center.

Tracheal stenosis

While still an uncommon cause of airway obstruction, the incidence of tracheal stenosis in adults has increased with the use of assisted ventilation. The etiology, diagnosis, and treatment of tracheal stenosis are discussed. Special attention is paid to post-intubation tracheal stenosis and to tracheal resection as its most successful treatment option.