Children's ENT and Facial Plastic Surgery
Minnesota's Only Pediatric Otolaryngology, Facial Plastic, & Reconstructive Surgery Practice
At Children's ENT and Facial Plastic Surgery, we’re not only committed to delivering state-of-the-art care, but we are also committed to advancing the knowledge necessary to deliver that care. Our areas of clinical research span the entire breadth of pediatric otolaryngology and facial plastic surgery as well as cleft and craniofacial care. We invite you to explore the various papers we have published over the years in the peer reviewed medical literature.
Airway Disorders
Airway management for intubation in newborns with pierre robin sequence.
Laryngoscope. 2012 Jun;122(6):1401-4. doi: 10.1002/lary.23260. Epub 2012 Mar 27.
OBJECTIVES/HYPOTHESIS:
To review airway management in Pierre Robin sequence (PRS) newborns undergoing general anesthesia and to determine if endotracheal intubation is safe in this population.
STUDY DESIGN:
Case series and retrospective chart review at a tertiary children's hospital.
METHODS:
PRS newborns who underwent endotracheal intubation or other airway intervention before 3 months of age between January 2000 and July 2011 were identified from a pediatric otolaryngology practice database. Indications for airway intervention, anesthetic management, method of intubation, and comorbid conditions were collected.
RESULTS:
Thirty-three PRS newborns were identified. Twenty had isolated PRS, and 13 had PRS related to a coexisting syndrome. Thirteen of 35 (37%) endotracheal intubations performed in PRS newborns prior to mandibular distraction osteogenesis were accomplished with direct laryngoscopy. The remaining 22 of 35 (63%) who failed intubation with direct laryngoscopy were intubated over a flexible fiberoptic bronchoscope. No significant difference was observed between the isolated and syndromic PRS newborns with regard to technique utilized for intubation. No patient required rescue laryngeal mask airway or emergent tracheotomy, and no case resulted in death.
CONCLUSIONS:
This series demonstrates that endotracheal intubation is safe and effective in PRS newborns. In patients who failed intubation with direct laryngoscopy, intubation over a flexible fiberoptic bronchoscope provided a reliable alternative method. Although airway management in PRS newborns poses a significant challenge, experienced otolaryngologists and anesthesiologists can successfully manage these difficult airway cases.
Children's Hospitals and Clinics of Minnesota, Pediatric ENT Associates, Minneapolis, Minnesota, USA.; Medical School, University of Minnesota , Minneapolis, Minnesota, U.S.A.
Pediatric tracheal and endobronchial tumors: an institutional experience.
Arch Otolaryngol Head Neck Surg. 2011 Sep;137(9):925-9.
OBJECTIVES: To report the pathologic findings in cases involving endotracheal and endobronchial tumors in the pediatric population and to describe the presenting symptoms and treatment modalities for endotracheal and endobronchial tumors.
DESIGN: Retrospective chart review.
SETTING: Tertiary care children's hospital.
PATIENTS: The study included 14 patients with endotracheal and endobronchial tumors.
MAIN OUTCOME MEASURES: Patients were selected if bronchoscopy was performed to obtain biopsy specimens from the trachea or bronchus.
RESULTS: There were 14 cases that met the inclusion criteria between 1993 and 2009. The patients ranged in age from 4 to 18 years. The most common presenting symptom was recurrent pneumonia (n = 6), followed by wheezing or asthma that was unresponsive to treatment (n = 4). Nine lesions (64%) were malignant and 5 (36%) were benign. Of the malignant tumors, 5 (55%) were carcinoid, 3 (33%) were mucoepidermoid carcinoma, and 1 was adenoid cystic carcinoma. There were 1 or 2 cases of each of the following benign to intermediate malignant potential lesions: histoplasmosis nodules, chondroid hamartoma, pulmonary chondroma, and inflammatory myofibroblastic tumor. In 12 cases, definitive treatment included surgical resection. Three of these cases required postoperative chemotherapy and radiotherapy.
CONCLUSIONS: The results of this series suggest that in the pediatric population tracheal and endobronchial tumors are most likely to be carcinoid tumors or mucoepidermoid carcinomas, both malignant processes. For patients with recurrent pneumonias or chronic wheezing, an occult tumor is a diagnostic consideration that may require additional studies.
Pediatric ENT Associates, Minneapolis, Minnesota, USA. barne284@umn.edu
Type IV laryngotracheoesophageal cleft: report of long-term survivor successfully decannulated.
Int J Pediatr Otorhinolaryngol. 2011 Sep;75(9):1207-9. Epub 2011 Jul 12.
Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that results from failed posterior fusion of the cricoid cartilage and incomplete development of the tracheoesophageal septum. LTEC presents with increased secretions, respiratory distress, aspiration and recurrent pulmonary infections. The severity of presenting symptoms is dependent on the type of cleft. LTEC is most commonly classified into four types (I, II, III and IV) based on the inferior extent of the cleft. Types III and IV LTEC are associated with high morbidity and mortality and require timely diagnosis and repair for survival. Most patients who survive repair of Type IV LTEC have long-term tracheotomy dependency with minimal chance of decannulation. We report on a case of a long-term survivor of Type IV who has been safely decannulated.
Department of Otolaryngology, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, United States. owusuja@yahoo.com
Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Incidence of operative endoscopy findings in recurrent croup.
Otolaryngol Head Neck Surg. 2011 Apr;144(4):596-601. Epub 2011 Feb 24.
OBJECTIVE: Develop an evidence-based model for predicting operative endoscopy findings in patients with recurrent croup.
STUDY DESIGN: Case series with chart review.
SETTING: Tertiary care children's hospital.
SUBJECTS AND METHODS: Retrospective chart review was performed on 124 patients who received consultation for recurrent croup between 2000 and 2009. Direct laryngoscopy and bronchoscopy findings were categorized as normal, mildly abnormal (incidental findings or grade I subglottic stenosis), moderately abnormal (grade II subglottic stenosis), or severely abnormal (grade III-IV subglottic stenosis).
RESULTS: Of 124 consultations for recurrent croup, 81 patients (average age 3.5 years) underwent operative endoscopy. Normal examinations occurred in 33 of 81 (41%). Abnormal findings were encountered with the following frequency: mildly abnormal, 40 of 81 (49%); moderately abnormal, 6 of 81 (7.5%); and severely abnormal, 2 of 81 (2.5%). Relative risk (RR) of either moderately abnormal or severely abnormal findings was increased for patients who had a history of previous intubation (RR = 9.8; P = .002), prematurity (RR = 6.4; P = .01), or inpatient consultation (RR = 5.3; P = .028). The rate of moderately or severely abnormal findings in patients without the risk factors of intubation and age younger than 1 year was 0 of 48 (0%; confidence interval, 0%-7.4%). Mild abnormalities in this group were encountered in 27 of 48 (56%).
CONCLUSION: Mild airway abnormalities are common in children with recurrent croup and cannot be ruled out based on history. In the absence the risk factors of previous intubation, age younger than 1 year, or inpatient consultation, the incidence of a significantly abnormal finding is quite low. A predictive model based on this evidence is discussed.
Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN 55455, USA. jabb0005@umn.edu
Complete peripartum airway management of a large epignathus teratoma: EXIT to resection.
Int J Pediatr Otorhinolaryngol. 2011 Mar 4. [Epub ahead of print]
We present a case of a female infant that was diagnosed on prenatal ultrasound with an oral mass, and subsequently underwent a planned EXIT procedure to secure the airway. Ultimately the epignathus teratoma was excised at 3 days of age. The number of cases in which neonates have survived epignathus teratomas has increased in the past decade due to improved prenatal imaging and the development of the EXIT procedure. This case demonstrates the importance of a multidisciplinary approach that must be established when a prenatal diagnosis raises concern for airway compromise, and the thorough work-up required for definitive management.
Pediatric ENT Associates, Children's Hospitals and Clinics of Minnesota-Minneapolis, Suite 450, 2530 Chicago Ave. S., Minneapolis, MN 55404, USA; Department of Otolaryngology, University of Minnesota, MMC 396 Mayo 8396, 420 Delaware St, Minneapolis, MN 55455, USA.
Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Use of intraoperative laryngeal electromyography to evaluate stridor in children with arthrogryposis.
Ann Otol Rhinol Laryngol. 2011 Mar;120(3):150-4.
OBJECTIVES: Arthrogryposis is a rare, congenital condition characterized by joint contractures of the extremities with muscle weakness and fibrosis. The otolaryngological manifestations of this disorder may include stridor, chronic aspiration, and Pierre Robin sequence, among others. Prior reports of vocal fold immobility associated with arthrogryposis have attributed it to recurrent laryngeal nerve paralysis, rather than to cricoarytenoid joint restriction. The objective of this study was to determine whether children with arthrogryposis and vocal fold immobility demonstrated laryngeal electromyography (L-EMG) findings consistent with recurrent laryngeal nerve paralysis or with cricoarytenoid joint restriction.
METHODS: A retrospective, institutional chart review of children with otolaryngological manifestations of arthrogryposis was performed; 6 children were identified. Three patients had vocal fold immobility documented by flexible laryngoscopy. These 3 children were prospectively evaluated with direct laryngoscopy and intraoperative L-EMG.
RESULTS: The 3 children with arthrogryposis and vocal fold dysfunction had laryngoscopy-confirmed vocal fold immobility or significant restriction of motion. The intraoperative L-EMG tracings obtained from all 3 patients demonstrated motor unit action potentials without evidence of denervation.
CONCLUSIONS: This series, albeit small, suggests that the vocal fold dysfunction related to arthrogryposis may be attributable to cricoarytenoid joint restriction or poor laryngeal coordination, rather than to nerve paralysis, as originally postulated.
Department of Otolaryngology, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts 02111, USA.
Airway interventions in children with Pierre Robin Sequence.
Otolaryngol Head Neck Surg. 2008 Jun;138(6):782-7.
OBJECTIVE: To describe the interventions required for successful airway management in children with Pierre Robin Sequence (PRS).
STUDY DESIGN: Case series.
SUBJECTS AND METHODS: The records of both a cleft and craniofacial clinic and a pediatric otolaryngology clinic were searched, and all children with PRS were identified. Data concerning feeding interventions, airway interventions, and comorbid conditions were extracted.
RESULTS: Seventy-four cases of PRS were identified. Thirty-eight of the 74 children required airway intervention other than prone positioning. Fourteen of these 38 were managed nonsurgically with nasopharyngeal airway and/or short-term endotracheal intubation, whereas the remaining 24 required surgical intervention. Eighteen of the 24 underwent distraction osteogenesis of the mandible, one underwent tracheostomy, and five underwent tracheostomy followed by eventual distraction.
CONCLUSION: In our series, over 50 percent of children with PRS required an airway intervention. These were both nonsurgical and surgical. As otolaryngologists, we must be prepared for the challenges children with PRS may present and the interventions that may be necessary to successfully manage these difficult airways.
Children's Hospitals and Clinics of Minnesota-Minneapolis, Minneapolis, MN 55455, USA. stri0106@umn.edu
Resolving feeding difficulties with early airway intervention in Pierre Robin Sequence.
Laryngoscope. 2008 Jan;118(1):120-3.
OBJECTIVES/HYPOTHESIS: To observe rates of gastrostomy tube (g-tube) placement in Pierre Robin Sequence (PRS) and to determine whether relieving airway obstruction solves feeding difficulties.
STUDY DESIGN: All PRS referrals to a multidisciplinary cleft team for children at a tertiary pediatric hospital from January 1988 to June 2006 were retrospectively reviewed.
METHODS: Patients were analyzed for occurrence of g-tube placement, neurologic disorders, and airway intervention including tracheotomy and mandibular distraction osteogenesis.
RESULTS: Sixty-seven PRS patients were divided into two categories: 51 (76.1%) isolated PRS (iPRS) and 16 (23.9%) with additional disorders and syndromes (sPRS). Patients were then placed into two subgroups: those who received early airway intervention and those who received late or no airway intervention. Of the 51 iPRS children, 12 (23.5%) received early airway intervention, none of whom required a g-tube. There were 39 (76.5%) children who received late or no airway intervention, and 5 (12.8%) of these required g-tube placement. Of the 16 sPRS children, 8 (50%) received early airway intervention, and 7 (87.5%) of these still required a g-tube. Of the remaining 8 (50%) sPRS patients who received late or no airway intervention, 5 (62.5%) required a g-tube.
CONCLUSION: In children with iPRS, feeding difficulties can be resolved with early airway intervention. Delaying airway intervention may necessitate feeding assistance because all of the iPRS children who required a g-tube fell into this category. The presence of additional disorders and syndromes further complicates treatment because most of the sPRS children required g-tubes regardless of airway intervention.
Georgetown University School of Medicine, Washington, D.C., U.S.A.
Tracheotomy and decannulation rates in a level 3 neonatal intensive care unit: a 12-year study.
Laryngoscope. 2006 Jan;116(1):136-9.
OBJECTIVE: The objective of this study was to determine the rates of tracheotomy tube placement and subsequent decannulation in all admissions to a single-site, tertiary newborn intensive care unit (NICU).
METHODS: Records from total admissions to a tertiary single-site NICU between January 1, 1991, and December 31, 2002, were retrospectively analyzed. Long-term medical follow-up for this cohort included data through September 1, 2003. All patients were analyzed for occurrence of tracheotomy tube placement and decannulation, airway procedures, and comorbidities.
RESULTS: There were 10,428 total NICU admissions during the 12-year study period. Seventy-eight (0.7%) of these patients underwent tracheotomy tube placement. Sixty-six of these 78 (85%) infants survived. None of the 12 deaths were related to tracheotomy tube placement. The most common indications for tracheotomy tube placement were subglottic stenosis (32%), chronic lung disease (28%), craniofacial abnormality (14%), chronic ventilator dependency (11%), and a neurologic disorder (8%). Decannulation was achieved in 41 of 66 (62%) survivors. Patients who failed decannulation had a major neurologic disorder, underlying pulmonary disorder, or both.
CONCLUSION: A baseline tracheotomy tube placement rate of 0.7% was observed in this single-site tertiary NICU setting. Decannulation was accomplished early in life in two thirds of the surviving infants. Those infants failing decannulation had either severe underlying pulmonary or neurologic disorders.
Childrens Hospital-Minneapolis, Minnesota, USA. sidma001@umn.edu
Mandibular distraction to relieve airway obstruction in children with cerebral palsy.
Arch Otolaryngol Head Neck Surg. 2004 Jun;130(6):741-5.
OBJECTIVE: To determine the effectiveness of distraction osteogenesis of the mandible for relief of airway obstruction in neurologically impaired children.
DESIGN: Prospective pilot study.
SETTING: Tertiary care children's hospital.
PATIENTS: Five children with upper airway obstruction secondary to hypotonia were identified by airway endoscopy, pulse oximetry, and polysomnography. Four children were tracheotomy-dependent because of upper airway obstruction, and 1 was being considered for tracheotomy because of progressive airway obstruction.
INTERVENTIONS: All patients underwent distraction osteogenesis of the mandible for relief of their airway obstruction.
MAIN OUTCOME MEASURES: Treatment success was determined by endoscopy, continuous pulse oximetry, and polysomnography.
RESULTS: Four of the 5 children underwent distraction osteogenesis of the mandible with successful resolution of airway obstruction or tracheotomy decannulation. One child did not show adequate improvement of upper airway obstruction and remained tracheotomy-dependent. Follow-up was 2 to 40 months.
CONCLUSIONS: Children with cerebral palsy and hypotonia of the upper airway may achieve relief of their chronic airway obstruction following distraction osteogenesis of the mandible. Appropriate selection criteria must be adhered to, including demonstration of tongue base obstruction on flexible laryngoscopy.
Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minn, USA
Spontaneous tracheal and subglottic tears in neonates.
Laryngoscope. 2002 Aug;112(8 Pt 1):1387-93.
OBJECTIVES/HYPOTHESIS: Spontaneous rupture of the trachea or subglottis as a complication of difficult delivery has not been reported in the United States literature. There have been a few cases reported in the European literature. The present report describes a series of newborns with this complication and discusses the signs and treatment options of this difficult, life-threatening problem.
STUDY DESIGN: Retrospective review.
METHODS: Newborns born between 1996 and 2001 who were treated for spontaneous subglottic or tracheal rupture at a tertiary care children's hospital neonatal intensive care unit were reviewed.
RESULTS: Four cases of spontaneous subglottic rupture were seen at the hospital. In three of the four cases the tracheas were intubated on an emergency basis after subcutaneous air was noted in the anterior aspect of the neck. In the fourth patient the trachea was not intubated until the subglottic tear was visualized intraoperatively. Two of the four patients died. One died without securing of an airway; the other died of complications of prolonged hypoxia. Eight cases from European literature of spontaneous neonatal subglottic and tracheal tears are reviewed and are compared with the cases presented in the current report.
CONCLUSIONS: Early detection of airway rupture by flexible endoscopy is essential for timely diagnosis and appropriate treatment. Standard endotracheal intubation can exacerbate the problem and should be deferred if possible until direct airway visualization can be accomplished. Signs associated with tracheal tears include subcutaneous emphysema, respiratory distress, pneumothorax, and pneumomediastinum. These should lead to emergent consultation with otolaryngologists for examination and securing of the airway.
Children's Hospital-Minneapolis and the Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, USA.
Distraction osteogenesis of the mandible for airway obstruction in children.
Laryngoscope. 2001 Jul;111(7):1137-46.
OBJECTIVES: Objectives of the study were to determine the effectiveness of distraction osteogenesis of the mandible to relieve airway obstruction in children with tongue-base airway obstruction and to describe the new surgical techniques developed for use in infants and young children.
STUDY DESIGN: Prospective, nonrandomized study.
METHODS: Analysis of 11 children with severe airway obstruction secondary to tongue-base obstruction was performed. Patients were between 2 weeks and 5.5 years of age. All patients underwent distraction osteogenesis of the mandible.
RESULTS: Twelve distraction procedures in the 11 children in the study were accomplished; decannulation or extubation was successful in all children.
CONCLUSION: Distraction osteogenesis of the mandible can be used to treat tongue-base airway obstruction in appropriately selected children.
Pediatric Ear, Nose and Throat Associates, Minneapolis, Minnesota 55404, USA.
Management of acute pulmonary hemorrhage in children.
Laryngoscope. 2001 Jan;111(1):33-5.
OBJECTIVE: Acute pulmonary hemorrhage can result from a variety of causes. This report offers a diagnosis and treatment plan for children with acute, life-threatening pulmonary hemorrhage resulting from a variety of causes.
METHODS: Retrospective review of children with acute pulmonary hemorrhage cared for at a tertiary care children's hospital during from January 1, 1993 to September 1, 1999.
PATIENTS: Fourteen children were identified with life-threatening pulmonary hemorrhage during the study period.
INTERVENTIONS: Bronchoscopy was the keystone to diagnosis of pulmonary hemorrhage in this series. All of the children underwent multiple procedures to stabilize the airway and control blood loss. These interventions included CO2 laser bronchoscopy, Nd-YAG laser bronchoscopy, endoscopic balloon occlusion of a lobe or main bronchus, topical airway vasoconstrictors, endoscopic tumor excision, transcatheter embolization of bronchial vessels, and lobectomy. OUTCOMES: Three children died and 11 survived without neurological sequelae.
CONCLUSIONS: Control of acute pulmonary hemorrhage is a difficult problem and often requires multiple procedures. Endoscopic control is usually required for palliation until more definitive therapy can be undertaken.
Pediatric ENT Associates, Minneapolis, Minnesota, USA. sidma001@umn.edu
The child with a tracheotomy. A review of the surgical options in airway reconstruction.
N C Med J. 1990 Oct;51(10):507-10.
Division of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7070.
Effects of cleft lip and palate on the nasal airway in children.
Arch Otolaryngol Head Neck Surg. 1988 Sep;114(9):987-92.
Comment in Arch Otolaryngol Head Neck Surg. 1989 Jun;115(6):750-1.
Clefts of the lip and palate often produce significant nasal deformities and reduced nasal airway size. The purpose of this study was to assess how type of cleft affects nasal cross-sectional area and mode of breathing. The pressure-flow technique was used to estimate nasal airway size and modified inductive plethysmography was used to determine percent of nasal breathing in 60 children with cleft lip and palate aged 6 to 15 years. Ninety-five normal children served as controls. The data demonstrate that nasal size decreased among cleft types as follows: children with bilateral cleft lip and palate had largest airway, followed by unilateral cleft lip, cleft of the hard and soft palate, cleft of the soft palate, and unilateral cleft lip and palate. The data also indicated that most subjects with cleft were mouth breathers. Results of otolaryngologic examinations suggest that septal deformities affecting nasal valve function are responsible for much of the impairment, especially in the group with unilateral cleft lip and palate. The differences among groups appear to relate to developmental differences associated with the original defect and the surgical procedures used in primary repair.
Department of Dental Ecology, School of Dentistry, University of North Carolina, Chapel Hill 27599-7455.
Surgical management of distal tracheal stenosis in children.
Laryngoscope. 2011 Dec;121(12):2665-71. doi: 10.1002/lary.22355.
OBJECTIVES/HYPOTHESIS: The objective of this study was to describe the long-term outcomes of tracheoplasty for distal tracheal stenosis, demonstrate the utility of cardiopulmonary bypass for intraoperative airway management, and compare perioperative morbidity and mortality of slide tracheoplasty for distal tracheal stenosis to costochondral graft, and resection with end-to-end anastomosis.
STUDY DESIGN: Retrospective chart review.
METHODS: A retrospective chart review of all patients undergoing tracheoplasty for distal obstruction and also requiring the use of cardiopulmonary bypass for intraoperative airway management from 1994 to 2009 was performed. The setting for the study was a tertiary care children's hospital.
RESULTS: A total of 11 patients, aged 1 month to 12 years, were identified. Four patients underwent slide tracheoplasty, two had end-to-end anastomosis, and five had costochondral graft. Average cardiopulmonary bypass time was 120 minutes, 60 minutes, and 63 minutes, respectively. The only complication of cardiopulmonary bypass was a superficial wound infection. There was one late death due to airway obstruction after repair of severe cardiac anomalies. The numbers of bronchoscopies required for resolution of granulation tissue in the slide tracheoplasty and end-to-end anastomosis groups were less than for the cartilage graft group. Three patients in the cartilage graft group required tracheostomy, and one remained tracheostomy dependent at last follow-up. None in the slide tracheoplasty or end-to-end anastomosis groups required a tracheostomy during management.
CONCLUSIONS: Improvements in operative techniques and perioperative management have led to significant decreases in morbidity and mortality. At our institution, slide tracheoplasty has become the preferred technique for all except very short segment stenosis, and cardiopulmonary bypass is used in all cases involving the distal trachea.
Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA. dvalenci@umn.edu
Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.
Gefitinib therapy for life-threatening laryngeal papillomatosis.
Arch Otolaryngol Head Neck Surg. 2005 Jan;131(1):64-7.
Division of Pediatric Hematology Oncology, Children's Hospitals and Clinics, Minneapolis, MN 55455, USA. Bruce.Bostrom@childrensmn.org
Mandibular distraction osteogenesis to relieve Pierre Robin airway obstruction.
Am J Otolaryngol. 2006 Nov-Dec;27(6):436-9.
Children with Pierre Robin sequence can present challenging airway management issues. We describe a neonate with a life-threatening airway obstruction secondary to severe micrognathia and glossoptosis. When the patient was 9 days old, bilateral distraction osteogenesis was performed to lengthen the mandible by 17 mm. The patient was subsequently extubated without further airway or swallowing difficulties.
Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN 55905, USA.
Apnea spells in an infant with vallecular cyst.
Ann Otol Rhinol Laryngol. 2003 Sep;112(9 Pt 1):821-4.
Comment in Ann Otol Rhinol Laryngol. 2004 Sep;113(9):765.
Dept of Otorhinolaryngology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
Tracheopathia osteoplastica: effective long-term management.
Otolaryngol Head Neck Surg. 2003 Sep;129(3):303-4.
Department of Otorhinolaryngology, Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
Cleft & Craniofacial
Pierre robin sequence: evaluation, management, indications for surgery, and pitfalls.
Otolaryngol Clin North Am. 2012 Jun;45(3):695-710.
This article reviews the various treatment methods for airway obstruction and feeding difficulty in infants with Pierre Robin Sequence (PRS), and highlights the benefits and limitations of early mandibular distraction osteogenesis in particular as a way of managing both airway obstruction and feeding difficulty in these children.
Department of Otolaryngology - Head & Neck Surgery, Floating Hospital for Children - Tufts Medical Center, Tufts University School of Medicine, Box 850, 800 Washington Street, Boston, MA 02111, USA.
Airway management for intubation in newborns with pierre robin sequence.
Laryngoscope. 2012 Jun;122(6):1401-4. doi: 10.1002/lary.23260. Epub 2012 Mar 27.
OBJECTIVES/HYPOTHESIS:
To review airway management in Pierre Robin sequence (PRS) newborns undergoing general anesthesia and to determine if endotracheal intubation is safe in this population.
STUDY DESIGN:
Case series and retrospective chart review at a tertiary children's hospital.
METHODS:
PRS newborns who underwent endotracheal intubation or other airway intervention before 3 months of age between January 2000 and July 2011 were identified from a pediatric otolaryngology practice database. Indications for airway intervention, anesthetic management, method of intubation, and comorbid conditions were collected.
RESULTS:
Thirty-three PRS newborns were identified. Twenty had isolated PRS, and 13 had PRS related to a coexisting syndrome. Thirteen of 35 (37%) endotracheal intubations performed in PRS newborns prior to mandibular distraction osteogenesis were accomplished with direct laryngoscopy. The remaining 22 of 35 (63%) who failed intubation with direct laryngoscopy were intubated over a flexible fiberoptic bronchoscope. No significant difference was observed between the isolated and syndromic PRS newborns with regard to technique utilized for intubation. No patient required rescue laryngeal mask airway or emergent tracheotomy, and no case resulted in death.
CONCLUSIONS:
This series demonstrates that endotracheal intubation is safe and effective in PRS newborns. In patients who failed intubation with direct laryngoscopy, intubation over a flexible fiberoptic bronchoscope provided a reliable alternative method. Although airway management in PRS newborns poses a significant challenge, experienced otolaryngologists and anesthesiologists can successfully manage these difficult airway cases.
Children's Hospitals and Clinics of Minnesota, Pediatric ENT Associates, Minneapolis, Minnesota, USA.; Medical School, University of Minnesota , Minneapolis, Minnesota, U.S.A.
Prevalence of positional plagiocephaly in teens born after the "back to sleep" campaign.
Otolaryngol Head Neck Surg. 2012 Jan 12. [Epub ahead of print]
OBJECTIVES: To determine the prevalence of positional plagiocephaly and brachycephaly in teenagers born after the "Back to Sleep" campaign but before orthotic helmet treatment became widely available and to provide long-term outcomes data on those children with plagiocephaly who were not treated with remolding therapy.
STUDY DESIGN: Cross-sectional analysis.Setting. Local high schools in the Minneapolis-St Paul Metro area.
SUBJECTS AND METHODS: Subjects were selected if they attended participating high schools and were born after the Back to Sleep campaign began. Skull measurements, including transcranial diameter, length, and width, were taken. Overall facial appearance was inspected for any apparent abnormal characteristics. Cranial vault asymmetry and cephalic index were calculated for each participant. Plagiocephaly was diagnosed if cranial vault asymmetry was >1 cm. Brachycephaly was diagnosed if the cephalic index was >0.90.
RESULTS: There were 1045 participants, ranging from 12 to 17 years old, with an average age of 15.7 years. The prevalence of plagiocephaly was 1.1%. The prevalence of brachycephaly was 1.0%. The overall prevalence of a deformational cranial abnormality was 2.0%. Of those who met diagnostic criteria of plagiocephaly or brachycephaly, 38.1% were noted to have abnormal facial characteristics.
CONCLUSIONS: The prevalence of plagiocephaly and brachycephaly in teenagers is significantly lower than the 20% to 48% prevalence found in infants in previous studies, suggesting most children will outgrow the condition without intervention. Additional studies are needed to determine which patients might benefit from treatment and which will likely have resolution without intervention, since treating all infants who meet criteria results in significant overtreatment.
Children's Hospitals and Clinics of Minnesota, Pediatric ENT Associates, Minneapolis, Minnesota, USA.
Mandibular distraction osteogenesis in infants younger than 3 months.
Arch Facial Plast Surg. 2011 May-Jun;13(3):173-9. Epub 2011 Jan 17.
OBJECTIVES: To examine the long-term outcomes and complications in infants with upper airway obstruction and feeding difficulty who underwent bilateral mandibular distraction osteogenesis (MDO) within the first 3 months of life and to identify any preoperative characteristics that may predict the long-term outcome following early MDO intervention for airway obstruction.
METHODS: An institutional, retrospective medical chart review was performed. Inclusion criteria were bilateral MDO performed at an age younger than 3 months, with a minimum follow-up of 3 years. A quantitative outcome measures scale was developed, and patients were scored based on long-term postoperative complications as well as airway and feeding goals. Factors such as need for an additional surgical procedure were also considered.
RESULTS: Nineteen children were identified as having undergone MDO before 3 months of age and having more than 3 years of follow-up data. The mean age at distraction was 4.8 weeks (range, 5 days-12 weeks); the mean length of follow-up was 5.6 years (range, 37-122 months). Of these 19 patients, 14 had isolated Pierre Robin sequence (PRS) and 5 had syndromic PRS. All patients with isolated PRS had a good or intermediate long-term result. Infants with comorbidities such as developmental delay, seizures, or arthrogryposis had the poorest outcomes.
CONCLUSIONS: Bilateral MDO is a relatively safe and effective means of treating airway obstruction and feeding difficulty in infants with PRS. The effects of this procedure, which carries a relatively low morbidity, persist through early childhood in most patients.
Department of Otolaryngology-Head & Neck Surgery, Tufts University School of Medicine, PO Box 850, 800 Washington St, Boston, MA 02111, USA. ascott@tuftsmedicalcenter.org
Rates and risks of gastrostomy tubes in infants with cleft palate.
Arch Otolaryngol Head Neck Surg. 2011 Mar;137(3):275-81.
OBJECTIVES: To review data on a cohort of infants with cleft palate to (1) determine rates of gastrostomy (G)-tube placement, (2) identify contributing comorbidities, and (3) use relative risk analyses to improve management of cleft palate in infants with feeding difficulty.
DESIGN: Retrospective medical record review.
SETTING: Tertiary care children's hospital.
PATIENTS: Infants with cleft palate born between January 1, 2000, and December 31, 2008, without G-tubes prior to referral were included. Comorbidities were analyzed, including syndromes and chromosomopathies (syn/chrom) and cardiac, respiratory, neurologic, and gastrointestinal diagnoses. These comorbidities were analyzed independently. MAIN OUTCOME MEASURE: Gastrostomy-tube placement.
RESULTS: Of 214 infants with cleft palate, 34 required G-tubes. Of these, 19 had syn/chrom. Independent of these diagnoses, 17 infants had 1 system comorbidity and 12 had multisystem comorbidities. Of the 180 patients without G-tubes, 20 had syn/chrom. Independent of these diagnoses, 10 infants had 1 system comorbidity and 2 had multisystem comorbidities. Rates of G-tube placement ranged from 3% in infants without any comorbidity to 94% in infants with respiratory comorbidity. Relative risks of G-tube placement with syn/chrom, 1 system comorbidity, and multisystem comorbidities were 5.68 (95% confidence interval, 3.18-10.16), 21.79 (8.76-54.17), and 29.66 (12.18-72.21), respectively.
CONCLUSIONS: Diagnosis of syn/chrom or major comorbidity significantly increases risk of G-tube placement. Regardless of syn/chrom association, problems affecting the heart, respiratory system, central nervous system, and lower esophageal sphincter are the most significant risk factors, implying that particular comorbidities are more influential than a simple diagnosis of syn/chrom. These data should help identify children at greatest risk for G-tubes and those expected to overcome feeding difficulties, leading to more persistent use of nonsurgical therapy before resorting to G-tubes.
Department of Otolaryngology, Children's Hospitals and Clinics of Minnesota and University of Minnesota, Minneapolis, MN, USA.
A theoretical cause of nasal obstruction in patients with repaired cleft palate.
Am J Rhinol Allergy. 2011 Jan-Feb;25(1):58-60.
BACKGROUND: During cleft palate repair, mucoperiosteal flaps are elevated from the palatal shelves and the nasal septum to accomplish tension-free closure of the nasal floor. This study was designed to geometrically describe how palate repair inherently limits airflow by decreasing nasal cavity cross-sectional area and increasing nasal airflow resistance. In addition, this study investigates whether the width of the repaired cleft palate directly affects the degree of postoperative airflow resistance.
METHODS: A simplified geometric model of normal nasal cavity anatomy was compared with an equivalent schematic representing an individual with an unrepaired palatal cleft. Mathematical equations approximating the cross-sectional areas of normal and cleft nasal cavities were created. The theoretical postoperative loss of nasal cavity cross-sectional area was then considered for both unilateral and bilateral palatal clefts.
RESULTS: According to this geometric model, the cross-sectional area of the nasal cavity is decreased in patients who undergo cleft repair. Repaired bilateral clefts experience a greater area loss than their unilateral counterparts.
CONCLUSION: Nasal cavity resistance is higher in patients who have undergone cleft repair than in individuals who have not undergone cleft repair. because tension-free closure of the nasal floor inherently reduces cross-sectional breathing area. The wider the cleft, the higher the resistance to nasal airflow postoperatively. This iatrogenic source of nasal resistance is likely additive to other anatomic contributors to airflow resistance observed in individuals with cleft nasal deformities.
Department of Otolaryngology, Floating Hospital for Children-Tufts Medical Center, Boston, Massachusetts, USA.
Distraction osteogenesis of the mandible for airway obstruction in children: long-term results.
Otolaryngol Head Neck Surg. 2010 Jul;143(1):90-6. Epub 2010 May 21.
OBJECTIVE: To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia.
STUDY DESIGN: Case series with chart review.
SETTING: Tertiary care children's hospital.
SUBJECTS AND METHODS: The records of a pediatric otolaryngology practice and tertiary children's hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified.
RESULTS: Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure.
CONCLUSION: Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.
Pediatric ENT Associates, Children's Hospitals and Clinics of Minnesota-Minneapolis, Suite 450, 2530 Chicago Ave. S., Minneapolis, MN 55404, USA. btibesar@pedsent.com
Hoarseness in children with cleft palate.
Otolaryngol Head Neck Surg. 2009 Jun;140(6):902-6. Epub 2009 Mar 9.
OBJECTIVE: Determine the rate of hoarseness in children with cleft palate (CP). Understand the relationship between velopharyngeal insufficiency (VPI) and hoarseness in children with CP.
STUDY DESIGN: Case series with chart review.
SUBJECTS AND METHODS: Retrospective chart review of 185 patients with CP treated by a Children's Hospital Cleft Team and born between 1991 and 2001.
RESULTS: Of total patients, 54.1 percent were male and 45.9 percent female. All types of CP were represented. The overall rate of hoarseness was 20.0 percent at age 3-4 and 18.4 percent at age 6-7. The presence of VPI did not correlate with the presence of hoarseness or dysphonia. VPI decreased when comparing age 3-4 (58.4%) with age 6-7 (30.2%, P < 0.001), but the hoarseness rates did not change, 20.8 percent at age 3-4 and 19.5 percent at age 6-7 (P = 0.56).
CONCLUSION: Patients with CP are thought to have increased risk of voice disturbances due to compensatory articulation mechanisms used when a patient has VPI. However, this study of 185 patients with CP showed no relationship between VPI and hoarseness. The overall rate of hoarseness of this population with CP was within the reported range for the normal population of children. These findings suggest that the theory that VPI causes hoarseness due to compensatory speech mechanisms may be incorrect.
Children's Hospitals and Clinics of Minnesota, Minneapolis location, Minneapolis, MN, USA. koep0072@umn.edu
Mandibular distraction osteogenesis in the pediatric patient.
Curr Opin Otolaryngol Head Neck Surg. 2008 Dec;16(6):548-54.
PURPOSE OF REVIEW: To provide a concise review of recent advances in mandibular distraction osteogenesis as it applies to the field of pediatric otolaryngology.
RECENT FINDINGS: The successful use of mandibular distraction osteogenesis is becoming well established in the literature. Large case series with long-term follow-up are lending strong evidence in support of mandibular distraction osteogenesis in the management of airway obstruction and craniofacial deformities resulting from mandibular deficiency. These recent publications offer refinements in patient selection as well as expanding indications for this surgical intervention. At the same time, an emphasis on reduction of complications and better patient compliance has led to a search for improved device technology. Additionally, there has been an increased interest in understanding of the basic science of distraction osteogenesis at a molecular level. Numerous researchers are investigating the cellular mechanisms involved in distraction osteogenesis bone healing and are attempting to manipulate these factors to improve patient outcomes. SUMMARY: The field of pediatric distraction osteogenesis continues to advance with active research and study. As clinical experience increases, new models of device design and molecular manipulation have emerged on the scene, promising improved patient outcomes and fewer complications.
Pediatric ENT Association, Minneapolis, Minnesota 55404, USA. btibesar@pedsent.com
Distraction osteogenesis of the mandible.
Curr Opin Otolaryngol Head Neck Surg. 2004 Dec;12(6):513-8.
PURPOSE OF REVIEW: Airway obstruction and craniofacial deformities resulting from mandibular deficiency are challenging and complex clinical problems. Mandibular distraction osteogenesis is playing a rapidly expanding role in the treatment of these children and has supplanted traditional management techniques in many centers. Several recent studies have reviewed clinical experience, described technical refinements, and addressed issues in patient selection and preoperative workup.
RECENT FINDINGS: The extension of mandibular distraction osteogenesis to newborns with Pierre Robin sequence or craniofacial syndromes associated with micrognathia and airway obstruction has radically altered treatment protocols at several institutions. Early bilateral mandibular distraction has obviated tracheostomy in most newborns, with low operative morbidity. In addition, early decannulation and resolution of obstruction has occurred when mandibular distraction osteogenesis was applied to selected micrognathic children. Some of these patients were tracheotomized and others presented with severe obstructive symptoms. Studies have described success with external and internal distraction techniques. Recent publications have also demonstrated the surgeon's ability to mold the regenerate safely, the dynamic characteristics of the consolidation phase, and success with secondary and tertiary distraction. SUMMARY: After 15 years of clinical use in children for craniofacial deformities, recent advances in distraction osteogenesis have obviated tracheostomy in most newborns with micrognathia and severe airway obstruction. Applications of this technique to children with airway issues related to micrognathia or retrognathia have been rapidly expanding. In addition, refinements in distraction technique have advanced treatment of nonairway-related mandibular deformities.
The Cleveland Clinic Foundation Head and Neck Institute, Division of Facial Aesthetic and Reconstructive Surgery, Cleveland, Ohio 44195, USA. Mnmfritz@aol.com
Osteogenic distraction in the face.
Facial Plast Surg Clin North Am. 2002 May;10(2):181-90.
University of Southern California, Children's Hospital of Los Angeles, Division of Otolaryngology, 4650 Sunset Boulevard, Box 58, Los Angeles, CA 90027, USA.
Results of cleft palate repair with the double-reverse Z-plasty performed by residents.
Otolaryngol Head Neck Surg. 1994 Jul;111(1):76-80.
The double-reverse Z-plasty (Furlow) repair of soft palate clefts has the advantages of lengthening the soft palate while reconstructing the palatal muscle sling to optimize velopharyngeal function. Because soft tissue from the hard palate is not mobilized to lengthen the soft palate, this technique has an additional theoretic advantage of minimizing disturbances of maxillofacial growth. Cited disadvantages of the technique include increased technical difficulty and operating time compared with other procedures. We performed a retrospective study of 20 consecutive Furlow repairs of the soft palate performed by residents under supervision of one attending surgeon between 1989 and 1992. All children had complete cleft of the soft palate; 14 had incomplete cleft and six had complete cleft of the hard palate, which were repaired by a modified Von Langenbeck technique or with vomer flaps. Mean age of patients was 15 months, and mean operating time (including placement of pressure-equalizing tubes) was 162 minutes, with an average estimated blood loss of less than 25 ml. Average time until adequate oral intake was achieved was 1.7 days, and duration of hospitalization averaged 2.4 days. Immediate postoperative complications included transient tongue edema in one patient and atelectasis and pneumonia in one patient with multiple congenital anomalies. Delayed postoperative complications included symptoms of sleep apnea in four patients, which subsequently improved after tonsillectomy and/or superior adenoidectomy. Fistulas occurred in two patients (10%), which compares favorably with published results of other techniques. Preliminary functional evaluations reveal that all repairs appear to have adequate length and good mobility; speech evaluations are in progress.(ABSTRACT TRUNCATED AT 250 WORDS)
Department of Surgery, University of Connecticut Health Center, Farmington.
Triangular flap repair of the unilateral complete cleft lip.
Facial Plast Surg. 1993 Jul;9(3):184-7.
Minneapolis Ear, Nose and Throat Clinic, Minnesota 55404.
Effects of cleft lip and palate on the nasal airway in children.
Arch Otolaryngol Head Neck Surg. 1988 Sep;114(9):987-92.
Comment in Arch Otolaryngol Head Neck Surg. 1989 Jun;115(6):750-1.
Clefts of the lip and palate often produce significant nasal deformities and reduced nasal airway size. The purpose of this study was to assess how type of cleft affects nasal cross-sectional area and mode of breathing. The pressure-flow technique was used to estimate nasal airway size and modified inductive plethysmography was used to determine percent of nasal breathing in 60 children with cleft lip and palate aged 6 to 15 years. Ninety-five normal children served as controls. The data demonstrate that nasal size decreased among cleft types as follows: children with bilateral cleft lip and palate had largest airway, followed by unilateral cleft lip, cleft of the hard and soft palate, cleft of the soft palate, and unilateral cleft lip and palate. The data also indicated that most subjects with cleft were mouth breathers. Results of otolaryngologic examinations suggest that septal deformities affecting nasal valve function are responsible for much of the impairment, especially in the group with unilateral cleft lip and palate. The differences among groups appear to relate to developmental differences associated with the original defect and the surgical procedures used in primary repair.
Department of Dental Ecology, School of Dentistry, University of North Carolina, Chapel Hill 27599-7455.
Conscious sedation in pediatric speech endoscopy.
Int J Pediatr Otorhinolaryngol. 2009 Dec;73(12):1686-90. Epub 2009 Sep 20.
OBJECTIVE: Speech nasoendoscopy is one of the gold standards for evaluating velopharyngeal insufficiency. The vast majority of pediatric patients are able to tolerate this procedure within the clinic under local anesthetic. However, a select group of pediatric patients is unable to cooperate with the examination. Conscious sedation is commonly used in pediatrics to aid in patient tolerance and cooperating with selected procedures. Conscious sedation has never been reported in the literature for use in speech endoscopy. The purpose of this study is to describe a technique for performing sedated speech endoscopy and to review our experience with sedated speech endoscopy in a selected group of patients who were unable to cooperate with examination under local anesthesia alone.
METHODS: A retrospective chart review was performed of pediatric patients between the ages of 2 and 15 who underwent conscious sedation for the speech nasoendoscopy. All examinations were performed at a tertiary care pediatric hospital. Sedation agent, tolerance of procedure, success of procedure, and complications associated with the procedure were recorded.
RESULTS: Fifty-seven sedated speech endoscopies were evaluated. Adequate examinations were obtained in 93% of patients overall and 100% of the patients evaluated while sedated with nitrous oxide. Complication rates and post-endoscopy speech management are reported.
CONCLUSIONS: Sedated speech endoscopy is a promising modality for evaluating velopharyngeal insufficiency in the pediatric population that may not otherwise be able to cooperate with examination in the clinic.
Department of Otolaryngology, University of Minnesota, Children's Hospitals and Clinics of Minnesota, United States.
Distraction osteogenesis for cleft palate closure in a canine model.
Arch Facial Plast Surg. 2005 Nov-Dec;7(6):398-404.
Comment in Arch Facial Plast Surg. 2005 Nov-Dec;7(6):405.
OBJECTIVE: To assess the utility of distraction osteogenesis (DO) when applied to closure of a hard palate cleft in dogs.
METHODS: A midline hard palate cleft was created in 10 mature dogs. Two were controls and had no distraction; the other 8 dogs underwent osteotomies with installation of customized DO devices to the hard palate. After a 10-day latency, distraction commenced at 1 mm/d. After a 14-day consolidation period, the device was removed and the mucosa closed. Each dog was injected with fluorochrome labels and serially killed at 2-week intervals. Bone healing was analyzed further with traditional histologic analysis and fluorochrome labeling.
RESULTS: No serious complications occurred. Bone resorption and cleft widening occurred in both control dogs. Complete bone closure of the hard palate cleft was achieved with DO in 5 of 8 experimental dogs. Three experimental dogs had bone resorption and incomplete palatal closure.
CONCLUSIONS: The application of DO techniques in closure of a hard palate cleft in a canine model is safe and well tolerated. Furthermore, in some cases, it proved effective in achieving bony closure of the cleft. Further investigation is warranted into innovative use of DO in treating children born with cleft palate.
Department of Otorhinolaryngology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
Complications and satisfaction with pediatric osseointegrated external ear prostheses.
Laryngoscope. 2009 Jul;119(7):1270-3.
OBJECTIVES: To determine the complication rate and the patient satisfaction of titanium osseointegrated ear implants for congenital microtia and anotia. To discuss external ear prostheses as a treatment option for children with microtia.
STUDY DESIGN: Retrospective chart review of patient records from a tertiary pediatric otolaryngology practice.
METHODS: The charts were reviewed for all pediatric patients who had undergone titanium implants for attachment of auricular prostheses from 2000-2006. Data collected included demographic information, congenital syndrome, number and size of screws placed, occurrence of skin reactions, presence of other complications, and length of time patients wore the prosthetic ear.
RESULTS: Eight patients, nine ears, were implanted. Median age was 7 years old. 6/8 had oculoauriculovertebral (OAV) syndrome, and 2 had isolated microtia. All titanium screws achieved complete osseointegration, and no implants have failed. 5/27 (18%) of the screws contacted dura, but no patients exhibited CSF leak, meningitis, or other central complications. 3/9 ears developed skin complications at the abutment sites, and 1/9 required revision soft tissue surgery. All the patients without current skin complications wear their prosthesis full time during waking hours.
CONCLUSIONS: Titanium osseointegrated ear prosthesis is a safe and useful procedure for children with microtia. It should be presented as an option for these patients, with low complication rates and high acceptance rates by the patients.
Children's Hospitals and Clinics of Minnesota, University of Minnesota, Department of Otolaryngology, Head and Neck Surgery, Minneapolis, Minnesota 55455, USA. koep0072@umn.edu
Education
Psychomotor skills training in pediatric airway endoscopy simulation.
Otolaryngol Head Neck Surg. 2011 Jul;145(1):43-50.
OBJECTIVE: To develop a robust psychomotor skills curriculum to teach pediatric airway foreign body retrieval and to assess the effect of this curriculum on residents' confidence in and ability to perform the complete task in an infant airway mannequin.
STUDY DESIGN: Instructional course. Objective Structured Assessment of Technical Skills (OSATS).
SETTING: Surgical simulation laboratory.
SUBJECTS AND METHODS: A half-day simulation-based course was developed to train otolaryngology residents in bronchoscopic foreign body retrieval. This complex psychomotor skill was deconstructed into subtasks. The following curricular learning objectives were presented and assessed: understanding of tracheobronchial anatomy, ability to adequately visualize the larynx with laryngoscopy, proficiency in rigid bronchoscopy, and familiarity with foreign body instrumentation. Residents were objectively evaluated on their ability to perform the complete task on a simulator before and after the course using an OSATS grading system. Confidence in successfully assembling the instruments and completing the task was assessed at these time periods.
RESULTS: Seventeen otolaryngology residents completed the study. Confidence in assembling the instruments and in performing the complete task increased on average by 81% and 43%, respectively (P < .001). Using a 15-point OSATS grading system, the average score for the precourse was 7 and for the postcourse was 11.3 (P < .001).
CONCLUSION: Simulation-based subtask training shows promise as an effective and reproducible method to teach the complex psychomotor task of airway foreign body retrieval. Completion of the curriculum led to a significant improvement in residents' confidence in and ability to perform bronchoscopic foreign body retrieval in an infant airway mannequin.
Department of Otolaryngology--Head & Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA. jabb0005@umn.edu
Assessing instrument handling and operative consequences simultaneously: a simple method for creating synced multicamera videos for endosurgical or microsurgical skills assessments.
Simul Healthc. 2011 Oct;6(5):299-303.
INTRODUCTION: There has been an increasing interest in assessment of technical skills in most medical and surgical disciplines. Many of these assessments involve microscopy or endoscopy and are thus amenable to video recording for post hoc review. An ideal skills assessment video would provide the reviewer with a simultaneous view of the examinee's instrument handling and the operative field. Ideally, a reviewer should be blinded to the identity of the examinee and whether the assessment was performed as a pretest or posttest examination, when given in conjunction with an educational intervention.
METHODS: We describe a simple method for reliably creating deidentified, multicamera, time-synced videos, which may be used in technical skills assessments. We pilot tested this method in a pediatric airway endoscopy Objective Assessment of Technical Skills (OSATS). Total video length was compared with the OSATS administration time.
RESULTS: Thirty-nine OSATS were administered. There were no errors encountered in time-syncing the videos using this method. Mean duration of OSATS videos was 11 minutes and 20 seconds, which was significantly less than the time needed for an expert to be present at the administration of each 30-minute OSATS (P < 0.001).
CONCLUSIONS: The described method for creating time-synced, multicamera skills assessment videos is reliable and may be used in endosurgical or microsurgical skills assessments. Compared with live review, post hoc video review using this method can save valuable expert reviewer time. Most importantly, this method allows a reviewer to simultaneously evaluate an examinee's instrument handling and the operative field while being blinded to the examinee's identity and timing of examination administration.
Otolaryngology Department, University of Minnesota, Minneapolis, MN 55455, USA. jabb0005@umn.edu
Voice
Hoarseness in children with cleft palate.
Otolaryngol Head Neck Surg. 2009 Jun;140(6):902-6. Epub 2009 Mar 9.
OBJECTIVE: Determine the rate of hoarseness in children with cleft palate (CP). Understand the relationship between velopharyngeal insufficiency (VPI) and hoarseness in children with CP.
STUDY DESIGN: Case series with chart review.
SUBJECTS AND METHODS: Retrospective chart review of 185 patients with CP treated by a Children's Hospital Cleft Team and born between 1991 and 2001.
RESULTS: Of total patients, 54.1 percent were male and 45.9 percent female. All types of CP were represented. The overall rate of hoarseness was 20.0 percent at age 3-4 and 18.4 percent at age 6-7. The presence of VPI did not correlate with the presence of hoarseness or dysphonia. VPI decreased when comparing age 3-4 (58.4%) with age 6-7 (30.2%, P < 0.001), but the hoarseness rates did not change, 20.8 percent at age 3-4 and 19.5 percent at age 6-7 (P = 0.56).
CONCLUSION: Patients with CP are thought to have increased risk of voice disturbances due to compensatory articulation mechanisms used when a patient has VPI. However, this study of 185 patients with CP showed no relationship between VPI and hoarseness. The overall rate of hoarseness of this population with CP was within the reported range for the normal population of children. These findings suggest that the theory that VPI causes hoarseness due to compensatory speech mechanisms may be incorrect.
Children's Hospitals and Clinics of Minnesota, Minneapolis location, Minneapolis, MN, USA. koep0072@umn.edu
General
Symptom duration and CT findings in pediatric deep neck infection.
Otolaryngol Head Neck Surg. 2009 Feb;140(2):183-6.
OBJECTIVE: To investigate whether children with less than 48 hours of localized symptoms of deep neck infection are less likely to have an abscess on CT scan.
STUDY DESIGN: Case series.
SUBJECTS AND METHODS: The charts of children seen in a tertiary children's hospital for deep neck infections between 2000 and 2007 were reviewed.
RESULTS: Of 179 children identified, 167 (93.3%) underwent a CT scan of the neck of which 102 (61.1%) were positive for abscess. There was no significant difference in the rate of abscess on CT between children with less than 48 hours of localizing symptoms and 48 or more hours of symptoms at 58.1 percent and 58.3 percent, respectively (P = 0.98). Furthermore, there was no significant difference in age, gender, C-reactive protein levels, disease location, or length of stay between children with and without abscess on CT. White blood cell counts were significantly higher in the abscess group (P = 0.01); however, the median white blood cell count in both groups was above normal.
CONCLUSION: Because duration of symptoms does not predict finding of abscess on CT, it is appropriate to obtain a CT scan upon presentation in all children with symptoms concerning for neck abscess.
University of Minnesota, Otolaryngology-Head and Neck Surgery, Minneapolis, MN, USA. stri0106@umn.edu
Platelet-rich plasma for pediatric tonsillectomy patients.
Laryngoscope. 2008 Oct;118(10):1765-7.
OBJECTIVES/HYPOTHESIS: To determine if placement of autologous platelet-rich plasma (PRP) on the tonsil beds at the time of tonsillectomy would decrease postoperative pain and complications.
STUDY DESIGN: Double blind, randomized, prospective study.
METHODS: Seventy children were recruited to participate in the study, ranging in age from 4 to 15 years. They were randomized to treatment (PRP) or control groups. The parents, patients, and nurses were blinded as to which group they were in. Postoperative pain scores were obtained using the FACES pain scale and recorded in a home diary.
RESULTS: Seventy patients were recruited to the study, and 12 did not submit their diaries and were considered to drop out of the study. Demographic data were similar for both control and treatment groups. Median pain scores, medication use, days to normal diet, and office visits did not differ between the two groups.
CONCLUSIONS: PRP applied once at the time of tonsillectomy does not improve postoperative pain or recovery in pediatric patients.
Department of Otolaryngology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota 55404, USA. sidma001@umn.edu
Tracheal agenesis in newborns.
Laryngoscope. 2004 Sep;114(9):1633-6.
OBJECTIVES/HYPOTHESIS: A series of three newborns with tracheal agenesis is described. The preferred methods of diagnosis, description of the clinical course, and a review of the pertinent embryology, associated anomalies, and clinical management are presented.
STUDY DESIGN: A retrospective study of a clinical series of referred patients from 2002 to 2003 who were seen at a single institution.
METHODS: Chart review for clinical course and pathological specimens was performed in all cases. Three patients were identified with tracheal agenesis.
RESULTS: All three newborns died within 48 hours of birth. All of the children underwent emergency laryngoscopy and neck exploration. Gross and microscopic pathological examination was accomplished on all patients.
CONCLUSION: Although tracheal agenesis is rare, it may be more common than previously thought. The diagnosis is not straightforward, and the prognosis is grim. The embryology of the trachea and other foregut derivatives is closely related, and associated birth defects are common.
Pediatric ENT Associates, PA, Minneapolis/St. Paul, Minnesota, USA. tlander@pedsent.com
Orbital complications of sickle cell disease.
Int J Pediatr Otorhinolaryngol. 1990 Jun;19(2):181-4.
Swelling and pain of the peri-orbital tissues in patients with sickle cell disease has been described. This has most often been ascribed to orbital apex syndrome, but there are recent reports in the literature of frontal bone infarctions compounding this syndrome. We will present a case report of a child with sickle cell disease with bilateral orbital abscesses and frontal bone infarctions. The literature pertaining to the diagnosis and treatment of the orbital complications of sickle cell disease is reviewed. We stress that intravenous antibiotics are not adequate therapy for orbital abscesses and that these must be drained surgically.
Division of Otolaryngology, Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7070.
Exacerbation of sickle cell disease by obstructive sleep apnea.
Arch Otolaryngol Head Neck Surg. 1988 Aug;114(8):916-7.
It is difficult to recognize and treat the factors that exacerbate the vascular crises of sickle cell disease. We describe a 12-year-old black girl with sickle cell anemia who, since the age of 9 years, has been repeatedly hospitalized for pain associated with vaso-occlusive disease. A diagnosis of obstructive sleep apnea was suggested by the history and physical examination and was confirmed by polysomnography. Following preoperative transfusion, the patient underwent elective tonsillectomy and adenoidectomy. She has been free of vaso-occlusive pain and crises for over two years and has not been hospitalized since her surgery. Post-operative polysomnography has shown no evidence of obstructive sleep apnea. It is our hypothesis that repeated oxygen desaturation during periods of obstructive sleep apnea was the cause of this patient's frequent vaso-occlusive crises. She not only obtained complete relief of her symptoms, but objective sleep study measurements were normal following surgery. Obstructive sleep apnea is a recent diagnosis, and its pathologic effects are only beginning to be known. Physicians taking care of patients with hemoglobinopathies need to be aware of possible contributing factors to their patients' disease, and an aggressive approach to their diagnosis and possible relief should be sought.
Division of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7070.
Sialendoscopy in children.
Int J Pediatr Otorhinolaryngol. 2010 Apr;74(4):347-50. Epub 2010 Feb 8.
BACKGROUND: The definitive cause of most cases of recurrent salivary gland inflammation in children remains unknown. Relatively little has been written about the use of sialendoscopy as a diagnostic and therapeutic tool in children. OBJECTIVE: To evaluate the safety and efficacy of sialendoscopy as a diagnostic and therapeutic tool for recurrent salivary gland inflammation in children.
STUDY DESIGN: Retrospective case series.
METHODS: Medical records of all patients who underwent sialendoscopy for recurrent salivary gland inflammation from a single tertiary-care pediatric otolaryngology practice were reviewed. Comparison of pre-procedure vs. post-procedure frequency and severity of disease was reviewed. Operative reports, images, and video were analyzed for causes of inflammation.
RESULTS: Six patients (aged 3-16 years old) underwent sialendoscopy (3/6 bilateral parotid, 2/6 unilateral parotid, 1/6 unilateral submandibular). There were no complications. No post-operative recurrence was noted in 3/6 patients; decreased frequency of recurrence was noted in 2/6 patients; repeat sialendoscopy was required in 1/6. Operative findings from sialendoscopy from 10 parotid glands showed fibrinous debris (7/10), mucoid debris (1/10), purulent debris (1/10), or duct stenosis (1/10). No stones were noted.
CONCLUSIONS: Sialendoscopy is a safe, minimally invasive procedure that may decrease the frequency of recurrences for salivary gland inflammation in children. In contrast to previously published work, the most common cause of salivary gland obstruction in this series was debris, rather than stones. Increased use of sialendoscopy as a diagnostic and therapeutic tool will allow for improved understanding of the causes of and management for recurrent salivary gland inflammation in children.
Otolaryngology Department, University of Minnesota, Minneapolis, MN, USA. jabb0005@umn.edu
Nasal health in Down syndrome: a cross-sectional study.
Otolaryngol Head Neck Surg. 2006 May;134(5):741-5.
OBJECTIVE: To investigate peripheral nasal pathology as a contributor to olfactory impairment in DS.
STUDY DESIGN: Twenty DS and 16 non-DS subjects were recruited. Nasal history and symptoms were assessed by self-report or informant. Olfactory threshold, odor identification, and nasal endoscopy were assessed on each subject.
RESULTS: DS subjects were impaired on olfactory threshold (P<0.0001) and odor identification (P<0.001). Although DS subjects tended toward upper-respiratory infections, sleep-disordered breathing, and nasal itching, differences were not significant (P=0.07, 0.06, and 0.058, respectively). There were no significant differences on self-reported nasal history or symptoms. Endoscopy showed equivalent health in DS and control subjects.
CONCLUSION: This DS population shows olfactory impairment. However, nasal health is comparable in DS subjects and controls. Nasal dysfunction is unlikely to contribute to olfactory impairment in DS. SIGNIFICANCE: Olfactory deficits in DS appear to be secondary to central, rather than rhinologic, pathology. EBM rating: B-2b.
Division of Head and Neck Surgery, University of California, San Diego Medical Center, San Diego, California 92120, USA.
Cystic hygroma of the skull base.
Arch Otolaryngol Head Neck Surg. 1999 Dec;125(12):1390-3.
Cystic hygroma is a benign developmental tumor formed by lymph vessels that occurs in 1 of 12000 individuals and presents most frequently in the head and neck. It is often difficult to manage because the tumor frequently envelopes nearby vital structures. Lesions that extend significantly above the hyoid are especially difficult to excise because of the complexity of achieving a complete excision. This article describes a series of 3 cases of cystic hygroma that presented in the head and neck and, on further investigation, were found to also involve the skull base. This anatomic location is exceedingly rare, and these 3 cases represent new and difficult challenges not previously discussed in the literature, to our knowledge.
Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical School, Minneapolis 55455, USA.
Growth factor therapy to improve soft tissue healing.
Facial Plast Surg. 2002 Feb;18(1):41-52.
The advent of new U.S. Food and Drug Administration-approved products containing growth factors to improve soft tissue healing signifies a new era for wound healing. Over the last decade, some clinical growth factor studies have been promising, whereas others have not shown any positive effect. What many of these studies have shown is that the state of a healing wound is not only dependent on its growth factor milieu but also on other variables (wound care, tissue oxygen state, bacteria count, and nutritional status of the patient). This article describes recent progress with growth factors on soft tissue structures (skin, mucosa, and nerve) relevant to the facial plastic and reconstructive surgeon.
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Minnesota School of Medicine and Hennepin County Medical Center, Minneapolis, MN 55455, USA.
Ears & Hearing
Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes.
Int J Pediatr Otorhinolaryngol. 1998 Nov 15;46(1-2):91-101.
Acute otitis media (AOM) in children with tympanostomy tubes in place typically presents with otorrhea (draining ear). Because therapy is not standardized, various topical and systemic antibiotics of unproven efficacy and safety have been used in this indication. This study compared the safety and efficacy of ofloxacin otic solution, 0.3% (OFLX) with that of Augmentin oral suspension (AUG) in pediatric subjects 1-12 years of age with tympanostomy tubes and acute purulent otorrhea. Subjects were randomized to receive 10d of OFLX, 0.25 ml topically bid, or of AUG, 40 mg/kg per day. Audiometry was performed in subjects > or =4 years of age. Overall cure rate for clinically evaluable subjects was 76% with OFLX (n = 140) and 69% with AUG (n = 146; P = 0.169). Overall eradication rates for OFLX and AUG were similar for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and were superior with OFLX for Staphylococcus aureus and Pseudomonas aeruginosa (P<0.05 for both). OFLX had a greater overall pathogen eradication rate (96% vs. 67%; P<0.001). Treatment-related adverse event rates were 31% for AUG and 6% for OFLX (P<0.001). Neither treatment significantly altered hearing acuity. Topical ofloxacin 0.3% otic solution 0.25 ml bid was as effective and better tolerated than systemic therapy with Augmentin oral suspension 40 mg/kg per day in treating AOM in children with tympanostomy tubes.
Daiichi Pharmaceutical Corporation, Fort Lee, NJ 07024, USA.
Characteristics of electrically evoked potentials in patients with auditory neuropathy/auditory dys-synchrony.
Int J Audiol. 2004 Dec;43 Suppl 1:S22-7.
The primary goal of this study was to compare the characteristics of the post-implant evoked potentials with preimplant evoked potentials in patients with auditory neuropathy (AN) or dys-synchrony. AN is typically characterized by sensorineural hearing loss, reduced speech perception, abnormal temporal processing, and unusual patterns of results with various objective audiological tests. In some cases, these patients may be appropriate candidates for a cochlear implant. In this article, we highlight evoked potential findings in two children diagnosed with AN who were provided with multichannel cochlear implants. Preoperative, interoperative and postoperative evoked potential measures show that the restoration of neural synchrony may occur at multiple levels of the auditory pathways in patients with AN when appropriate diagnostic tests, cochlear implantation and rehabilitation are provided.
Mayo Clinic, Rochester, MN 55905, USA. shallop.jon@mayo.edu
Internal auditory canal decompression and cochlear implantation in Camurati-Engelmann disease.
Otolaryngol Head Neck Surg. 2004 Dec;131(6):1004-6.
Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Nose and Sinuses
Sinus surgery in cystic fibrosis patients: comparison of sinus and lower airway cultures.
Int J Pediatr Otorhinolaryngol. 2008 Sep;72(9):1365-9. Epub 2008 Jul 3.
OBJECTIVE: The aim of this study is to determine whether cross-infection occurs between infections in the sinuses and lower airways in Cystic Fibrosis patients, and to determine whether the infections begin in the sinuses before spreading to the lungs.
METHODS: Retrospective study of pediatric Cystic Fibrosis patients who underwent simultaneous sinus surgery and bronchial washings. The results of the cultures were reviewed to determine if the same organisms colonized both the sinuses and lower airways.
RESULTS: Staphylococcus aureus (Staph. Aureus) was found in 40.7% of the sinuses but only 33.3% of the lower airways. One patient had Staph. Aureus in the lower airway but not the sinuses. Pseudomonas, Hemophilus Influenza, and Moraxella showed similar patterns: multiple instances of positive sinus cultures and negative bronchial cultures, but only a small number of cases with positive lower airway cultures and negative sinus cultures.
CONCLUSION: The data showed that as patients age, they are more likely to have infections in both upper and lower airways, but infections start in the upper airways at a younger age. In many cases, organisms were cultured from sinuses in patients who had negative lower airway cultures. In only a few instances, organisms grew in the lower airways and not the sinuses. In most cases, the bacteria that caused sinus infections at a young age caused the lung infections in older patients. This is the paper to show that bacteria spread from the sinuses to the lungs to cause infections in Cystic Fibrosis patients, and not vice-versa.
Children's Hospitals and Clinics of Minnesota-Otolaryngology, 910 E 26th Street, Suite 323, Minneapolis, MN 55404, United States. barne284@umn.edu
Bilateral lateral rhinotomy incisions for medial maxillectomies in the management of pediatric invasive fungal sinusitis.
Laryngoscope. 2001 Nov;111(11 Pt 1):1960-3.
OBJECTIVE: To determine if simultaneous, bilateral lateral rhinotomies for medial maxillectomies would result in central skin or bone loss in pediatric patients with invasive fungal disease.
STUDY DESIGN: Retrospective chart review.
SETTING: Tertiary care children's hospital.
PATIENTS: Three children underwent surgery between April 1996 and June 1998. Ages at treatment ranged from 11 to 14 years. All had bilateral, biopsy-proven invasive fungal disease of the lateral walls of the nose. All were undergoing chemotherapy for acute lymphocytic leukemia (ALL) or acute myelocytic leukemia (AML).
INTERVENTION: Bilateral lateral rhinotomies for medial maxillectomy. Two of 3 also had simultaneous total septectomy.
MAIN OUTCOME MEASURE: Skin survival and patient survival.
RESULTS: All three patients had bilateral simultaneous medial maxillectomy for invasive fungal disease in the presence of profound pancytopenia secondary to treatment of leukemia. One patient had minor nasal edema postoperatively, but none showed any loss of the central nasal skin or facial skeleton. All patients survived the invasive fungal disease with follow-up of at least 24 months. All patients underwent multiple debridements after the original surgery, and 3 of 6 eyes had permanent epiphora requiring dacryocystorhinostomies.
CONCLUSIONS: Bilateral simultaneous lateral rhinotomies are safe in children and did not result in any central skin loss. Aggressive bilateral surgery for invasive fungal disease is compatible with a good esthetic outcome and long-term survival.
Department of Otolaryngology-Head & Neck Surgery, University of Minnesota Hospital, Minneapolis, Minnesota, USA.
Treatment and outcomes for epistaxis in children with Glanzmann's thrombasthenia.
Laryngoscope. 2010 Dec;120(12):2374-7.
OBJECTIVES/HYPOTHESIS: :To understand Glanzmann's thrombasthenia and provide insight to the management of epistaxis in children with this disease.
STUDY DESIGN: Retrospective chart review.
METHODS: All children diagnosed with Glanzmann's thrombasthenia and treated for epistaxis at Children's Hospitals and Clinics of Minnesota were identified and a retrospective chart review was performed. Outpatient charts, hospitalization records, and operative reports were reviewed from 1999 up to 2009 and appropriate data were extracted. The episodes of epistaxis, therapy used, complications, and success rates for controlling hemorrhage were noted.
RESULTS: Five children with a total of 63 clinical encounters for epistaxis were identified. Forty-seven encounters required hospitalization, close to half of which necessitated medical care in the intensive care unit. Nearly all encounters required infusion of hemostatic therapy with either single or multiple agents. Seventy-one procedures for life-threatening hemorrhage were performed. The most common (n = 24) intervention was administration of bovine collagen matrix, which was successful only half of the time (50%). Anterior and posterior nasal packing with or without hemostatic material completely resolved hemorrhage in 35% of the procedures.
CONCLUSIONS: To date, no form of medical or surgical intervention in children with this condition has consistently demonstrated its ability resolve nasal hemorrhage. The role of the otolaryngologist is to control bleeding during major episodes of nasal hemorrhage that do not respond to medical management. These patients usually have remarkable improvement in the frequency and severity of epistaxis in adolescence and then require much less aggressive therapy.
Department of Otolaryngology, University of Minnesota Medical School, Minneapolis, Minnesota, USA. rosa0048@umn.edu
Vascular Malformations
Excision of periorbital hemangiomas to correct visual abnormalities.
Arch Facial Plast Surg. 2011 May-Jun;13(3):195-8.
OBJECTIVE: To determine whether early surgical excision of complicated periorbital hemangiomas (CPHs) reversed refractive errors and prevented further visual complications; CPHs can cause visual complications including astigmatism, strabismus, and occlusion of the visual axis with resultant amblyopia.
DESIGN: Retrospective review of patient series from a tertiary care pediatric referral center. Nine patients with CPHs were managed by otolaryngology and ophthalmology services with complete surgical excision. Preoperative eye examination findings were compared with postoperative findings.
RESULTS: Comparison of preoperative and postoperative refraction measurements and/or eye examination findings indicated reduction of astigmatism and substantial improvement in vision as measured by refractive changes and reduction of pupillary occlusion.
CONCLUSIONS: Total excision of CPHs is a safe and effective approach. When completed early, excision provides definitive therapy, reduces or eliminates astigmatism, and can prevent amblyopia in pediatric patients when pupillary occlusion is present.
Department of Otolaryngology–Head and NeckSurgery, University of Minnesota Medical School, Minneapolis, USA.
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