Faculty Bibliography

OBJECTIVES: (1) To assess the safety and efficacy of outpatient intracapsular tonsillectomy, which has been recently described as a less invasive means of treating obstructive tonsillar hypertrophy, in children younger than 3 years; and (2) to challenge the standard dictum that children younger than 3 years should be admitted to the hospital after tonsil and adenoid surgery. DESIGN: Retrospective cohort study via medical chart review and telephone interview. SETTING: Pediatric otolaryngology group practice with academic affiliation.Patients Children with symptomatic tonsillar and adenoid hypertrophy (n = 226) who underwent microdebrider-assisted intracapsular tonsillectomy between September 1, 2000, and October 1, 2002. METHODS: Comparison of study group (children <3 years old, n = 38; mean age, 30.3 months; 20 boys and 18 girls) with control group (children > or =3 years, n = 188), measuring pain, oral intake, analgesic requirements, complications, need for readmission, and relief of symptoms. RESULTS: There were no statistically significant differences in pain, oral intake, or analgesic requirements. All children, regardless of age, were discharged home within 4 hours of surgery. No child in either group required readmission, and there were no complications related to the time of discharge. Younger children experience equivalent symptomatic improvement. CONCLUSION: Children younger than 3 years may undergo intracapsular tonsillectomy as outpatients without sacrificing safety or efficacy

OBJECTIVE: To better define the clinical manifestations, radiologic imaging and the surgical management of cervical thymic lesions in children. STUDY DESIGN: Multi-center retrospective case review. METHODS: The charts of all children with pathologically confirmed thymic lesions at six children's hospitals (1990-2002) were reviewed for demographics, physical findings, X-ray findings, operative outcomes and pathology. RESULTS: There were a total of 15 children, 2 of whom had ectopic cervical thymus and 13 who had thymic cysts. They ranged in age from 1 month to 18 years. Thymic lesions were more common in males. Ectopic cervical thymus was best defined by MRI whereas thymic cyst had a more consistent appearance on CT. All children had successful surgical resection with no recorded complications or recurrences. CONCLUSIONS: Cervical thymic lesions are rare. Ectopic cervical thymus tends to be found primarily in infants whereas thymic cysts occur in a wider age range. Radiologic imaging is important but is not histologically specific. Definitive diagnosis and cure requires complete surgical excision.

OBJECTIVES: To study complications of powered intracapsular tonsillectomy and adenoidectomy (PITA) in pediatric patients with obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective chart review and long-term follow-up in office or by telephone interview. METHODS: We studied 278 patients who underwent PITA between September 2000 and October 2002. Outcome measures were postoperative bleeding, velopharyngeal insufficiency, need for hospital readmission, tonsil regrowth, and return of snoring or sleep apnea symptoms. RESULTS: All 278 children treated by PITA had immediate resolution of symptoms of OSA. Complications were noted in 11 patients (3.9%). Nine patients (3.2%) experienced tonsil regrowth with snoring, two of whom evolved to a return of OSA that was definitively managed by means of a complete tonsillectomy. Two patients (0.7%) had self-limited bleeding. None of the patients developed persistent velopharyngeal insufficiency or required hospital readmission. CONCLUSIONS: Microdebrider-assisted PITA is a safe and effective alternative for children otherwise treated with traditional tonsillectomy for symptoms of OSA due to adenotonsillar hypertrophy. This series suggests a 3.9% overall rate of complications, with the most common noted as tonsillar regrowth without recurrence of OSA. Prospective trials with longer follow-up may define higher complication rates

OBJECTIVE: To provide preliminary clinical data regarding endoscopically placed nitinol stents for children with tracheal obstruction as a temporizing measure to allow for trach tube decannulation while awaiting growth to allow for tracheal resection. METHODS: This case series describes the experiences of two children (ages 5 and 15) who were dependent upon tracheotomy because of acquired tracheal obstruction. Both patients had combined tracheomalacia and tracheal stenosis. After failing tracheoplasty with rib graft augmentation both patients suffered from extensive tracheal disease, which was too long to allow for immediate tracheal resection. INTERVENTION: Endoscopic placement of nitinol stents in the obstructed tracheal segment using fluoroscopic guidance. All tracheotomy tubes were removed immediately after successful stent deployment with the patient still under general anesthesia. RESULTS: Four stents were placed in total. The first patient's initial stent was too narrow and was, therefore, removed and replaced at a later date with a larger diameter stent. The second patient experienced distal migration of his initial stent requiring stent removal and replacement at a later date. Both patients remain successfully decannulated (follow-up, 25 and 26 months) and are currently living more normal lives as they grow and await tracheal resection. CONCLUSION: Preliminary use of nitinol stents for pediatric tracheal obstruction has enabled successful decannulation in two children with complicated airways. Our results with this series of patients suggest that nitinol stents can be safely used in children as a temporizing measure until tracheal resection can be safely performed. With this approach children can live free from the hassles of trach care, social isolation and peer ridicule. Limited pediatric experience exists in the literature about nitinol stents. Thus, our experience with stent selection and placement will help others avoid problems encountered in this initial series

OBJECTIVE: To evaluate the use of topical mitomycin in choanal atresia repair to reduce the development of granulation tissue and cicatrix. DESIGN AND SETTING: Retrospective case series in 2 tertiary care centers. PATIENTS: Twenty patients with either unilateral or bilateral congenital choanal atresia underwent repair using the transnasal endoscopic approach, the transpalatal approach, or both. INTERVENTIONS: The surgeons favor the use of the endoscopic transnasal drillout technique for all unilateral cases of choanal atresia and for selected bilateral cases. We describe our experience and treatment paradigm for these 20 patients (15 with unilateral atresia, 5 with bilateral atresia). Topical application of mitomycin was used, and in some cases postoperative stenting, for a period of 1 to 2 weeks. In 8 cases, a second application of mitomycin was used. Follow-up ranged from 3 months to 2 years (mean, 9 months). OUTCOME MEASURE: The patency of the choanae without respiratory distress or nasal drainage, as assessed by endoscopic evaluation, determined a successful repair. RESULTS: Of the 20 patients, 17 retained patent airways. Three patients experienced improvement from a total atresia to a narrowed, stenotic choana. CONCLUSIONS: The use of mitomycin as an adjunct to the surgical repair of choanal atresia may offer improved patency with a decreased need for stenting, dilatations, and revision surgery. Newer endoscopic techniques with powered instrumentation further enhance the safety and efficacy in the repair of choanal atresia

OBJECTIVE: to study the role of KTP laser in management of subglottic hemangioma. DESIGN: retrospective analysis of patients with subglottic hemangioma treated by the senior authors. Setting: tertiary care teaching hospital. PATIENTS: twelve patients with subglottic hemangiomas. INTERVENTION: patients were treated with KTP laser (eight cases), CO(2) laser (two cases) or observation (two cases). MAIN OUTCOME MEASURE: resolution of symptoms, decrease in size of subglottic hemangioma or tracheotomy decannulation. RESULTS: All patients treated with KTP laser or CO(2) laser had resolution of symptoms and five tracheotomy-dependent children were decannulated. CONCLUSION: subglottic hemangioma is a potentially life-threatening disease seen in young children. Most authors recommend use of either CO(2) or open surgical excision. There is very little data available on the use of KTP lasers in the management of subglottic hemangiomas. The KTP laser beam is preferentially absorbed by hemoglobin making this laser system more applicable to the treatment of vascular tumors such as the hemangioma. KTP laser is a good tool for management of subglottic hemangioma with a low incidence of complications

Epidermal inclusion cyst (EIC) is a recognized cause of an anterior neck mass in children. Controversy exists as to the proper surgical management of an anterior neck EIC: is simple excision adequate treatment, or is a Sistrunk procedure necessary? A retrospective review of the operative logs of the two senior authors (M.M.A., R.F.W.) from 1993 to the present revealed 16 children, ages 6 months to 9 years (mean, 4.5 years), with a diagnosis of anterior neck EIC. An accurate intraoperative diagnosis of an EIC in all cases allowed for a simple excision of the mass rather than a Sistrunk procedure. The final histologic diagnosis was EIC in all 16 patients. Follow-up of these 16 patients for a mean of 4.5 years revealed no recurrences or complications. When the diagnosis of EIC can be made confidently in the operating room, simple excision is an adequate surgical treatment

OBJECTIVE: To describe the role of OtoScan laser-assisted myringotomy (OtoLAM) for indications other than chronic otitis media or recurrent acute otitis media. STUDY DESIGN: Cross-sectional review. METHODS: Twenty-seven office-based OtoLAM procedures were performed in 21 patients for "atypical" reasons. The indications included middle ear dysfunction with necessary air travel (n = 10) or hyperbaric oxygen treatment (n = 6), mastoiditis with postauricular cellulitis (n = 2), canal exostosis prohibiting tympanostomy (n = 1), acute otitis media accompanied by seizures (n = 1), and chronic middle ear effusion in a patient with hemophilia (n = 1). RESULTS: In each of the 20 cases available for follow-up, middle ear disease resolved with closure of the laser-assisted myringotomy. At a later date, two patients (10%) underwent another OtoLAM in the opposite ear and four patients (20%) required repeat OtoLAM in the same or both ears. Three patients (15%) ultimately underwent myringotomy tube placement because of recurrent middle ear dysfunction. CONCLUSIONS: Although this report contains preliminary data, the data suggest that OtoLAM may provide an additional option in the care of certain patients who have previously been treated with myringotomy tubes.

When treating a child with a palatal abnormality for otitis media or a nasal obstruction, otolaryngologists often face the question of whether the benefits of adenoidectomy are worth the risk of the development of velopharyngeal insufficiency. Treatment options for these patients include a complete adenoidectomy, a partial adenoidectomy, or no surgical intervention. In this retrospective study, we describe the outcomes of 22 such patients who were treated with a superior adenoidectomy performed with a St. Clair adenoidforceps under indirect vision with a laryngeal mirror. All patients experienced a complete or near-complete resolution of their nasal obstruction, and none developed permanent velopharyngeal insufficiency. Only three patients experienced a recurrence of otitis media. Our experience suggests that superior adenoidectomy is a safe and effective procedure.

Patients undergoing hyperbaric oxygen (HBO2) therapy often experience middle ear barotrauma. Not infrequently this disrupts therapy and may require myringotomy tube placement. A new, simple, office-based procedure known as OtoScan Laser Assisted Myringotomy (OtoLAM) provides temporary middle ear ventilation, which offers significant potential benefis for HBO2 patients. Five patients whose middle ear disease complicated their HBO2 therapy have undergone nine OtoLAM procedures in 11 ears. All patients tolerated the procedure without complications and immediately returned to HBO2 treatment. Based on this preliminary experience, we recommend OtoLAM for selected HBO2 patients with problematic middle ear dysfunction.