Faculty Bibliography

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.

Solid ectopic cervical thymus is an extremely uncommon etiology of a neck mass in an infant. It occurs in the line of descent of the thymus from the angle of the mandible to the superior mediastinum. Nine cases of ectopic cervical thymus in infants have been reported in the literature. Only two of nine cases were solid, the remaining seven were thymic cysts. A preoperative diagnosis is seldom considered and is often misdiagnosed as a possible malignancy or a lymph node. We present a case of a 2-month-old infant with an asymptomatic enlarging right neck mass. Patient underwent complete excision of the mass.

OBJECTIVE: To describe our clinical experience with congenital teratomas of the head and neck. STUDY DESIGN: A retrospective review of the six patients as well as a review of the literature in the setting of academic referral centers. METHODS: In six infants with teratomas, four in the cervical region and two arising from the nasopharynx, surgical excision of all tumors was performed. Outcome measures were clinical and radiographic follow-up and the use of a-fetoprotein (AFP) for postoperative monitoring. RESULTS: There was no recurrence of teratomas. CONCLUSIONS: Surgical excision is the treatment for congenital teratomas. Postoperative monitoring for recurrences should include AFP levels in difficult cases.

OBJECTIVE: To demonstrate the potential use of Mitomycin-C (MMC) in the treatment of difficult and recurrent tracheal stenosis. DESIGN: Case series. SETTING: Tertiary care setting. PATIENTS: A retrospective chart review was performed on five pediatric patients with severe, recurrent tracheal granulation and cicatrix after tracheal reconstruction who were treated with topical MMC as an adjunct to bronchoscopy and laser treatment. MMC was applied intraoperatively on saturated pledgets at a dose of 0.1 mg/ml for 2 min to the area where the cicatrix had been lysed. The five patients were able to be decannulated. DISCUSSION: Mitomycin-C is an anti metabolite known to inhibit fibroblast proliferation in vitro. This agent has been used with a high success rate in glaucoma filtration surgery to promote patency of the trabecula. The results of this preliminary application in the pediatric airway as well as the mechanism of action will be discussed.

We review our treatment experience of subglottic stenosis in 66 children. Sixty-one of these children required some form of airway expansion using cartilage grafts. Eight children had grade I (Cotton classification), 15 grade II, 28 grade III, and 15 grade IV stenosis. All patients with grade I and II lesions were decannulated. Ninety-three percent of grade III patients and 67% of grade IV patients were also ultimately decannulated. Laryngotracheal reconstruction with costal cartilage grafting has become widely accepted for treatment of severe laryngotracheal stenosis. Several modifications of this technique have been employed to treat our patients. Recently, we have used a modified single-stage technique with an endotracheal tube stent, externally secured for 1 week, to avoid postoperative intensive care unit admission for sedation and/or paralysis, and its related complications. Posterior graft design and placement without sutures was also performed in 20 cases. A two-surgeon technique that involves a simultaneous endoscopic control of incision of the stenotic area was employed. These modifications will be described in detail.

We sought to define the role of fibrogenic peptides in subglottic stenosis (SGS). Biopsy specimens were obtained from patients with stenosis following endotracheal intubation (group 1, n = 5, mean age 5), patients without a history of any precedent trauma, ie. idiopathic stenosis (group 2, n = 3, mean age 40), and those without stenosis (group 3, n = 3, mean age 70). Formalin-fixed biopsy specimens were analyzed following immunohistochemical staining to determine if epidermal growth factor (EGF), platelet-derived growth factor-AA and -BB (PDGF-AA/BB), transforming growth factor-beta 1 and -beta 2 (TGF-beta 1, beta 2), or basic fibroblast growth factor (bFGF) was deposited in these tissues. Blinded analysis revealed TGF-beta 2 and PDGF-AA to be present in seven of eight biopsy specimens from SGS and absent in controls. Staining for PDGF-BB was observed in the mucosa and submucosa and occasionally within vessel walls. Staining of individual growth factors appeared to correlate closely with the presence of granulation tissue. Essentially no bFGF or TGF-beta 1 was observed. Differences were found between patients in groups 1 and 2; tissue from group 1 revealed deposition of EGF and PDGF-BB in submucosa, epithelium, and vasculature. In summary, our experimental findings implicate PDGF and TGF-beta 2, perhaps acting in concert, in mediating the pathologic fibrotic process observed in subglottic stenosis. Epidermal growth factor, in conjunction with TGF-beta and PDGF, may also have a role, but further investigation is needed to more precisely define it

OBJECTIVE: To determine whether reverse transcriptase (RT) in situ polymerase chain reaction (PCR) can facilitate the diagnosis of nontuberculous ('atypical') mycobacterial (NTM) cervical adenitis. DESIGN: Retrospective review of 12 patients with neck masses clinically diagnosed as NTM cervical adenitis. SETTING: University medical center caring for both ambulatory and hospitalized children. PATIENTS: Twelve pediatric patients (all younger than 9 years) with cervicofacial masses. INTERVENTION: Surgical excision of the presenting mass. MAIN OUTCOME MEASURES: Reverse transcriptase in situ PCR was used to detect mycobacterial RNA in excised tissue. All specimens were also cultured and stained for acid-fast bacilli. RESULTS: Reverse transcriptase in situ PCR was positive for NTM in 7 of 12 cases. CONCLUSIONS: Infection with NTM may be an extremely indolent process, and the success of RT in situ PCR depends on the presence of mycobacterial nucleic acids. Even in cases in which the findings of RT in situ PCR were positive, infected cells were few in number. Because of the sparsity of infection in the positive cases, NTM may be even more rare in the negative cases, ie, those in which mycobacterial nucleic acids do not exist and cannot be detected by any means, including RT in situ PCR. Although RT in situ PCR, cultures, stains for acid-fast bacilli, and tuberculin tests using purified protein derivative are all helpful in diagnosing NTM cervical adenitis, when nucleic acids are present RT in situ PCR is the simplest, most reliable, and quickest to perform and the results are easiest to interpret