Faculty Bibliography

OBJECTIVE: To determine whether the intravenous administration of dexamethasone sodium phosphate before tonsillectomy and adenoidectomy can reduce the morbidity from, and increase the safety of, this procedure. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: A university medical center, caring for both ambulatory and hospitalized children. PATIENTS: Eighty children aged 3 to 15 years undergoing tonsillectomy and adenoidectomy for either chronic tonsillitis or adenotonsillar hypertrophy (obstructive sleep apnea and/or upper airway obstruction). INTERVENTIONS: Forty-one children received intravenous dexamethasone sodium phosphate (1 mg/kg up to 16 mg) and 39 received placebo before undergoing an electrocautery dissection tonsillectomy and adenoidectomy. MAIN OUTCOME MEASURES: Postoperative oral intake, pain, vomiting, temperature, and complications. RESULTS: Patients who received intravenous dexamethasone had significantly less trismus, vomiting, and elevations of temperature 6 hours after surgery and more oral intake (liquids and soft solids) at 24 hours. Three children, all of whom were in the placebo group, had emergency department visits for pain and dehydration. Each group had one child who had a secondary hemorrhage (no surgery needed), one child who had pneumonia, and one child who had night terrors. CONCLUSIONS: Treatment with intravenous dexamethasone before electrocautery tonsillectomy and adenoidectomy is safe, increases early postoperative oral intake, and decreases morbidity

Pneumoparotitis is a rare cause of enlargement of the parotid gland; it is often misdiagnosed and therefore incorrectly treated. We report three pediatric cases of self-induced pneumoparotitis and detail the clinical presentation, pathogenesis, radiographic findings, and treatment options. We also review the literature on the subject. In children, inflammatory swelling of the parotid gland is usually due to acute viral or bacterial infection, juvenile recurrent parotitis, or allergic, autoimmune, or systemic disease. Infrequently, swelling may result from air being forced through Stensen's duct, resulting in pneumoparotitis. This may occur as a transient or recurrent phenomenon. Recurrent parotid insufflation is not entirely benign and may predispose to sialectasias, recurrent parotitis, and even subcutaneous emphysema

A woman with chronic hemoptysis as her only complaint had extensive testing and did not respond to antibiotic therapy. Radiologic examination of the sinuses identified a mass which, on surgical exploration, was found to be the result of a fungus, Pseudallescheria boydii. Although this fungus is known to be a cause of epistaxis, this is the first instance in which it has been reported to cause hemoptysis.

Two cases of pediatric isolated cervical emphysema caused by foreign bodies are presented. This report emphasizes the need for roentgenograms, flexible nasolaryngoscopy, and situational barium swallows to identify the exact location of a tear and to determine whether the situation requires direct laryngoscopy and esophagoscopy to remove a foreign body, or an open surgical repair of a mucosal disruption. The treatment of this self-limited condition usually requires only antibiotics, fasting, intravenous fluid, and most importantly, close observation for signs of perforation

The differential diagnosis of large cystic masses in the newborn should include heterotopic brain tissue. This lesion is attributed to early displacement of pluripotential cells and cyst formation may result from cerebrospinal fluid production by choroid plexus-like structures. Treatment consists of surgical excision

Coronal computed tomography (CT) scans are currently the optimal study to display the normal and abnormal anatomy in children with chronic and recurrent acute sinusitis after failure of medical therapy. To assess the extent and distribution of disease as well as associated anatomic abnormalities in this pediatric population, 74 coronal CT scans of children with continued symptoms of sinusitis after failure of extensive medical therapy were reviewed retrospectively. Twelve children with cystic fibrosis showed the characteristic features of medial displacement of the lateral nasal wall in the middle meatus and uncinate process demineralization, creating the appearance of a maxillary sinus mucocele. Nine of these 12 children had increased attenuation in the maxillary sinus on soft-tissue windows. In the remaining 62 children, a significantly greater frequency of disease, when compared with that reported for adults, was seen in the maxillary, anterior ethmoid, posterior ethmoid, and frontal sinuses. Children with asthma (n = 33) had more extensive disease. Bony anatomic abnormalities were similar to those reported for adults, except for a lower incidence of septal deformity

Laryngotracheal reconstruction (LTR) has been employed for the treatment of severe laryngotracheal stenosis for the past 6 years at Johns Hopkins Hospital. Thirty-one children underwent LTR with costal cartilage grafting, 24 of whom had Aboulker stents placed. Short stents were used in 22 patients. Six patients received definitive treatment in a single-stage LTR; 1 child had no stent placed. Twenty-six (84%) of the 31 patients were decannulated. It was concluded that decannulation can be obtained in selected patients with the short Aboulker stent or single-stage LTR. A new classification system for laryngotracheal stenosis, based on objective measurements and the separate analysis of posterior glottic fibrosis, was developed. The proposed classification system allows recommendations for treatment. Moreover, it can be easily reproduced and may facilitate comparison of results

A retrospective study of pediatric patients with obstructive sleep apnea who underwent adenotonsillectomy between 1987 and 1990 was undertaken to determine the frequency of postoperative respiratory compromise and to determine if risk factors for its development could be identified. Sixty-nine patients less than 18 years old had polysomnographically documented obstructive sleep apnea and were observed postoperatively in the pediatric intensive care unit. Of these, 16 (23%) had severe respiratory compromise, defined as intermittent or continuous oxygen saturation of 70% or less, and/or hypercapnia, requiring intervention. Compared with patients without respiratory compromise, these patients were younger (3.4 +/- 4 vs 6.1 +/- 4 years) and had more obstructive events per hour of sleep on the polysomnogram (49 +/- 41 vs 19 +/- 30). They were more likely to weight less than the fifth percentile for age (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.4 to 18.7), to have an abnormal electrocardiogram and/or echocardiogram (OR, 4.5; 95% CI, 1.3 to 15.1), and to have a craniofacial abnormality (OR, 6.2; 95% CI, 1.5 to 26). Multiple logistic regression analysis revealed the most significant risk factors were age below 3 years and an obstructive event index greater than 10. Children with obstructive sleep apnea are at risk for respiratory compromise following adenotonsillectomy; young age and severe sleep-related upper airway obstruction significantly increase this risk. We recommend in-hospital postoperative monitoring for children undergoing adenotonsillectomy for obstructive sleep apnea