Faculty Bibliography

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: Anomalies of the fourth branchial arch complex are exceedingly rare, with approximately forty cases reported in the literature since 1972. The authors report experience with six fourth arch anomalies. METHODS: Retrospective chart review of six consecutive patients presenting to the pediatric otolaryngology service at a tertiary care center with anomalies referable to the fourth branchial arch. RESULTS: All six patients presented within the first or second decade of life. All six had left-sided disease. Four patients presented with recurrent neck infection, one with asymptomatic cervical masses, and one with a neck mass and respiratory compromise. One patient had prior surgery presented with a recurrence. Diagnosis of fourth arch anomalies was suggested or confirmed by computed tomography and flexible laryngoscopy. Treatment was surgical in five patients; one patient is awaiting surgery. Surgical procedures included resection of the mass and endoscopic cauterization of the inner opening of the cyst. CONCLUSIONS: The presentation of a cervical mass, especially with recurrent infections and especially on the left side, in a child in the first or second decade of life heightens suspicion for an anomaly of the fourth branchial arch. Diagnosis can be difficult, but is aided by the use of flexible laryngoscopy, Computed tomography (CT) scanning and ultrasonography. Surgical resection of the cyst and cauterization of its pyriform sinus opening should be undertaken to minimize recurrence

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

Congenital nasal pyriform aperture stenosis is a rare cause of airway obstruction in the newborn. Immediate recognition and therapy are essential for this potentially life-threatening condition. After initial management, which includes establishment of an oral airway, surgical repair of the stenotic bony inlet has been traditionally considered. We present a long-term follow-up of two patients with congenital pyriform aperture stenosis, who were managed expectantly. Pertinent embryology, clinical presentation, and general treatment strategies for these patients are also discussed

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.