Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with and without Blue-Dyed Food

The purpose of this prospective study was to determine if fiberoptic endoscopic evaluation of swallowing (FEES) maintains high intra- and interrater reliability in detecting pharyngeal dysphagia and aspiration without the addition of FD&C Blue No. 1 to food. Twenty consecutive adults referred for a swallow evaluation participated. Nine subjects received blue-dyed food and 11 subjects received regular nondyed food, i.e., yellow pudding and white skim milk. Four variables were rated: (1) the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow; (2) evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow; (3) laryngeal penetration defined as material in the laryngeal vestibule but not passing below the level of the true vocal folds either before or after the pharyngeal swallow; and (4) tracheal aspiration defined as material below the level of the true vocal folds either before or after the pharyngeal swallow. Three speech–language pathologists experienced in interpreting FEES results independently and blindly reviewed the digitized videotape three times. Intrarater agreements for the four variables with blue-dyed and non-blue-dyed food trials were 100% and monochrome trials ranged from 95% to 100%. Average kappa values for interrater reliability ranged from moderate to excellent agreement (0.61–1.00) for all viewing conditions. Kappa values for blue-dyed trials versus monochrome trials were 0.83 and for non-blue-dyed trials versus monochrome trials were 0.88, indicative of excellent reliability under both viewing conditions. FEES maintains both high intra- and interrater reliability in detecting the critical features of pharyngeal dysphagia and aspiration using either blue-dyed or non-blue-dyed foods. The endoscopist, therefore, can be assured of reliable FEES results using regular, non-dyed food trials.This research was supported in part by the McFadden, Harmon, and Mirikitani Endowments.     

Nasal cerebrospinal fluid leaks: critical review and surgical considerations

Otolaryngologists have assumed a major role in the evaluation and management of anterior skull base defects that result in cerebrospinal fluid (CSF) leaks and meningoencephaloceles. To achieve the best possible results for patients with CSF leaks, a thorough understanding of the underlying pathophysiology and a critical analysis of management principles and treatment options is essential. Surgical and medical management of these patients is highly individualized and depends on a number of factors, including etiology, anatomic site, patient age, and underlying intracranial pressure. This review article will highlight the history, physiology, pathophysiology, diagnosis, surgical techniques, and postoperative care relevant to nasal CSF leaks and encephaloceles.     

Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial

OBJECTIVES: To conduct the first prospective, randomized, controlled trial evaluating and comparing the medical and surgical treatment of polypoid and nonpolypoid chronic rhinosinusitis (CRS). MATERIALS AND METHODS: Ninety patients with CRS were equally randomized either to medical or surgical therapy. All patients underwent pre- and posttreatment assessments of visual analogue score (VAS), the Sinonasal Outcome Test-20 (SNOT-20), the Short Form 36 Health Survey (SF-36), nitric oxide (NO), acoustic rhinometry, saccharine clearance time (SCT), and nasal endoscopy. Each patient had three assessments: before starting the treatment, after 6 months, and, finally, after 1 year. RESULTS: Both the medical and surgical treatment of CRS significantly improved almost all the subjective and objective parameters of CRS (P <.01), with no significant difference being found between the medical and surgical groups (P >.05), except for the total nasal volume in CRS (P <.01) and CRS without polyposis (P <.01) groups, in which the surgical treatment demonstrated greater changes. CONCLUSION: CRS should be initially targeted with maximal medical therapy (e.g., a 3 month course of a macrolide antibiotic, douche, and topical steroid), with surgical treatment being reserved for cases refractory to medical therapy. The presence of nasal polyps is not a poor prognostic factor for the efficacy of CRS therapy, either surgical or medical.     

Origin of nasal polyps: an endoscopic autopsy study

OBJECTIVES/HYPOTHESIS: To further elucidate the natural history, etiology, and pathogenesis of nasal polyps, the present study of their anatomical site of origin was undertaken. The possibility for preferred areas or certain patterns in the places of origin was also considered. STUDY DESIGN: Autopsies were examined consecutively. METHODS: Endoscopic examination of the nasal cavity and paranasal sinuses, including endoscopic sinus surgery, was performed in 69 autopsies. The place of origin and attachment of each polyp was meticulously described. Polyps were photographically documented in situ and removed, together with the corresponding mucosa, for later histological examination. The cause of death of the patients was either cardiopulmonary disease or malignant diseases. Median age was 73 years (age range, 47-94 y). RESULTS: Nasal polyps were found in 22 of the 69 autopsies, corresponding to a frequency of 32%. In all, 54 polyps were found. Thirty-nine polyps were small (length, 2-5 mm), 10 were medium-sized, and 5 were large. No complaints of symptoms from the nasal polyps were registered. Most of the polyps (40 of 54 [74%]) originated in relation to sinus outlets. Most of these (34 of 54 [63%]) were found in the middle or superior meatus (13 of 54 [24%]). CONCLUSION: The results seemed to indicate that the frequency of nasal polyps is high and that most of the polyps originate from the mucosa of the ostia, clefts, and recesses in the ostiomeatal complex where the initial stage of sinonasal polyposis seems to take place. Continuous postmortem studies in autopsy materials and systematic endoscopic examinations for "silent," asymptomatic nasal polyps in various groups of patients will lead to a better understanding of the natural history of nasal polyps.     

Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease

BACKGROUND: Percutaneous endoscopic gastrostomy is the standard for long-term enteral access. It can provide enteral nutrition or gastrointestinal decompression. Utilization of the gastrostomy for decompression has traditionally been reported in the setting of malignant obstruction. However, decompressive gastrostomy can play a role in the treatment of nonmalignant bowel dysfunction as well. METHODS: Over a 2-year period, 20 of 121 percutaneous endoscopic gastrostomies attempted by this surgical endoscopist were for gastrointestinal decompression. RESULTS: Eleven of 18 gastrostomies successfully placed for decompression were for benign conditions. In 5 patients with fistulous disease, the purpose of decompression was to divert the gastrointestinal tract until operative repair. Four of these patients have since undergone definitive surgery. CONCLUSIONS: This series presents the successful use of the percutaneous endoscopic gastrostomy for decompression of nonmalignant conditions. In such scenarios, the drainage gastrostomy can be employed as a bridge to future surgery, or as a means of long-term decompression for bowel dysfunction.     

Feasibility study of normal and septic tracheal imaging using optical coherence tomography

BACKGROUND AND OBJECTIVES: Optical coherence tomography (OCT) is an imaging technology that may be adapted for use with flexible fiberoptic bronchoscopy, potentially allowing it to play an important role in pulmonary diagnostics. The goal of this study was to evaluate the feasibility of OCT to image tracheal pathology. STUDY DESIGN/MATERIALS AND METHODS: Tracheas were harvested from normal and septic New Zealand White rabbits and imaged using OCT. Two delivery devices were employed. One was a moving stage with an objective lens and collimator, the other a linear scanning flexible fiberoptic catheter using a GRIN lens and prism for endoscopic OCT. After OCT images were obtained from normal and septic tracheas, the excised tissues were prepared for standard histologic examination. Areas imaged by OCT were compared with corresponding histology slides. RESULTS: OCT images demonstrated in detail tracheal sub-surface structures such as the epithelium, lamina propria, submucosa, and cartilage. The appearance of structures imaged by OCT corresponded very well with histologic pictures obtained by light microscopy. The OCT images from septic tracheas showed marked swelling of the mucosal and submucosal layers. Such pathology was equally imaged by either the moving stage or fiberoptic catheter for endoscopic OCT. CONCLUSIONS: OCT images of the trachea can distinguish many sub-surface structural features usually requiring biopsy and light microscopy for visualization. Marked differences between normal and septic trachea were apparent in OCT images. In the future, OCT may be a valuable tool for evaluating tracheal pathology in situ with high image resolution.     

Endoscopic drainage of pancreatic pseudocysts in children

Background/Purpose

Symptomatic pancreatic pseudocysts have traditionally been managed with surgical, percutaneous, and, more recently, endoscopic drainage. Although the role of the latter is well defined in the adult population, its utility in children needs to be clarified. The authors reviewed their experience with endoscopic drainage of pancreatic pseudocyst (EDPP).

Methods

A retrospective chart review was conducted, and relevant demographic and clinical data were obtained for all patients with pancreatic pseudocysts managed with endoscopic drainage in the period from 1997 through 2001, inclusive.

Results

Three children had successful endoscopic drainage of pancreatic pseudocysts. They were 9, 13, and 14 years old, and were all boys. The etiology of the pancreatitis was idiopathic related to anomalous pancreatic divisum ducts in the first 2 and azathioprine induced in the latter. The first 2 patients had endoscopic transpapillary drainage, whereas the third had an endoscopic cystduodenostomy. All patients had complete resolution of the pseudocyst clinically and radiologically after follow-up periods of 3, 31, and 21 months, respectively. The first needed a subsequent pancreaticojejunostomy for persistent symptoms related to chronic pancreatitis. A successful endoscopic drainage of a posttraumatic pancreatic pseudocyst has previously been reported from our institution.

Conclusions

This experience would indicate that endoscopic drainage of pancreatic pseudocyst is an effective and relatively safe option of managing this problem in children.     

Normal and abnormal embryonic development of the anorectum in rats

Background

The embryologic and pathologic aspect of anorectal malformation (ARM) remains poorly understood. There is no universally accepted theory to explain anorectal embryology and the abnormal development that produces ARM. The aim of this study was to observe the developmental processes of anorectum in rats and to explore the abnormal embryonic development that leads to ARM.

Methods

Rat embryos with ARM were obtained by treating pregnant rats with administration of ethylenethiourea (ETU). Normal rat embryos and embryos with ARM from gestational days 12.5 to 20 were sectioned serially and sagittally and stained with H & E. The relevant structure including cloaca and urorectal septum (URS) were examined in a temporospatial sequence.

Results

Characteristics of anorectum development in ARM rat embryos treated by ETU were as follows: (1) URS never fused with cloaca membrane. (2) Dorsal cloacal membrane was maldeveloped. (3) Cloacal configuration was abnormal. (4) Tail groove never appeared. All type of ARM was the rectourethal fistula and common cloaca in ETU-treated rat embryos and was discernible on gestation day 16.

Conclusions

Absence of the tail groove and maldevelopment of the dorsal cloacal membrane, cloacal configuration, and urorectal septum are likely to be responsible for the formation of ARM. Failure of fusion of the URS with cloacal membrane is the immediate reason for rectourethral fistula or common cloaca in ETU-treated rats.     

Endoscopic management of the intranasal glioma

The authors report the endoscopic management of a boy with nasal glioma who was only 35 days old. The nasal glioma is a rare congenital nasal abnormality, which manifests as a mass of extracranial cerebral tissue unconnected with the brain. For surgical excision, some surgeons suggest initial craniotomy for excluding intracranial extension. The authors successfully removed the intranasal glioma by endoscopic surgery without craniotomy on a 35-day-old boy. Intranasal endoscopic surgery is a less-invasive and safe procedure and does not result in postoperative facial scarring and deformity. Therefore, the use of endoscopic surgery in place of lateral rhinotomy procedure is recommended.     

Gastrostomy revision: incidence and indications

Background/purpose

Although quite reliable, gastrostomy may require revision. However, there are no reports in the literature specifically delineating identifiable risk factors or circumstances that lead to gastrostomy revision in children with gastrostomy. The purpose of this report was to determine the rate of revision and correlate any factors that may lead to revision.

Methods

A retrospective chart review was performed on 1,042 children who underwent gastrostomy at The Children’s Hospital, Denver, Colorado, between 1992 and 2002. Charts of children who underwent gastrostomy were reviewed for pertinent clinical factors and compared with those who required gastrostomy revision.

Results

Of the 1,042 children, who had gastrostomies, 67 revisions were required in 61 children (6%). Of the many possible factors that could have had an influence on the revision rate, only fundoplication, percutaneous endoscopic gastrostomy (PEG), migration of the gastrostomy site, and time correlated with the need for gastrostomy revision.

Conclusions

Parents should be made aware that there is a 6% chance that their child’s gastrostomy may need revision and that the need for revision may increase with PEG, initial construction before 18 months of age, and the advancing age of the gastrostomy. Surgeons should avoid placing the gastrostomy near the costal margin, making a large gastrostomy exit tract through the abdominal wall and inserting a gastrostomy into the nutritionally depleted pulmonary stressed neurologically challenged child without first attempting to improve the child’s nutritional status.