Diagnostic and therapeutic efficiency in croup and epiglottitis

Croup and epiglottitis continue to be potentially life-threatening diseases in children. Early distinction is imperative as definitive treatment differs significantly. To determine the correlation of various clinical features, x-rays, and laboratory tests with diagnosis and management planning, a retrospective chart analysis of 194 children with croup (N = 169) and epiglottitis (N = 25) was performed. The clinical history and physical findings were most important in differential diagnosis. Patient age, lateral neck x-ray, and white blood count (WBC) strongly correlated with diagnosis. Counter immunoelectrophoresis (CIE) results did not alter therapy. No blood cultures were positive unless the patient had: WBC over 15,000 with more than 10 stabs, WBC over 20,000, or WBC with more than 20 stabs. Ampicillin resistant H. influenzae occurred in 21% of positive blood cultures. Capillary blood gases did not correlate with clinical need for intubation. It is suggested that a selective evaluation of patients with epiglottitis and croup can be performed in a more cost-effective manner without sacrifice in patient care.     

Acute epiglottitis: intubation versus tracheostomy

Acute epiglottitis is a disease with significant mortality. The patient, usually an otherwise healthy pre-school child, develops a sore throat and muffled voice from swollen supraglottic structures, and may progress rapidly to respiratory arrest. Early diagnosis and airway maintenance can prevent these fatalities. Whether to secure an airway by tracheostomy or endotracheal intubation is the subject of much discussion. Nineteen series totalling 738 cases of epiglottitis plus 11 new cases are reviewed. These patients were treated as follows: Tracheostomy = 348 (3 deaths - 0.86%); Endotracheal intubation = 216 (2 deaths - 0.92%); medical management with no artificial airway = 214 (13 deaths - 6.1%). The difference in morbidity and mortality between tracheostomy or nasotracheal intubation is so slight that the choice should be determined by local factors. Medical management with no artificial airway should not be used in children.     

An update on inflammatory disorders of the pediatric airway: epiglottitis, croup, and tracheitis

Acute infections of the respiratory tract are common in pediatric patients. Respiratory disease is the leading cause of hospitalization in children less than 4 years of age and is responsible for many physicians' office and emergency department visits.(1) The severity of upper respiratory tract infection ranges from mild, self-limited disease to potentially life-threatening airway obstruction. The prepared clinician can often make a diagnosis based solely on the history and physical examination, using radiographs and laboratory examinations to aid in diagnosis when the clinical picture is unclear. At times, airway collapse is imminent, and the clinician must proceed directly to endoscopy for definitive diagnosis and airway protection. This article will discuss the pathogenesis, clinical presentation, and management of epiglottitis, croup, and bacterial tracheitis in the pediatric population.     

Acute epiglottitis in children: experiences with tracheotomy and intubation

Acute epiglottitis is one of the most serious and potentially fatal conditions dealt with in paediatric laryngology. The infectious agent is mostly Haemophilus influenzae. An active and planned treatment to secure the airway is necessary to reduce the morbidity and mortality. The ‘watch and wait’ attitude should be abandoned. Tracheotomy or intubation should be performed. Mostly literature today is in favour of intubation. However, both tracheotomy and intubation can be used, and if properly managed the complication rate with both methods is low. This series comprised 102 children of whom 79 were tracheotomized and 23 were intubated. No differences could be found between intubation or tracheotomy time (2.3 and 2.9 days respectively) or in hospital stay (6.7 and 6 days). The complication rate was low in both groups except for subcutaneous and mediastinal emphysema in the tracheotomy group but these did not cause any serious problems.     

Nasotracheal intubation and tracheostomy in acute epiglottitis and laryngotracheal bronchitis

Acute infectious respiratory distress in children has known different modalities of treatment during these past few years, but controversy remains between tracheostomy and naso-tracheal intubation as ways to cope with the problem. This study, which was undertaken at St. Justine's Hospital in Montreal, reports our complications with the two methods and shows that non-fatal complications are about the same but less serious with naso-tracheal intubation, whereas mortality was 3.2% with tracheostomy and 0% with naso-tracheal intubation. These results entitle us to think that naso-tracheal intubation is the treatment which should be used. This study also reviews different incidence in regards to age, sex, and seasonal prevalence between croup and epiglottitis and also compares the duration of hospital care between the two modalities.     

Molded tympanic heterograft. An eight-year experience

Between 1974 and 1983 the molded tympanic heterograft has been employed in over 1500 cases of tympanic membrane reconstruction at the Second ENT Clinic of the University of Parma, Italy. The results obtained in 1042 patients operated on from July 1974 to December 1981 are reported herein. The tympanic heterograft offered our patients a 90% chance of cure and anatomic restoration of the middle ear; a functional recovery and serviceable hearing can be expected in more than 85% of cases. The heterograft is available in sealed sterilized vials that can be stored at room temperature; its sterility can be maintained for up to five years. There is no need for a graft bank because the heterograft can be kept in the operating theater among the other prostheses that are readily available to the surgical team.     

Endoscopic endonasal management of encephaloceles in children: An eight-year experience

Objective

Skull base encephaloceles are difficult to diagnose and to treat. Traditionally, they are approached externally via craniotomic routes. Endoscopic management of skull base defects is the standard treatment in adults. Our aim is to evaluate the efficacy and safety of endoscopic endonasal repair of basal encephaloceles in the paediatric population.

Methods

Retrospective evaluation of paediatric encephaloceles managed endoscopically at a tertiary referral centre.

Results

Eleven subjects fitted the criteria of the study. Mean age at surgery was 6.1 ± 4.6 SD years, while mean follow-up was 46.5 ± 28 SD months. Most of the defects were located in the anterior cranial fossa. All patients were managed successfully with no complications.

Conclusions

Endonasal endoscopic management of congenital encephaloceles is feasible in paediatric patients. Meticulous pre-op neuroimaging is of paramount importance when dealing with such cases.     

Tracheotomy — A satisfactory method in the treatment of acute epiglottitis. A clinical and functional follow-up study

A follow-up study, including clinical examination, X-ray and function tests, of 27 children with acute epiglottitis treated with tracheotomy at the ENT-Department, Mölndal Hospital during 1971–1975 has been performed. The function tests were an important part of the investigation and included measurement with the He-dilution technique, flow—volume curves and the forced oscillation technique. No child had any detectable tracheal stenosis or any other serious per- or postoperative complication. The only complication at all was one ugly scar on the neck. The tracheotomized patient needs very little sedation and the time spent at the intensive care unit can be shorter than for those patients treated with nasotracheal intubation.     

A comparison of endotracheal intubation and tracheostomy in the management of acute epiglottitis in children in the tropics

In children, acute epiglottitis is rapidly fatal due to airway obstruction by swollen supraglottic structures, but the oedema is short-lived. Therefore, in many centres short-term endotracheal intubation has replaced tracheostomy as the method of choice for relieving the obstruction. We have tried both methods in 15 children over a period of three years under conditions of limited material and human resources. Tracheostomy was found to be safer. It was concluded that it is better to have a live healthy child with a small scar in the neck than a dead child without a scar.     

Acute epiglottitis in the adult.

Acute epiglottitis in the adult is a rare disease, which has shown an appreciable increase since the sixties and in our locality since 1984. We present a review of the cases registered in our hospital, analyzing their aetiology, evolution and treatment. The disease is most likely to be suspected in the presence of any patient having a sudden dysphagia, especially if he shows symptoms of an acute infection and a lack of oropharyngeal pathology.     

Ipratropium treatment for rhinorrhoea in patients with perennial rhinitis. An open follow-up study of efficacy and safety

The efficacy and safety of intranasal ipratropium therapy for rhinorrhoea were tested in an open follow-up study of 20 adult patients with perennial rhinitis. The reduction of nasal hypersecretion of 40-45% obtained with 80 micrograms four times daily in a placebo-controlled study, was maintained over the next 4 weeks although the mean daily dose was reduced to 180 micrograms. The spray treatment was well tolerated and rhinoscopy, measurements of the sense of smell and the secretory responsiveness of the nose before and 10-48 months after the start of the trial did not reveal any signs of serious local adverse effects. It is concluded that ipratropium nasal spray is effective in the treatment of rhinorrhoea and appears to be safe for long-term use.     

Special considerations in epiglottitis in children.

The often perplexing clinical findings in acute epiglottitis are produced by the relative absence of cyanosis and hypercapnia in the face of severe hypoxemia, since expiration and CO2 elimination are not impaired. A serious situation arises when intubation is unseccessful. Six hundred otolaryngologists were polled to determine whether life-saving tracheotomy in such a situation could be performed within the time limits.     

Neonatal nasotracheal intubation: An evaluation

A retrospective review of 100 surviving infants, all requiring nasotracheal intubation in the neonatal period for greater than 24 hr. was performed to assess the morbidity of this form of airway management. Seventy infants needed only one intubation, 22 were intubated twice and 8 infants required 3 intubations. No infant had evidence of laryngeal or tracheal sequelae, either in the immediate newborn period or on follow-up. Nasotracheal intubation by an experienced practitioner with appropriate tube fixation and toilet coupled with the use of low pressure ventilation and a consistent extubation routine will result in very low long-term tracheal morbidity in the neonate.     

The cytological diagnosis of nasopharyngeal carcinoma from exfoliated cells collected by suction method. An eight-year experience

A specially designed metallic tube, which is connected to a suction-pump and passed through the oral cavity into the nasopharynx for collecting exfoliative cells by negative pressure suction, is recommended in the diagnosis of nasopharyngeal carcinoma (NPC). From the beginning of 1973 through October 1976, among 458 cases of NPC, 405 cases were cytologically positive (with a positive rate of 88.4 per cent), and 433 cases were biopsy positive (with a positive rate of 94.3 per cent). In 1977, from January to October, among 116 cases of NPC, 103 cases were cytologically positive (with a positive rate of 88.8 per cent), and 108 cases were biopsy positive (with a positive rate of 93.1 per cent). The cytopathological features of the exfoliative NPC cells were correlated with the histopathological types of NPC. The degree of lymphocytic infiltration among the cancer cells in smears was compared with that in biopsies. They coincided roughly with each other. It indicates that one might interpret the immunological lymphocytic reaction by the number and typing of lymphocytes in smears too. The authors conclude that this cytological method is fairly dependable, less traumatic to the mucosa, convenient, and easily managed. A large number of tumor cells can be collected. It can also reflect the histologic typing of cancer cells. It can be used as a routine procedure in the clinico-pathological diagnosis of NPC, as well as in a mass screening program.     

Tracheotomy in acute supraglottitis (epiglottitis) : The treatment of choice

The provocative title of this presentation has been chosen quite deliberately, knowing full well that the subject of management of patients with severe airway obstruction is a very controversial one. The views expressed do not necessarily represent those of all of the staff dealing with these problems at the Hospital for Sick Children.