Synchronous airway lesions in children: An analysis of characteristics and comorbidities

Objectives

To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy.

Methods

Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial).

Results

Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06–9.41; OR 3.0, 95% CI 1.05–8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84–6.52; OR 2.0, 95% CI 0.76–5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention.

Conclusions

The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.     

Anatomic Variants on Computed Tomography in Congenital Aural Atresia and Stenosis

Objectives

To quantitatively analyzing the anatomic variants on temporal computed tomography (CT) in congenital external auditory canal stenosis (EACS), congenital aural atresia (CAA), and normal ear structure.

Methods

Through a retrospective study, we analyzed 142 temporal high-resolution CT studies performed in 71 microtia patients. The following 6 parameters were compared among the three groups: Marx classification, medial canal diameter, vertical facial nerve (VFN) anterior displacement, tegmen mastoideum position, tympanic cavity volume, and malleus-incus joint or malleus-incus complex (MIC) area.

Results

The results showed that the microtia distributions in the Marx classification in these three groups were significantly different, as 86% (31 of 35) of ears with major microtia (third-degree dysplasia) had an atresia, and in 54.8% (23 of 42) of the minor microtic (first-degree or second-degree) ears, the bony or cartilaginous part of the external auditory canal was stenotic. Measurement data also showed that the potential medial canal diameter of the atresia group was obviously shorter than that of the stenosis group. The VFN anterior displacement and temporomandibular joint backward-shift together lead to medial canal diameters in ears with atresic canals that is smaller than those with stenotic canals. The tegmen mastoideum position was not significantly different between the three groups.

Conclusion

The mal-development of the external auditory canal is significantly associated with auricle and middle ear developmental anomalies. Compared with CAA ears, EACS have better development of the auricle, canal, tympanic cavity and MIC and relatively safer surgical operation except for the position of the tegmen mastoideum and the VFN.     

Second branchial cleft fistulae: Patient characteristics and surgical outcome

Backgrounds

Second branchial cleft anomalies predispose to recurrent infections, and surgical resection is recommended as the treatment of choice. There is no clear consensus regarding the timing or surgical technique in the operative treatment of these anomalies. Our aim was to compare the effect of age and operative techniques to patient characteristics and treatment outcome.

Methods

A retrospective study of pediatric patients treated for second branchial sinuses or fistulae during 1998–2012 at two departments in our academic tertiary care referral center. Comparison of patient characteristics, preoperative investigations, surgical techniques and postoperative sequelae.

Results

Our data is based on 68 patients, the largest series in the literature. One-fourth (24%) of patients had any infectious symptoms prior to operative treatment. Patient demographics, preoperative investigations, use of methylene blue, or tonsillectomy had no effect on the surgical outcome. There were no re-operations due to residual disease. Three complications were observed postoperatively.

Conclusions

Our patient series of second branchial cleft sinuses/fistulae is the largest so far and enables analyses of patient characteristics and surgical outcomes more reliably than previously. Preoperative symptoms are infrequent and mild. There was no difference in clinical outcome between the observed departments. Performing ipsilateral tonsillectomy gave no outcome benefits. The operation may be delayed to an age of approximately three years when anesthesiological risks are and possible harms are best avoided. Considering postoperative pain and risk of postoperative hemorrhage a routine tonsillectomy should not be included to the operative treatment of second branchial cleft fistulae.     

Effects of FGF-2 and OP-1 in vitro on donor source cartilage for auricular reconstruction tissue engineering

Objective

Microtia is a congenital partial or total loss of the external ear with current treatment approaches involving autologous construction from costal cartilage. Alternatively, tissue engineering provides possible use of normal or microtia auricular chondrocytes harvested from patients. This study investigated effects in vitro of basic fibroblast growth factor (FGF-2) and osteogenic protein 1 (OP-1) on human pediatric normal and microtia auricular chondrocytes and their potential proliferation and differentiation for cellular expansion. A working hypothesis was that FGF-2 promotes proliferation and OP-1 maintains an auricular phenotype of these cells.

Methods

Two patients, one undergoing otoplasty and one an ear construction, yielded normal and microtia auricular chondrocytes, respectively. The two donor sets of isolated chondrocytes were equally divided into four experimental cell groups. These were controls without added growth factors and cells supplemented with FGF-2, OP-1 or FGF-2/OP-1 combined. Cells were cultured 3, 5, 7, and 10 days (3 replicates/time point), counted and assayed by RT-qPCR to determine elastin and types II and III collagen gene expression.

Results

Compared to control counterparts, normal and microtia chondrocytes with OP-1 alone were similar in numbers and varied in elastin and types II and III collagen expression over all culture times. Compared to respective controls and chondrocyte groups with OP-1 alone, normal and microtia cell groups with FGF-2 had statistically significant (p < 0.05) enhanced proliferation and statistically significant (p < 0.05) decreased elastin and types II and III collagen expression over 10 days of culture.

Conclusions

FGF-2 effects on normal and microtia chondrocytes support its use for increasing cell numbers while OP-1 maintains a chondrocyte phenotype, otherwise marked by increasing type III collagen expression and cellular dedifferentiation to fibroblasts in culture.     

Epidemiological analysis of Microtia: A retrospective study in 345 patients in China

Objective

To study the epidemiologic characteristics of microtia in China and to investigate the possible risk factors with respect to the classification of microtia.

Methods

A total of 345 patients with microtia were studied. All patients were taken an intentional physical examination and classified into five types. A detailed questionnaire concerning the maternal conditions during pregnancy was filled out by patient's mother. The frequencies of the relative factors were counted and the variables were statistically analyzed using Chi Square and Fisher's tests in the five types of microtia.

Results

Most cases of microtia (88.12%) were sporadic and 72.75% of all cases occurred in males. It was more seen unilateral, especially affected on the right side (55.94%). A total of 195 patients (56.52%) were isolated microtia. In the rest of non-isolated microtia patients, 37.97% of the cases had hemifacial microsomia, which was the most common associated deformity. Thirty-four patients (9.86%) belonged to typical familial microtia. Three maternal factors showed significant differences in the five types of microtia, which were perinatal virus infection, high prior miscarriages and prevention treatments for threatened abortion.

Conclusions

The majority of microtia cases in China are sporadic and usually more common in males. Mothers who have prior miscarriages over 3 times or perinatal virus infection seem to be more likely to have severe microtia infants.     

Wyniki strukturalne myringoplastyki metodą podkładania

Introduction

The method of tympanic membrane repairing is called myringoplasty.

Aim of the study

We analysed the reasons of failure of this procedure.

Material and methods

The structural results were observed among 36 patients under restricted criteria with diagnosed chronic otitis media. The unsuccessful procedure was one with reperforation. We studied Eustachian tube function and also localisation and size of the perforation.

Results

The failure rate was 25%, which was mainly observed among individuals with incorrect Eustachian tube function – 70% and margin perforations – 50%. The localisation and the size of the perforation did not matter.

Conclusions

The main reasons of myringoplasty failure were incorrect Eustachian tube function and margin perforations of tympanic membrane.     

Zastosowanie chrząstki w mikrochirurgii ucha środkowego. Wskazania,technika, wyniki

Aim

The use of cartilage in tympanoplasties in the shape of monolytic cartilage–perichondrium autografts or several particles as a cartilage-palisade.

Materials and methods

The retrospective analysis concerned 216 clinical cases. The cartilage palisade technique was performed in 163 tympanoplasties. In 53 cases the tympanoplasty was carried out with the use of the monolytic cartilage–perichondrial composite graft: cartilage-island, cartilage-cork or cartilage-mat.

Results

In the type I and II of tympanoplasty the air bone gap (ABG) <10 dB showed 70% of patients operated with the use of monolytic cartilage–perichondrial composite autografts and 73% using the cartilage-palisade technique.

Conclusions

The usefulness of cartilage in tympanoplasties is much the same in cartilage–palisade technique as well as in monolytic, non-palisade technique.     

Use of positron emission tomography scanning in metastatic head and neck cutaneous squamous cell cancer: Does it add to patient management?

Purpose

To evaluate the impact of whole-body positron emission tomography in comparison to staging by conventional methods alone in management of patients with head and neck cutaneous squamous cell cancer (cSCC) with confirmed regional nodal metastasis.

Materials and methods

This is a retrospective case cohort study carried out at a tertiary referral cancer centre. The participants were thirty-one adults with head and neck cSCC and regional nodal metastasis. The original treatment plan based on conventional cross-sectional imaging and clinical examination was compared to the final treatment plan after additional PET staging to evaluate the impact of 18F-FDG PET–CT on patient management.

Results

Addition of 18F-FDG PET–CT did not change the management in 24/31 (77%) of patients. In four cases the 18F-FDG PET–CT failed to pick up biopsy proven metastatic disease. Two patients who had reduced extent of surgery have shown no features of regional failure after one year of follow-up.

Conclusion

Overall the management in majority of head and neck cSCC patients with regional metastasis does not change by addition of 18F-FDG PET–CT over conventional imaging.     

Feasibility and toxicity of concurrent chemoradiation for elderly patients with head and neck cancer

Objectives

Although concurrrent chemoradiation is increasingly used for patients with locally advanced head and neck cancer, many elderly patients receive radiation alone due to toxicity concerns. We evaluate acute and late toxicity among patients age ≥ 65 who received concurrent chemoradiation for head and neck cancer.

Design

Retrospective review.

Setting

Tertiary care center.

Participants

Between 6/2003 and 8/2011, 40 consecutive patients age ≥ 65 underwent combined chemoradiation for head and neck cancer. Ten patients were treated in the postoperative setting and 30 underwent definitive chemoradiation. Twenty-eight patients received concurrent platinum-based chemotherapy and 12 received concurrent weekly paclitaxel. Treatment plans were designed to provide a dose of 66–72 Gy at 2–2.12 Gy/fraction to > 95% of the gross tumor volume in the definitive setting or for positive margins and 60–66 Gy at 2 Gy/fraction post-operatively. Median follow-up was 23.2 months (range: 0–94.4 months).

Main outcomes measures

Acute skin and mucosal toxicity, unplanned treatment interruptions, and chronic treatment related toxicity including gastrostomy tube dependence as graded by the CTCAE v3.0.

Results

Eight patients (20%) required a radiation treatment break of ≥ 3 days. Thirteen (33%) required unplanned hospitalization during or immediately following treatment. No grade 4 + skin or mucosal toxicity was noted. Five patients remained PEG tube dependent at > 1 year. One patient developed non-healing mandibular osteoradionecrosis > 3 years following chemoradiation. The 2-year Kaplan–Meier estimate of overall survival was 55%.

Conclusion

Higher-than-expected rates of in-patient hospitalization with significant acute toxicity were noted in this cohort with a correspondingly high rate of radiation treatment breaks. Late toxicity rates were similar to those observed in historical controls with younger patients. Careful patient selection criteria should be employed for elderly patients considering concurrent chemoradiation for head and neck cancer.     

Risk stratification based on thyroid cytology: Can we rely on national data?

Purpose

Determine correlation of malignancy rates between fine needle aspiration (FNA) biopsy and surgical specimen in an urban academic environment.

Methods

Retrospective review at an academic medical center of fine needle aspiration biopsies and surgical specimens in a head and neck otolaryngology practice between 2000 and 2012.

Results

Of the 74 biopsies diagnosed as follicular lesion, 34 (45.9%) were malignant. Of the 45 biopsies diagnosed as follicular neoplasm, 22 (48.9%) were malignant. These results are significantly higher than the average risk of malignancy cited by the American Thyroid Association of 5%–10% and 20%–30% for follicular lesions and neoplasms respectively.

Conclusions

The rate of malignancy based on a FNA diagnosis of indeterminate cytology (follicular lesion or follicular neoplasm) can vary greatly among different institutions. Thyroid surgeons should be aware of their local pathology practices to better guide therapy and counsel patients.     

Microdebrider removal under suspension laryngoscopy: An alternative surgical technique for subglottic hemangioma

Objective

To describe microdebrider removal of subglottic hemangiomas and evaluate the efficacy of this procedure.

Methods

This retrospective study was conducted at an otorhinolaryngology department. Seven consecutive patients with subglottic hemangiomas who failed to respond to pharmacologic treatment were treated by microdebrider removal under suspension laryngoscopy. Respiratory symptoms and hemangioma status were assessed preoperatively and postoperatively.

Results

The mean age of patients at disease onset was 68 days (range, 24–120 days), and their mean age at the time of surgical treatment was 132 days (range, 55–195 days). Their initial pharmacologic treatment included steroids, propranolol, and/or antibiotics. The mean percentage of airway obstruction was initially 36% (range, 30–50%), and this value changed to 61% (50–80) before surgery. Microdebrider removal of hemangiomas was successful in all patients without any intraoperative or postoperative complication. The mean operative time was 30 min (range, 21–47 min). Three patients required orotracheal intubation for 12 or 24 h after surgery, and no reintubation or tracheotomy was required in this series. Symptoms such as stridor and inspiratory retraction were resolved approximately 72 h after surgery, but wheezing was generally resolved at a later time point. One year later, no respiratory symptom was noted in these patients, and endoscopic examination revealed a sufficient glottis opening.

Conclusions

Surgical removal with a microdebrider is advantageous as a routine surgical technique for small and moderate pediatric subglottic hemangioma.     

Cochlin in autoimmune inner ear disease: Is the search for an inner ear autoantigen over?

Definition

Autoimmune inner ear disease (AIED) is characterised by a rapidly progressive, often fluctuating, bilateral sensorineural hearing loss over a period of weeks to months. It is an uncommon disease accounting for less than 1% of all cases of hearing impairment or dizziness. The diagnosis is often missed and this impacts on the prognosis as the condition responds well to steroids and immunosuppressants if recognised early.

Lacuna in knowledge

No useful specific test for autoimmunity affecting the inner ear exists.

Objective of study

To gather evidence regarding cochlin in AIED.

Methodology

Systematic review of human studies and animal experimental studies on inner ear antigens was undertaken.

Search strategy

We searched MEDLINE (1965–2012), and Pubmed for relevant studies. A combination of key words for inner ear, autoimmunity (autoimmune, immune mediated) and cochlin were used.

Results

A number of antigens have been implicated in autoimmune inner ear disease. Cochlin is a major component of the extracellular matrix in the inner ear and a promising candidate. We present evidence in literature on the role of this protein in the pathogenesis of autoimmune inner ear disease.     

Craniofacial modifications in Ivorian melanoderm children with chronic retronasal obstruction

Objective

To determine the influence of the chronic retro nasal airway obstruction on craniofacial morphology.

Methods

It was a case–control study which included fifty-eight melanoderm children aged from 3 to 6 years (31 males and 27 females), divided in 2 samples. A studied group of 29 habitual snorers presenting chronic retro nasal obstruction due to enlarged adenoid and a control group of 29 age matched children selected among patients consulting for routine evaluation. Patients who had used topical or systemic medication for the nose, as well as those who had undergone adenoidectomy were excluded from the study.Children were submitted to history taking then ENT and orthodontic examination. Linear and angular cephalometric measurements were used for craniofacial features evaluation.

Results

Significant craniofacial anomalies were found in patients presenting chronic retro nasal obstruction: shortened cranial base and mandibular plane length, widened cranio-cervical flexure, forwardness of hyoid bone, reduced nasopharyngeal airway space, widened of oropharyngeal and hypopharyngeal airway space.

Conclusions

Our study suggests that craniofacial modifications due to chronic retro nasal obstruction lead to pharyngeal airway readjustment. Persistent retro nasal obstruction should be corrected early in life in order to avoid skeletal modifications appearance.     

Revision surgery for chronic otitis media: Characteristics and outcomes in comparison with primary surgery

Objectives

To analyze the characteristics and outcomes of revision surgery for chronic otitis media (COM) with or without cholesteatoma, and to compare with those of primary surgery.

Methods

A retrospective chart review was performed on 208 patients who underwent revision surgery for COM over an 8-year period (1997–2004) and 51 patients who underwent a primary canal wall down mastoidectomy (CWDM), and were followed for more than 12 months.

Results

Recurrent or residual cholesteatoma was found in 49.5% of cases. The mastoid tip and perisinal air cells were the most frequent sites of residual air cells. As a result of revision surgery, a dry and safe ear was achieved in 88.5% of patients. A residual air–bone gap (ABG) of ≤30 dB was achieved in 70.1% of cases with a revision CWDM with ossiculoplasty. In comparison with 51 patients who underwent primary CWDM, the disease control rate was not different. However, postoperative hearing result after ossiculoplasty was worse and longer healing time was required after revision surgery.

Conclusion

The characteristics and surgical outcome of recurrent COM must be fully understood for complete control of the disease.     

Endolaryngeal dilatation versus laryngotracheal reconstruction in the primary management of subglottic stenosis

Objectives

The scope of the study is to compare endolaryngeal dilatations (ED) with laryngotracheal reconstruction with cartilage grafting (LTRCG) in terms of restenosis.

Methods

Pediatric subglottic stenosis patients treated in Hacettepe University, between 2002 and 2012 were retrospectively evaluated. Patients who had ED or LTRCG as primary management were included in the study. EDs were grouped into bronchoscopic dilatation (BD), laser incision and balloon dilatation (LBD) and cold knife incision and balloon dilatation (CKBD). The groups were evaluated in terms of restenosis and decannulation rates.

Results

There were 35 patients (9 females, 26 males; mean age 4.42). LTRCG was performed in 16 patients (9 anterior and 7 anterior and posterior grafts). EDs were performed in 19 patients with 6 CKBDs, 7 LBDs and 6 BDs. There were 3 grade II, 13 grade III cases in the LTRCG group while 4 grade I, 6 grade II, 8 grade 3 and 1 grade 4 in the ED group. Overall decannulation rate was 97% (34/35) in all patients. Restenosis was higher in the ED group (63.2%) than the LTRCG group (31.3%) with rates of CKBD 16.7% (1/6), LBD 71.4% (5/7) and BD 100% (6/6). Restenosis rates were found to be increasing with higher grades (grade I–25%, grade II–66%, grade III–85%).

Conclusion

ED may need more repetitive interventions than LTRCG due to restenosis. Less restenosis might be observed when balloon is used for dilatation and cold knife for mucosal incisions.     

The Gruppo Otologico experience of endolymphatic sac tumor

Objective

Endolymphatic sac tumor (ELST) is a rare low grade adenocarcinoma of the skull base. During the past decade the number of the reported cases has increased. This study exposes our experience in the management of ELST with a review of the literature.

Study design

Retrospective study of patients with ELST at a quaternary referral otology and skull base center.

Methods

A review of the records from the Gruppo Otologico revealed 7 patients treated for ELST. All papers containing series of three or more cases of ELST published in the English literature were selected for analysis.

Results

Hearing loss and tinnitus were present in almost all our cases. All of them were evaluated with audiometric tests, computed tomography and magnetic resonance imaging. All the patients were treated surgically with preservation of the facial nerve and preoperative embolization was performed in 5 patients. Genetic study was performed on all our cases and revealed the presence of von Hippel–Lindau syndrome in one patient who had the tumor as the initial manifestation of his syndrome. None of the patients received postoperative radiotherapy and one of them had recurrence of the tumor 13 years following surgery.

Conclusions

Complete surgical resection with preoperative embolization of large tumors is the mainstay treatment for ELST. The facial nerve should not be sacrificed unless it is totally invaded by the tumor. A long term follow up is recommended and the role of postoperative adjunctive radiotherapy is still controversial.     

Chordektomia wewnętrzna i zewnętrzna poprzez rozszczepienie krtani i zastosowaniem lasera CO2

Introduction

The aim of this work was to evaluate the therapy results of patients with glottic carcinoma in the T1NoMo advanced clinical stage on internal or external chordectomy via the thyroid cartilage with the use of CO₂ laser.

Material and methods

The study was conducted in 110 patients, including 7 women aged 52–68 and 103 men aged 52–73, who were treated in the Department of Otolaryngology and Laryngological Oncology, Military Medical Academy Teaching Hospital in Lodz, during the years 2010–2012, due to laryngeal carcinoma (T1N0M0).

Results

The studied material was subjected to external chordectomy via laryngofissure in 51 men (46.4%), and internal chordectomy with the use of CO₂ laser in 52 men (47.2%) and 7 women (6.4%). In the patients operated via laryngofissure, the following types of external chordectomy were performed: IV – in 25 cases (49.0%), Vc – in 12 cases (23.6%), and Vb and Vd – in 7 cases each (13.7% each). Internal chordectomy was conducted with the use of the following types: III – in 31 cases (52.5%), IV – in 15 cases (25.4%) and Vd – in 13 cases (22.1%). During the post-operative follow-up of 1–3 years, no recurrence of carcinoma was observed.

Conclusions

The place and size of carcinoma are often dependent on the type of internal and external chordectomy, which is preceded by tracheotomy and is usually dependent on a patient's consent. Too short post-operative follow-up does not allow for the comparison of effective therapies of the two surgical methods.