Ear,nose and throat manifestation of viral systemic infections in pediatric patients

Objective/MethodsAn exhaustive review of literature was performed to investigate available data and evidences regarding pediatric otolaryngologic manifestations of viral systemic infections.Results/ConclusionsModern otolaryngologists should be familiar with viral systemic infections since many have head and neck manifestations. Cooperation between otolaryngologist, paediatrician and virologist can be considered and excellent tool in diagnosis and treatment of these diseases in particular when complications occur.     

Pediatric human immunodeficiency virus infection: an otolaryngologist's perspective

Children with human immunodeficiency virus (HIV) frequently have recurrent otitis media, chronic rhinorrhea, parotitis, cough and other common pediatric otolaryngologic problems. As these complaints often occur before more unusual opportunistic infections or pulmonary conditions prompt a diagnosis of acquired immunodeficiency syndrome (AIDS), members of our specialty are liable to see HIV-positive children before infection with the virus has been recognized. Children with HIV infection are also likely to be referred to us after diagnosis, as is any immunosuppressed child with otolaryngologic infections. These children may require procedures such as bronchoscopy, sinus irrigations or tympanocentesis. The subject of this review is the natural history of pediatric HIV infection with special emphasis on otolaryngologic manifestations and recommendations for safe techniques of examination and treatment.     

Review of practical recommendations for otolaryngologists and head and neck surgeons during the COVID-19 pandemic

IntroductionOtolaryngologists are at very high risk of COVID-19 infection while performing examination or surgery. Strict guidelines for these specialists have not already been provided, while currently available recommendations could presumably change in course of COVID-19 pandemic as the new data increases.ObjectivesThis study aimed to synthesize evidence concerning otolaryngology during COVID‐19 pandemic. It presents a review of currently existing guidelines and recommendations concerning otolaryngological procedures and surgeries during COVID-19 pandemic, and provides a collective summary of all crucial information for otolaryngologists. It summarizes data concerning COVID-19 transmission, diagnosis, and clinical presentation highlighting the information significant for otolaryngologists.MethodsThe Medline and Web of Science databases were searched without time limit using terms ‘‘COVID-19”, “SARS-CoV-2” in conjunction with “head and neck surgery”, “otorhinolaryngological manifestations”.ResultsPatients in stable condition should be consulted using telemedicine options. Only emergency consultations and procedures should be performed during COVID-19 pandemic. Mucosa-involving otolaryngologic procedures are considered high risk procedures and should be performed using enhanced PPE (N95 respirator and full face shield or powered air-purifying respirator, disposable gloves, surgical cap, gown, shoe covers). Urgent surgeries for which there is not enough time for SARS-CoV-2 screening are also considered high risk procedures. These operations should be performed in a negative pressure operating room with high-efficiency particulate air filtration. Less urgent cases should be tested for COVID-19 twice, 48 h preoperatively in 24 h interval.ConclusionsThis review serves as a collection of current recommendations for otolaryngologists for how to deal with their patients during COVID-19 pandemic.     

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Routine peri-operative pediatric tracheotomy care

ObjectivesTo develop consensus recommendations for peri-operative tracheotomy care in pediatric patients.MethodsExpert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.ResultsConsensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals.ConclusionPediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population.     

Unusual otolaryngological manifestations of certain systemic bacterial and fungal infections in children

ObjectiveSystemic bacterial and fungal infections may sometimes present local manifestations within otolaryngological district whose early detection may be useful in establishing a correct diagnosis and more appropriate treatment. This paper reviews certain systemic bacterial and fungal diseases presenting ENT manifestations in the pediatric population from an otolaryngological perspective.MethodsA medline searching for specific issues was performed in order to achieve more information as possible with regards to ENT manifestation of systemic bacterial and fungal infections. Limits for pediatric age were used. Two separate sections for bacterial and fungal disease are included. The section on systemic bacterial infections considers cat-scratch disease, Lyme borreliosis, actinomycosis, Lemierre's syndrome and congenital syphilis, and the section on systemic fungal infections includes candidiasis, aspergillosis and histoplasmosis.ConclusionsPediatricians and ear, nose and throat (ENT) specialists, approaching head and neck disorders in children, should therefore consider them among the possible differential diagnoses. This means that physicians need to recognize the first head and neck manifestations of systemic infections promptly in order to be able to treat them efficaciously and avoid the dangerous systemic spreading of the infective process.     

Risiko von Blutungen nach Adenotomie und Tonsillektomie

Background

Hemorrhage after tonsillectomy and adenoidectomy remains a serious complication. Therefore, routine preoperative coagulation screening, including activated partial thromboplastin time (aPTT), prothrombin time (PT) and platelet count (PLC), are regularly performed, also for medicolegal reasons. In the recently published statement of the German Society of Otorhinolaryngology, Head and Neck Surgery the need for routine preoperative coagulation screening is discussed, but so far no standardized procedure had been established. According to this statement – at least for children – routine preoperative coagulation screening is not mandatory as long as the thorough medical history provides no evidence for a coagulation disorder (http://www.hno.org/kollegen/gerinnung_te_ae.html). The present study was undertaken to determine the occurrence of postoperative hemorrhage on the one hand, and the incidence of abnormal preoperative routine coagulation parameters or pathological anamnesis findings on the other.

Patients and Methods

In 688 patients, a standardized clinical history was obtained using a questionnaire. Coagulation screening included aPTT, PT, and PLC was also carried out. Bleeding complications were then correlated with anamnesis features and abnormalities in coagulation screening.

Results

In 39 (5.7%) of the 688 patients we found abnormal coagulation values, which were confirmed in repeated analyses. In six of these a detailed analysis revealed occult coagulation disorders requiring correction only in the case of bleeding complications who were previously unknown. Fifteen patients were already known to have a coagulation disorder, and the anamnesis identified no additional patient at risk. Thus, 21 patients with coagulation disorders requiring correction in the case of a bleeding complication underwent surgery. However, only eight (38%) of these showed abnormal routine coagulation parameters. Surgical treatment of postoperative hemorrhage was required in 12 patients, all of whom had normal values for aPTT, PT and PLC.

Conclusion

The frequently performed determination of routine coagulation parameters (aPTT, PT, PLC) is not able to reliably identify relevant coagulation disorders or to predict the risk for postoperative hemorrhagic complications after adenoidectomy or tonsillectomy.     

Otolaryngologic surgery in children with von Willebrand disease

OBJECTIVE: To assess the efficacy, safety, and complications of otolaryngologic surgery in children with von Willebrand disease (vWD) undergoing surgery. DESIGN: A prospective, controlled study of 41 children with vWD who underwent surgery between June 1, 1999, and January 31, 2001. SETTING: A tertiary care, university-based children's hospital. INTERVENTIONS: All children had a preoperative diagnosis of vWD. The patients were treated with either a protocol that includes the use of desmopressin acetate and tranexamic acid (37 children) or factor VIII concentrate in children with a positive history of seizures (4 children). MAIN OUTCOME MEASURES: Immediate and delayed postoperative bleeding, hyponatremia, seizures, and urine output. RESULTS: Two adenotonsillectomy patients (5%) had an immediate postoperative hemorrhage. Delayed postoperative bleeding was not detected in our patients. Severe hyponatremia occurred in 2 patients (1 of them with clinical manifestations). CONCLUSIONS: Our management of children with vWD was efficacious in otolaryngologic surgery. One child had important adverse effects with the use of desmopressin (seizure). Thus, the use of desmopressin should be weighed and closely monitored.     

Acquired bilateral adductor laryngeal paralysis in neonates and children: A case series and a systematic review

ObjectivesTo present a series of acquired bilateral adductor laryngeal paralysis (BAdLP) and review the literature on clinical manifestations and management.MethodsA retrospective review of a single tertiary care practice of pediatric otolaryngology was conducted. Patients were identified from a surgical database spanning twelve years of practice (2002–2013). The variables documented included gender, age at presentation, co-morbid conditions, documented laryngeal findings on endoscopy, management and outcome. A systematic review of the literature was conducted to identify reports on BAdLP in children and associated conditions.ResultsFive cases (four girls and one boy) ranging from 3 months to 16 years of age were identified. All cases were documented using rigid and/or flexible laryngoscopy. In four cases, the onset was after major cardiac surgery complicated by cerebral vascular accidents, while one followed a thalamic stroke. Four were managed with tube feeding. Only three papers reported BAdLP in children.ConclusionsThe cases identified were all acquired after a central neurological insult. The profile is distinct from the congenital adductor form of laryngeal paralysis previously described. However, the symptom complex is identical. We believe this is the largest case series from one center to be reported.     

Does topical application of tranexamic acid reduce intraoperative bleeding in sinus surgery during general anesthesia?

IntroductionTranexamic acid is a hemostatic agent, which inhibits fibrin degradation, which may be beneficial in controlling bleeding during surgery.ObjectivesThe purpose of this study was to provide a meta-analysis and review of the effects of tranexamic acid on hemorrhage and surgical fields and side effects on patients during endoscopic sinus surgery.MethodsTwo authors independently searched six databases (Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane library) from the start of article collection until July 2018. Postoperative complications such as intraoperative bleeding, operative time, hypotension, nausea, vomiting, and coagulation profile were included in the analysis of tranexamic acid (Treatment Group) and placebo (Control Group) during the operation.ResultsThe amount of blood loss during surgery was statistically lower in the treatment group compared to the placebo group, and the surgical field quality was statistically higher in the treatment group than in the placebo group. On the other hand, there was no significant difference in operation time, hemodynamics, or coagulation profile between groups. In addition, tranexamic acid had no significant effect on vomiting and thrombosis compared to the Control Group.ConclusionThis meta-analysis has shown that topical administration of tranexamic acid can reduce the amount of bleeding during surgery and improve the overall quality of the surgery. Hemodynamic instability during surgery, vomiting after surgery, or abnormal clotting profile were not reported. Additional studies are needed to confirm the results of this study because there are fewer studies.     

Evaluation and management of coagulation disorders in elective surgical patients

This is a review of coagulation disorders in elective surgical patients. The study represents both a personal experience in unusual bleeding and clotting disturbances and, in addition, a 15-year review of unique problems evaluated by the Coagulation Department of a local general hospital. Of this group of cases, 17 were selected to illustrate the purpose of this report. Potential “bleeders” due to coagulation defects may be missed preoperatively both by history and by commonly accepted screening tests. The incidence of this situation is fortunately rare, but unfortunately this dulls the likelihood of early diagnosis with the initiation of specific treatment measures. The limitations of preoperative screening tests were apparent and should not be considered a fail-safe detector of coagulation disorders. Qualitative and quantitative factor assays are the cornerstone for accurate diagnosis and a guide for specific replacement therapy. Although most surgeons will never have an in-depth knowledge of hematology, the importance of having some fundamental awareness is apparent. This study encourages surgeons not to take the hemostatic mechanism for granted, and to see the need for understanding hematologic diagnosis and treatment.     

合并轻度出血性疾病的扁桃体和(或)腺样体切除术患儿围手术期管理

目的 探讨合并轻度出血性疾病并接受扁桃体和(或)腺样体手术的患者围手术期处理方案,提高围手术期安全。方法 回顾分析6例合并诊断为轻度出血性疾病并行扁桃体和(或)腺样体手术患者资料。收集患者的基本信息、出血风险评估、手术方案、围术期控制出血策略等,结合文献复习分析此类患者的诊疗要点。结果 6例患者凝血情况：血友病A FVIII:C 4.8%, APTT 57.7s;血友病B:FIX:C 4.2%, APTT 59.3s;血友病B FIX:C 5.9%, APTT 57.2s; FIX:C 64.3%, APTT 52.3s; FVII:C 73.3%; FX:C 66.2%; FIX:C 58.4%; APTT 44s; APTT 35s; PLT 102×10⁹/L。3例血友病患者给予凝血因子替代治疗+抗纤溶治疗,2例凝血功能障碍患者给予新鲜冰冻血浆治疗,免疫性血小板减少患者治疗无特殊。在血液科、麻醉科、供血科配合下6例患者顺利完成腺样体扁桃体手术,手术的平均手术时间&平均出血量(血友病63.3 min&16.7 mL,凝血功能障碍47.5 min...     

Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage

PurposeTo determine if tranexamic acid (TXA) reduces the need for operative re-cauterization in the setting of a post-tonsillectomy hemorrhage (PTH).MethodsA retrospective chart review was performed on 1428 adult and pediatric patients who underwent tonsillectomy over a two-year period at a tertiary care hospital with continuous otolaryngologic coverage. Collected data of PTH patients included age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, length of stay (LOS), the requirement of a blood transfusion, day of PTH, TXA usage and route, complications from TXA administration, and TXA failure requiring operative intervention.ResultsThe incidence of pediatric PTH during the study period was 5.7 %. Twenty-seven out of fifty-five PTH patients received topical, nebulized, or intravenous TXA. No adverse effects were noted with TXA administration. TXA usage provided resolution of the PTH in 77.8 % of patients. No significant differences were found in age, gender, BMI, LOS, ASA classification, rate of blood transfusion, or TXA treatment modality between the patients that received TXA and those that did not.ConclusionsTreatment of PTH with TXA appears to reduce the need for operative control of PTH. In the setting of reducing operative risk, improving health care utilization, or in a setting without immediate otolaryngologic provider coverage, the role of TXA is promising. Further larger clinical or multi-institution studies are needed to determine the efficacy of TXA, its route of administration, and its optimal dosage.Level of evidenceLevel 4, Retrospective cohort study.     

The role of 24 h pH-recording in pediatric otolaryngologic gastro-esophageal reflux disease

The purpose of this study was to investigate the role of 24 h pH monitoring for the diagnosis of otolaryngologic including rhinologic manifestations of gastro-esophageal reflux (GER) in children and if possible to correlate the results with the efficacy of medical treatment. This is a retrospective study of 72 children from January 1997 to December 1999. The children were separated into three groups according to the main symptoms (although association of symptoms was frequent): rhinologic (n=28), laryngotracheal (n=28) and pharyngeal-otologic (n=16). With the classical gastroenterologic criterion (> or =4.2% of total time at pH < 4), the pH monitoring was positive in 56% of the patients. However, this criterion does not seem to be sensitive for otolaryngologic gastro-esophageal reflux disease (GERD) because multiple daytime short reflux episodes are often involved. Indeed, the pH monitoring was positive in 75% of the patients (82% in the rhinologic group) when a number of 40 episodes in 24h was also taken into account. The success rate of medical treatment was about 80% in case of positive pH recording. This study underlines that GER is an important factor in pediatric otolaryngologic diseases.     

The significance of bleeding disorders in patients with epistaxis

Background

Epistaxis can have a variety of different local or systemic causes. It is the cardinal symptom of von Willebrand disease (VWD), the most frequent congenital bleeding disorder with a prevalence of approximately 1%. The usual routine coagulation screening tests (PT, APTT, platelet count) are not sufficient to diagnose VWD, factor XIII (FXIII)-deficiency or platelet dysfunction.

Method

A prospective study was conducted implementing enhanced coagulation screening for bleeding disorders in a total of 100 inpatients admitted for epistaxis.

Results

A bleeding disorder was found in 13%. In eight patients VWD was diagnosed, in six patients FXIII-deficiency was found, and in one patient both.

Conclusion

The prevalence of bleeding disorders in patients with epistaxis is higher than in the general population. Epistaxis can be the primary symptom of chronic inflammatory disease or malignant disease. A thorough anamnesis is necessary and in cases of doubt additional testing for underlying disorders is recommended.     

Complications of revision surgery in case of bleeding after thyroid surgery: A systematic review

ObjectivesThe aim of this review is to evaluate complications in patients undergoing surgical control of bleeding after thyroid surgery. Secondly, we have analyzed the rate of the main complications.MethodsThe databases PubMed and EMBASE were searched for articles regarding complications after revision thyroid surgery for bleeding. A Systematic review methodology based on Preferred Reporting Items for Systematic Reviews and Meta-analysis was performed.ResultsNine studies met the inclusion criteria, six are retrospectives and three retrospectives controlled. The overall rate of bleeding after thyroid surgery was 1.38%. In these patients, the most common complication after revision surgery for bleeding is hypoparathyroidism 24.9% (95% CI: 20.7–29.5) followed by recurrent laryngeal nerve injury 8.1% (95% CI: 6.4–10.1) and wound infection 4.5% (95% CI: 2.5–7.6). Tracheostomy and other lethal complications are rarely described.ConclusionAlthough rare, complications after surgical control of bleeding in patients undergoing thyroid surgery can be serious. Therefore, in order to optimize the surgical outcomes, standardized protocol providing early detection and precise hemostasis procedure, is needed. Specific patient-informed consent for this condition should be created.     

Postoperative tonsillectomy bleeding complications in children: A comparison of three surgical techniques

Objective & hypothesisStated in the Null form: There will be no difference in primary or secondary hemorrhage rate in children undergoing tonsillectomy or adenotonsillectomy across three surgical techniques: PEAK Plasmablade, electric monopolar cautery, coblation.Study designRetrospective chart analysis.SettingAcademic Medical Center: Children's Hospital.Subjects & methodsElectronic chart data were collected from patient's age 2–18 years who underwent tonsillectomy, with or without adenoidectomy, at a tertiary pediatric hospital between June 2011 to May 2013 by electric monopolar cautery, coblation, or PEAK PlasmaBlade. Treatment outcomes following each of these surgical approaches, relative to rate of post-operative primary and secondary bleeding, hospital admission, and emergency department visits were compared.ResultsA total of 1780 patients that had tonsillectomy or adenotonsillectomy were evaluated. There was a significant difference in bleed rate by age with older patients having more bleeding post-procedure than their younger counterparts. There was also a difference in bleeding frequency by diagnosis. Patients with a diagnosis of OSA were less likely to experience a postoperative bleed than children with either recurrent tonsillitis or both. Significance was evident between post-op hemorrhage rate and instrumentation (χ² = 11.17, df = 2, p = 0.004). The majority of bleeds occurred with coblation (58.9%), while PEAK had only 17.8% and cautery 23%.ConclusionThe null hypothesis was rejected. That is, PEAK PlasmaBlade was safe and effective, with statistically less postoperative bleeding and ED visits, especially when compared to coblation techniques. Coblation patients had the highest rates of postoperative bleeding.     

An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy

Preoperative coagulation studies are commonly employed in order to try to identify the 2-4% of all patients undergoing tonsillectomy/adenoidectomy surgery who experience hemorrhagic complications. In an atmosphere of increasing cost consciousness, evaluation of the efficacy of screening tests is warranted. The records of 994 out of 1050 patients consecutively scheduled for tonsillectomy, adenoidectomy or T&A over a 2.5-year period were retrospectively reviewed in order to determine the usefulness of partial thromboplastin (PTT) and prothrombin time (PT) screening in predicting surgical and postsurgical bleeding. For patients with no history or clinical signs indicating possible bleeding disorder, preoperative PT and PTT failed to predict bleeding as an outcome. Also no patients were identified in this series to have previously undiagnosed coagulopathies on the basis of screening PT/PTT. The purpose of any screening test is to identify disease early enough for therapeutic intervention to be effective. Although preoperative PT/PTT will occasionally identify an unsuspected von Willebrand's or other coagulopathy, the prevalence of bleeding disorders in patients with negative history and examination is low enough that PT/PTT has essentially a zero predictive value for surgical bleeding. Screening PT/PTT should therefore be reserved for patients with known or suspected coagulopathies.     

Turbinate surgery in pediatric patients: A worldwide survey

ObjectiveImpaired nasal breathing is a common condition among pediatric patients, being rhinitis the most common cause. In recent years, turbinate surgery, mainly turbinate radiofrequency ablation (TRA), has increased in popularity amongst pediatric otolaryngologists and rhinologists as a safe and useful technique to address turbinate hypertrophy in pediatric patients. The present paper is designed with the aim of assessing the current worldwide clinical practice regarding turbinate surgery in pediatric patients.MethodsThe questionnaire was developed based on previous researches, by a group of 12 experts from the rhinology and pediatric otolaryngology research group belonging to the Young Otolaryngologists of the International Federation of Otorhinolaryngological societies (YO-IFOS). The survey was then translated to 7 languages and sent to 25 scientific otolaryngologic societies around the globe.Results15 scientific societies agreed to distribute the survey to their members. There were 678 responses from 51 countries. From them, 65% reported to usually perform turbinate surgery in pediatric patients. There was a statistically significant increased likelihood of performing turbinate surgery for those practicing rhinology, sleep medicine, and/or pediatric otolaryngology compared to other subspecialties. The main indication to perform turbinate surgery was nasal obstruction (93.20%); followed by sleep disordered breathing (53.28%), chronic rhinosinusitis (28.70%) and facial growth alterations (22.30%).ConclusionsThere is no general consensus on the indications and ideal technique for turbinate reduction in children. This dissension arises mainly from the lack of scientific evidence. The points with highest agreement (>75%) between respondents is the use of nasal steroids prior to surgery; reintroducing nasal steroids in allergic patients; and performing turbinate surgery as day-case surgery.