Postobstructive pulmonary edema after laryngospasm in the otolaryngology patient

CONTEXT: Post-obstructive pulmonary edema (PPE) is an uncommon complication which develops immediately after the onset of acute airway obstruction such as laryngospasm or epiglottitis (type I) or after the relief of chronic upper airway obstruction such as adenotonsillar hypertrophy (type II). OBJECTIVE: To describe the development of type I PPE following laryngospasm in pediatric and adult patients undergoing otolaryngologic surgical procedures other than those for treatment of obstructive sleep apnea. DESIGN: Retrospective case series of 13 otolaryngology patients from 1996 to 2003. SETTING: Tertiary care teaching hospital and its affiliates. PATIENTS: 13 patients (4 children, 9 adults, 5 males, 8 females) ranging in age from 9 months to 48 years. RESULTS: Operative procedures included adenoidectomy, tonsillectomy, removal of an esophageal foreign body, microlaryngoscopy with papilloma excision, endoscopic sinus surgery, septorhinoplasty, and thyroidectomy. Six patients required reintubation. Treatment included positive pressure ventilation, oxygen therapy, and diuretics. Seven patients were discharged within 24 hours and the others were discharged between 2 and 8 days postoperatively. There were no mortalities. CONCLUSION: Laryngospasm resulting in PPE may occur in both children and adults after various otolaryngologic procedures. Among the subgroup of children, our study is the first to report its occurrence in healthy children without sleep apnea undergoing elective surgery.     

Practice of pediatric otolaryngology: results of the future of pediatric education II project

OBJECTIVES: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. METHODS: Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age <18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people. CONCLUSIONS: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.     

The safety of preoperative sedation in children with sleep-disordered breathing

OBJECTIVE: To prospectively monitor children who received preoperative sedation with midazolam hydrochloride prior to adenotonsillectomy (T&A) for treatment of sleep-disordered breathing with continuous pulse-oximetry to detect potential respiratory compromise. DESIGN: Prospective, observational study. SETTING: Hospital-based pediatric otolaryngology practice. PATIENTS: Seventy children, aged 1-12 years, diagnosed with sleep-disordered breathing by clinical evaluation or polysomnography (PSG), with a median RDI of 14.25, undergoing T&A. METHODS: Children underwent a standardized anesthesia protocol including preoperative oral midazolam hydrochloride 0.5mg/kg, standard American Society of Anesthesiologists (ASA) monitoring, mask induction with sevoflurane, muscle relaxant with reversal if indicated, and intravenous dexamethasone sodium phosphate 0.5mg/kg. Children were monitored in the hospital until discharge criteria were met. Selected children with severe OSA were monitored overnight on the pediatric floor or the pediatric intensive care unit. Adverse respiratory events were defined as upper airway obstruction, hypoventilation, desaturation, bradycardia, or sustained lethargy. MAIN OUTCOME MEASURES: Incidence of pre and postoperative obstructive complications. RESULTS: During the study period only two patients (2.9%) had a measurable adverse event directly related to the administration of the sedation. CONCLUSION: Based on sporadic reports of adverse airway events in children with obstructive sleep apnea receiving sedation, these children frequently do not receive preoperative sedation. Given the low morbidity of preoperative sedation in our population, many children with sleep-disordered breathing may safely be pre-medicated.     

Ear,nose and throat disorders in children with Down syndrome

OBJECTIVE: To document the reasons for which children with Down syndrome were referred to a pediatric otolaryngology practice, the underlying causes for these referrals, and the complications of routine surgical therapy. STUDY DESIGN: The study is a retrospective review of children referred to the Pediatric Otolaryngology Clinic at the University of New Mexico Health Sciences Center (Albuquerque, NM) during a period of 2.5 years. METHODS: Data were collected on 55 parameters related to ethnicity, demographics, diagnosis, surgical therapy, complications, and systemic comorbid conditions. RESULTS: The ethnicity of the study population was predominantly Hispanic or Latino (62%). The majority of children (76%) were referred for upper airway obstruction. Obstructive sleep apnea and laryngomalacia were the most common disorders in these children. An otological disorder was diagnosed in 70% of the children. Complications occurred after 27% of procedures for insertion of pressure equalization (PE) tubes to treat recurrent otitis media. Systemic comorbid conditions were present in 93% of the children, and the most common was gastroesophageal reflux disease. CONCLUSIONS: Obstructive sleep apnea and laryngomalacia were the most common reasons for referral of children with Down syndrome. Routine surgical procedures that required general anesthesia caused complications that are not common in other children. Treatment for systemic comorbid conditions should be considered as a component of therapy for otolaryngological disorders in children with Down syndrome.     

Pediatric tracheotomies: changing indications and outcomes

OBJECTIVE/HYPOTHESIS: To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970. STUDY DESIGN: Retrospective chart review at a major tertiary care children's hospital. METHODS: On children who underwent tracheotomy at Children's Hospital of the King's Daughters (Norfolk, VA) between 1988 and 1998, inpatient and outpatient records were reviewed. Of 218 tracheotomies, sufficient data were available on 204. Indications for tracheotomy were placed into the following six groups: craniofacial abnormalities (13%), upper airway obstruction (19%), prolonged intubation (26%), neurological impairment (27%), trauma (7%), and vocal fold paralysis (7%). RESULTS: The average age at tracheotomy was 3.2 +/- 0.6 years. Although the prolonged intubation group was significantly younger than all others, the neurological impairment and trauma groups were significantly older. Decannulation was accomplished in 41%. Time to decannulation was significantly higher in the neurological impairment and prolonged intubation groups, but was significantly shorter in the craniofacial group. Complications occurred in 44%. Overall mortality was 19%, with a 3.6% tracheotomy-related death rate. Comparison of our series to other published series of pediatric tracheotomies since 1970 shows fewer being performed for airway infections and more for chronic diseases, with a corresponding increase in duration of tracheotomy and decreased decannulation rates. CONCLUSIONS: Tracheotomy is a procedure performed with relative frequency at tertiary care children's hospitals. While children receiving a tracheotomy have a high overall mortality, deaths are usually related to the underlying disease, not the tracheotomy itself.     

Congenital high airway obstruction syndrome and airway reconstruction: an evolving paradigm

OBJECTIVES: To refine the classic definition of, and provide a working definition for, congenital high airway obstruction syndrome (CHAOS) and to discuss the various aspects of long-term airway reconstruction, including the range of laryngeal anomalies and the various techniques for reconstruction. DESIGN: Retrospective chart review. PATIENTS: Four children (age range, 2-8 years) with CHAOS who presented to a single tertiary care children's hospital for pediatric airway reconstruction between 1995 and 2000. CONCLUSIONS: To date, CHAOS remains poorly described in the otolaryngologic literature. We propose the following working definition for pediatric cases of CHAOS: any neonate who needs a surgical airway within 1 hour of birth owing to high upper airway (ie, glottic, subglottic, or upper tracheal) obstruction and who cannot be tracheally intubated other than through a persistent tracheoesophageal fistula. Therefore, CHAOS has 3 possible presentations: (1) complete laryngeal atresia without an esophageal fistula, (2) complete laryngeal atresia with a tracheoesophageal fistula, and (3) near-complete high upper airway obstruction. Management of the airway, particularly in regard to long-term reconstruction, in children with CHAOS is complex and challenging.     

The use of balloon-expandable metallic stents in the treatment of pediatric tracheomalacia and bronchomalacia

OBJECTIVE: To evaluate the use of balloon-expandable metallic stents in the treatment of children with tracheomalacia and bronchomalacia in whom conventional therapy has failed. DESIGN: Retrospective case series. SETTING: Tertiary pediatric otolaryngology and cardiothoracic surgery referral center. PATIENTS: Six patients were identified as having undergone bronchoscopic placement of metallic balloon-expandable stents between 1994 and 1997. The age at stent placement, prior surgical interventions, and indications for and sites of stent placement were noted. Also, the complications related to stent placement and the current airway status of the patients were reviewed. INTERVENTIONS: Twelve balloon-expandable metallic angioplasty stents (Palmaz; Johnson & Johnson Interventional Systems Co, Warren, NJ) were placed bronchoscopically in 6 patients. Six stents were placed in the lower trachea, and 6 were placed in the main bronchi. The stents were balloon expanded under fluoroscopic guidance. MAIN OUTCOME MEASURE: Discontinuation of mechanical ventilation. RESULTS: The age at stent placement ranged from 1.5 to 38 months (mean age at placement, 10 months). The indications for stent placement were (1) tracheomalacia or bronchomalacia, (2) pericardial patch or slide tracheoplasty failure, and (3) bronchomalacia caused by tetralogy of Fallot and large pulmonary arteries. The primary complication of stent placement was postoperative granulation tissue formation. One patient required the removal of 2 tracheal stents because of granulation tissue formation. There were 2 deaths in the series, 1 possibly related to stent placement. Four of the 6 patients were weaned from mechanical ventilation, and 3 experienced prolonged relief of airway obstruction. CONCLUSIONS: Metallic balloon-expandable stents are effective in relieving lower tracheomalacia and bronchomalacia in select patients. Only patients in whom conventional therapy has failed should be considered for stent placement.     

Paediatric tracheostomy. Fifty-seven operations on fifty-three children

Fifty-seven operations on 53 patients represents the total experience of tracheostomy in children under 13 years during 1964-1985 in an area with half a million inhabitants. No complication occurred during surgery and no deaths were related to the operations. Complications followed 16 out of 30 (53%) operations on children under three years and four out of 27 (15%) of the remainder, an overall complication rate of 35%. Many fewer operations have been required since 1973 because of the successful employment of nasotracheal intubation in the treatment of upper and lower airway obstruction caused by acute infection. Obstruction by-pass remains the commonest function of tracheostomy, with congenital lesions and trauma now the commonest causes of obstruction as opposed to acute infection in the earlier years. Despite the successful use of nasotracheal intubation there were absolute indications for tracheostomy--blockage of the nasotracheal tube; inability to intubate a child with epiglottitis; and necessity for an artificial airway of long duration.     

Complications and determinants of length of stay for inpatient pediatric otolaryngologic procedures

OBJECTIVE: To identify clinical factors associated with morbidity, mortality, and length of stay (LOS) for inpatient pediatric otolaryngologic procedures. STUDY DESIGN: Retrospective cohort study. METHODS: Records of patients undergoing pediatric otolaryngologic procedures were extracted from the National Hospital Data Survey for the calendar years 1995 through 1999. These records were examined to determine demographics, morbidity, mortality, type of procedure (as defined by anatomic subsite), and LOS. The effects of morbidity and type of procedure on LOS were identified. RESULTS: A total of 4861 children underwent inpatient otolaryngologic procedures. The overall morbidity rate was 4.6%. The most common morbidity was pneumonia, occurring in 171 patients (3.5%). The presence of any morbidity was associated with a significantly increased LOS (18.4 days vs 4.6 days; P<.001). The occurrence of pneumonia was associated with an increase in LOS to 19.7 days vs 4.7 days in patients without pneumonia (P<.001). Procedures involving the larynx, trachea, or esophagus carried the longest LOS (12.3 days; P<.001) among all procedural categories. The overall mortality rate was distinctly low at 0.4%. However, the occurrence of morbidity was associated with an increased risk of death, with an odds ratio of 8.0 (P =.001). Mortality was highest (13 of 18 deaths) after procedures on the larynx, trachea, or esophagus. CONCLUSIONS: Medical complications in children undergoing inpatient otolaryngologic procedures are associated with significantly increased LOS. Despite procedural complexity, overall mortality is remarkably low. Efforts to decrease medical morbidity in this population may result in decreased LOS and improved clinical outcomes.     

Diagnosis and therapy for airway obstruction in children with Down syndrome

OBJECTIVES: To document the causes of upper airway obstruction in a population of children with Down syndrome and to highlight the role of associated comorbidities. DESIGN AND SETTING: Review of 23 cases involving children with Down syndrome who were referred for upper airway obstruction over a 2(1/2)-year period to the Pediatric Otolaryngology Service of the University of New Mexico, Albuquerque. METHODS: Data on the following variables were obtained: reason for referral, demographics, diagnosis, surgical procedures, complications, and comorbidities. RESULTS: The children ranged in age from 1 day to 10.2 years (mean age, 1.8 years; median age, 6 months). Thirteen children were male and 10 were female. None of the children had subglottic stenosis. Laryngomalacia was the primary diagnosis in 10 children (43%), 8 of whom were younger than 1 month. Obstructive sleep apnea was the primary diagnosis in 11 children (48%), 8 of whom were older than 2 years. All children with obstructive sleep apnea and 4 children with laryngomalacia had a secondary ear, nose, and throat disorder. Gastroesophageal reflux was a comorbidity in 14 children (61%). CONCLUSIONS: The causes, severity, and presentation of upper airway obstruction in children with Down syndrome are related to the age of the child and to associated comorbidities. The treatment of comorbidities and secondary ear, nose, and throat disorders is an integral component of the surgical management of upper airway obstruction in such cases.     

Pre- and postoperative evaluation by acoustic rhinometry of children submitted to adenoidectomy or adenotonsillectomy

INTRODUCTION: Nasal obstruction is a common symptom in children and its etiology includes septal deviation, choanal atresia, allergic rhinitis and hypertrophy of the adenoids. Hypertrophy of the adenoids and hypertrophic rhinitis are the most frequent causes of nasal obstruction in the pediatric population, with adenoidectomy being the main surgery carried out during childhood. OBJECTIVE: To analyze the rhinograms of children with nasal obstruction before and after surgery and to compare them with those obtained for children without respiratory complaints. STUDY DESIGN: A clinical prospective study. METHODS: Thirty-five patients with adenoid or adenotonsillar hypertrophy were submitted to otolaryngologic examination and acoustic rhinometry before and 30-60 days after surgery. The control group consisted of 18 children without nasal complaints. RESULTS: Significant differences in the rhinograms were observed before and after surgery, but not between patients and the control group. CONCLUSION: We conclude that acoustic rhinometry is well tolerated by children, and is a rapid and noninvasive method. The technique is valuable for interindividual comparisons, but not for the assessment of different groups.     

Tracheostomy in young patients: indications and long-term outcome

Diagnostic and treatment modalities have changed substantially over the past years in the field of pediatrics and neonatal medicine. As a result, the indications and outcome after tracheostomy in young patients have evolved. The aim of this study is to present our experience with pediatric tracheostomies and provide an up-to-date review of the literature with special focus on current trends. The complete medical records of 85 children and adolescents (up to age 18) which underwent tracheostomy from January 1990 until March 2008 were reviewed. Telephone interviews were conducted to evaluate the childrens further clinical course. The indications for tracheostomy were upper airway obstruction (27%), craniofacial syndromes (3.5%), long-term mechanical ventilation (22.3%), neurological deficit (25.9%), trauma and sequelae (16.5%) and bilateral vocal cord paralysis (4.7%). The average age of patients at the time of tracheostomy was 4.7 years (range, 2 days–18 years) but there were significant differences between the six indication groups. Children under the age of 7 years comprised 72.9% of all patients. The mean cannulation time was 21.6 months; 50.6% of the patients could be successfully decannulated. Life-threatening complications occurred in 6 patients (7%). The total mortality rate was 18.8%; the tracheostomy related mortality rate was 0%. In the past 30 years, short-term tracheostomy was commonly performed for infectious causes such as epiglottitis. Nowadays, the majority of patients are very young children with severe and chronic diseases. This fact accounts for the relatively low decannulation rates, long cannulation times and high mortality. The tracheostomy related mortality on the other hand, is comparatively low.     

Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea.

A retrospective study of pediatric patients with obstructive sleep apnea who underwent adenotonsillectomy between 1987 and 1990 was undertaken to determine the frequency of postoperative respiratory compromise and to determine if risk factors for its development could be identified. Sixty-nine patients less than 18 years old had polysomnographically documented obstructive sleep apnea and were observed postoperatively in the pediatric intensive care unit. Of these, 16 (23%) had severe respiratory compromise, defined as intermittent or continuous oxygen saturation of 70% or less, and/or hypercapnia, requiring intervention. Compared with patients without respiratory compromise, these patients were younger (3.4 +/- 4 vs 6.1 +/- 4 years) and had more obstructive events per hour of sleep on the polysomnogram (49 +/- 41 vs 19 +/- 30). They were more likely to weight less than the fifth percentile for age (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.4 to 18.7), to have an abnormal electrocardiogram and/or echocardiogram (OR, 4.5; 95% CI, 1.3 to 15.1), and to have a craniofacial abnormality (OR, 6.2; 95% CI, 1.5 to 26). Multiple logistic regression analysis revealed the most significant risk factors were age below 3 years and an obstructive event index greater than 10. Children with obstructive sleep apnea are at risk for respiratory compromise following adenotonsillectomy; young age and severe sleep-related upper airway obstruction significantly increase this risk. We recommend in-hospital postoperative monitoring for children undergoing adenotonsillectomy for obstructive sleep apnea.     

Airway pathologic abnormalities in symptomatic children with congenital cardiac and vascular disease

OBJECTIVE: To identify the epidemiological profile of airway abnormalities in symptomatic children with cardiac or vascular anomalies. DESIGN: Retrospective medical chart review. SETTING: Tertiary referral pediatric hospital. PATIENTS: Children with airway-related symptoms and coexistent cardiac or vascular abnormality were included. The source for patient identification was a prospectively kept database. MAIN OUTCOME MEASURES: Endoscopic airway diagnoses, presenting airway symptoms, cardiac diagnoses, other comorbid conditions and pertinent diagnoses, patient demographics, source of referral, treatments, and follow-up. RESULTS: The study population comprised 77 patients (45 male and 32 female; mean age, 18.2 months) treated between June 2002 and July 2006. Only 4 patients had no findings. The most common airway abnormality was laryngeal paralysis (n=32), followed by subglottic stenosis (n=18). Congenital and acquired lesions were equally encountered (n=70 and n=64, respectively). The most frequent presentation was intolerance to feed (n=51) (stridor and/or failure of extubation). Of the 77 patients, 32 (42%) required airway surgical intervention (open vs closed); 36 (47%) still require otolaryngologic follow-up; and 32 (42%) had a named syndrome or general multisystem condition. CONCLUSIONS: At least 3% of all children with cardiac disease will harbor airway problems. Laryngeal paralysis was the most common problem encountered. Given the successes achievable in treating children with complex cardiac abnormalities, attention should be paid to concomitant and consequential airway problems. Counseling processes should acknowledge the role of early otolaryngologic involvement.     

Antihypertensive drug-induced angioedema causing upper airway obstruction in children

Objective

Angioedema is a well-described complication arising from the use of antihypertensive agents in the adult population. However, its occurrence and potential for upper airway compromise in pediatrics has only been sporadically reported in the literature. Our objective is to report and review the occurrence of antihypertensive-induced angioedema in the pediatric population and the potential for airway compromise.

Methods

Charts of 42 patients admitted to Cincinnati Children's Hospital Medical Center with the discharge diagnosis of angioedema (ICD-9 code 995.1) from January 2000 to January 2010 were reviewed. Of the 42 charts, 3 cases had angioedema induced by antihypertensive drugs and all 3 resulted in upper airway obstruction. Summary and findings of the data collected from the medical chart review included demographics, chief complaint(s), past medical history, hospital course, antihypertensive drugs used, diagnostic test(s), medical treatment, and time from onset of symptoms to resolution. In addition, a PubMed literature search using the terms angioedema and antihypertensive drugs was performed to review its occurrence in pediatrics. The previous literature case reports were compared to our cases to further characterize and emphasize the clinical features of this occurrence in children and adolescents.

Results

Despite the well-known occurrence of antihypertensive drug-induced angioedema causing airway obstruction in adults, only 4 case reports have been previously published in children. At our institution, we describe 3 children who developed acute angioedema with upper airway obstruction after the chronic use of antihypertensive medications [2 drugs in the ACE inhibitor class (enalapril and lisinopril), and 1 drug in the calcium channel blocker class (CCB; amlodipine)]. In all 3 cases, the symptoms resolved within 1 week after the antihypertensive agent was discontinued.

Conclusion

Upper airway obstruction can occur at any age when taking antihypertensive drugs. Particular caution should be applied to ACE inhibitors and CCBs in this regard. With the increasing use of antihypertensive agents in the pediatric population, clinicians should be alert to the possibility of angioedema with upper airway obstruction as a potential lethal adverse effect.     

Airway complications from laryngoscopy and panendoscopy

Laryngoscopy and panendoscopy can cause airway complications. To determine the risk to the airway from reintubation following general anesthesia in otolaryngology patients, we examined recovery room and anesthesia records at the Albany Veterans Administration Medical Center covering a 10-year period. From this information we determined the incidence of recovery room reintubation and studied airway risk factors associated with otolaryngologic endoscopy. From 1975 to 1984, 10,060 surgical patients were intubated at the Albany VA Medical Center. Only 17 patients (0.17%) required reintubation. Of 1,365 otolaryngology patients intubated during the same period, 324 had laryngoscopy and 302 had panendoscopy. Significantly, four laryngoscopy patients (1.2%) and nine panendoscopy patients (3%) required recovery room intubation. Nine endoscopy patients needed reintubation within 1 hour of extubation. We conclude that the risk of postoperative airway compromise is significantly greater among patients who underwent diagnostic laryngoscopy and panendoscopy than among patients who had general anesthesia for other reasons.     

Anesthetic complications of tympanostomy tube placement in children

OBJECTIVE: To determine the incidence of perioperative anesthesia complications during bilateral myringotomy with tympanostomy tube placement (BMTT). SETTING: Tertiary care children's hospital where otolaryngology attending physicians and residents performed surgical procedures. Anesthesia providers included pediatric anesthesiologists, residents, nurse anesthetists, and students. METHODS: Medical record review was performed for a consecutive series of 3198 children undergoing BMTT (1000 prospectively, 2198 retrospectively). For the prospectively studied patients, major adverse events, which included laryngospasm and stridor, and minor adverse events, including upper airway obstruction, prolonged recovery, emesis, and persistent postprocedural agitation, were noted. Also recorded were the patient's American Society of Anesthesiologists (ASA) physical class status, age, concurrent medical conditions, and type of anesthesia provider. RESULTS: Fewer than 9% of prospectively studied pediatric patients experienced a minor adverse event, whereas a major event occurred in 1.9%. Eighty-one percent of the events experienced were attributable to agitation or prolonged recovery. Neither ASA status (P =.38), age (P =.15), nor type of anesthesia provider (P =.06) were significantly related to the occurrence of an adverse event. However, a child with an acute or chronic illness has 2.78 times the odds of experiencing an adverse event compared with a child with no illness (P<.001). CONCLUSIONS: Anesthesia administered for placement of tympanostomy tubes by physicians who specialize in the care of children in a tertiary care children's hospital is safe. The most significant predictor of a minor anesthetic event during BMTT is the presence of a preexisting medical condition or concurrent acute illness.     

Otolaryngologic manifestations of the mucopolysaccharidoses.

A retrospective review of 45 children with mucopolysaccharidoses was performed to determine the frequency of complications related to the head and neck. In this series, every patient had at least one complication involving the head and neck region, and in over half, operative intervention by the otolaryngologist was required. Upper airway obstruction occurred in 17 (38%) and necessitated a tracheostomy in 7 (16%). Cervical spine instability occurred in 8 (18%), making airway management difficult. Recurrent respiratory infections occurred in 17 (38%), and chronic recurrent middle ear effusions were noted in 33 (73%). This review demonstrates that children afflicted with the mucopolysaccharidoses frequently have otolaryngologic-related complications that are common throughout their life span and often the primary management issue in their continuing care. The otolaryngologic management of these patients is outlined based on the results of this study and review of the relevant literature.     

小儿危重呼吸道阻塞的临床诊断和治疗

目的探讨小儿危重呼吸道阻塞的临床诊断及治疗方案。方法1995年1月至2005年1月汕头市中心医院耳鼻咽喉头颈外科收治73例小儿危重呼吸道阻塞，采用快速诊断和及时治疗的临床处理方法，分析应用该方法的效果。结果73例危重患者中炎症性疾病28例，占38．4％；异物33例，占45．2％，其他还有喉乳头状瘤8例，喉气管支气管痉挛3例，咽部畸胎瘤1例。采用气管插管和气管切开分别为39例次和27例次，占53．4％和37．0％，只采用内科治疗9例。72例患者均于12h内确诊并解除重度呼吸道阻塞，1例未治自动出院。发生严重并发症者23例，发生率为31．5％；手术并发症3例，发生率为4．1％。死亡4例，治愈68例，治愈率为93．2％。结论小儿危重呼吸道阻塞的病因复杂，病情凶险，快速诊断、及时解除呼吸道阻塞和采取有效的病因治疗方案，有利于提高治疗效果。     

Assessment and management of pain in pediatric otolaryngology

IntroductionPain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction.ObjectivesThe aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services.MethodologyNarrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016.Results129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services.ConclusionsWe present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.