Pediatric Endoscopic Dacryocystorhinostomy Failures: Who and Why?

OBJECTIVE: The objectives of this study are to report outcomes of pediatric patients with nasolacrimal duct obstruction (NLDO) who underwent primary endoscopic dacryocystorhinostomy (DCR) and discuss causes of failure. STUDY DESIGN: The authors conducted a retrospective case series. METHODS: Charts of all patients less than 16 years of age who underwent primary endoscopic DCR from 1997 to 2004 were reviewed. Patients were grouped based on the presence or absence of facial anomalies or syndromes and whether the NLDO was congenital or acquired. Success was defined as complete resolution of symptoms, improvement included anatomic patency or partial symptoms, and failure as no improvement or demonstration of patency. RESULTS: Thirty-four patients (43 ducts) aged 11 months to 14 years were identified. There were 17 males and 17 females. Follow up ranged from 2 to 54 months (average, 21 months). Twenty-four patients (29 ducts) had congenital NLDO, seven patients (11 ducts) had congenital syndromes associated with craniofacial abnormalities, and three patients (three ducts) had acquired NLDO. In patients with congenital NLDO without craniofacial abnormalities or syndromes, 22 of 29 eyes (76%) were cured with another three (10%) showing improvement. Only one of 11 (9%) eyes of patients with congenital craniofacial abnormality or syndrome experienced complete resolution and only four of 11 (36%) eyes showed improvement. Of the patients with acquired NLDO, two of three (67%) of the eyes were cured and one (33%) improved. CONCLUSIONS: Endoscopic DCR is safe and effective for most children, although patients with craniofacial abnormalities or syndromes are extremely difficult to cure.     

Endoscopic Endonasal Management of Pseudotumor Cerebri: Is it Effective?

PURPOSE: To study the efficacy and safety of endoscopic endonasal optic nerve fenestration for the management of idiopathic intracranial hypertension (IIH). DESIGN: A prospective study at a tertiary care center. PATIENTS AND METHODS: All patients with a final diagnosis of IIH from July 2001 to March 2005 were included and subjected to detailed neuro-ophthalmologic examination and endoscopic endonasal optic nerve fenestration. Postoperative visual acuity and the perimetry was compared with the preoperative status, and the results were analyzed using the chi2 test. RESULTS:: Of the 18 patients included in the study, 17 had improvement in vision postoperatively. Fifteen patients had visual deterioration in the other eye as well, and of these, 12 had improvement, obviating the need for surgery on the other side. Complications were minimal and in the form of synechiae in two of the cases. DISCUSSION: A number of procedures have been described for the management of this entity, and each is associated with a significant morbidity; therefore, there was a need for a minimally invasive procedure. The procedure adopted in the series is minimally invasive and is associated with a 94.5% success rate and minimal morbidity. CONCLUSIONS: Endoscopic endonasal optic nerve fenestration is a safe, minimally invasive, and extremely effective procedure for the management of IIH.     

Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice?

Between 1991 and 1998, 12 patients with cerebrospinal fluid rhinorrhea were operated on using the intranasal endoscopic approach. The procedure was successful in 10 cases. The endoscopic approach failed in two patients who had larger bony defects and herniating meningoencephaloceles. This paper analyzes the case material with respect to the etiology and site of leakage. The value of computed tomography and magnetic resonance imaging for preoperative localization of the leak is discussed. The technique of underlay fascia graft is described and discussion ensues regarding potential pitfalls that may lead to failure of leak closure.     

Improved Infant Swallowing After Gastroesophageal Reflux Disease Treatment: A Function of Improved Laryngeal Sensation?

OBJECTIVE: The objective of this study was to describe improvements in pediatric swallowing after gastroesophageal reflux treatment. STUDY DESIGN: The authors conducted a retrospective database and chart review at two tertiary care children's hospitals. PARTICIPANTS: Patients (21 males, 7 females) ranged in age from 1 to 32 months. All patients had clinical evidence of gastroesophageal reflux disease (GERD) as well as evidence of dysphagia with aspiration (laryngeal vestibule and/or trachea) or hypopharyngeal pooling on flexible endoscopic evaluation of swallowing and sensation testing (FEESST) or videofluoroscopic swallow study (VSS). INTERVENTION: Each child underwent either medical or surgical intervention for control of their GERD. OUTCOME MEASURES: Outcome measures were change in laryngopharyngeal sensation and swallowing function with repeat swallow evaluation after GERD treatment. RESULTS: A significant improvement in both swallow function and sensory testing was demonstrated after GERD treatment. CONCLUSIONS: GERD may result in decreased laryngopharyngeal sensitivity, which may contribute to pediatric swallowing dysfunction. Control of GERD may improve swallow function. These findings have important clinical implications that need further study.     

Do biofilms contribute to the initiation and recalcitrance of chronic rhinosinusitis?

Chronic rhinosinusitis is a common disease whose underlying aetiopathogenesis has not been completely understood. Amongst a range of other potential environmental triggers in this disease, a role has recently been proposed for bacterial biofilms. Adopting the biofilm paradigm to explain the initiation and maintenance of this disease may help to clarify previous inconsistencies in this disease that have resulted in the role of bacteria being questioned. Of particular interest is the association of bacterial biofilms with recalcitrant disease states. Over the last five years, research has progressed rapidly since biofilms were first identified on the surface of diseased sinonasal mucosa. Their presence there has now been associated with more severe disease that is often recalcitrant to current management paradigms. Technological advances are allowing accurate characterization of the bacterial and fungal species within these biofilms, which would appear to be an important step in improving our understanding of how these bacterial communities might interact with the host to cause disease. This is an unanswered, yet highly important, question in this field of research that will undoubtedly be an area of investigation in the near future. As the body of evidence suggesting biofilms may be involved in this disease grows, research interest has switched to the development of antibiofilm therapies. Given the unique properties of bacteria existing in this form, biofilm eradication strategies will need to incorporate novel medical therapies into established surgical practices as we attempt to improve the outcomes of our most difficult patients.     

Timing of Endoscopic Sinus Surgery in Children: Is There an Impact on Outcome?

OBJECTIVES/HYPOTHESIS: Endoscopic sinus surgery in children continues to be a controversial issue. Major factors in determining when to operate are the duration of the disease and duration of medical treatment. STUDY DESIGN: Prospective study of children referred to a tertiary center. PATIENTS AND METHODS: Eighty-three patients underwent endoscopic sinus surgery for refractory chronic sinusitis. All patients were followed prospectively to evaluate their response to surgery for a mean follow-up period of at least 1 year. A chi2 analysis and logistic regression analysis were performed to determine statistical difference between duration of symptoms and outcome. RESULTS: The overall success rate of endoscopic sinus surgery was 80%. Children who had surgery between 6 and 12 months of symptoms despite continued medical therapy had an 84% success rate, those who had surgery between 12 and 18 months had a 74% success rate, and those with more than 18 months of treatment for symptoms had an 81% success rate (P > .05). CONCLUSIONS: Duration of the symptoms of chronic sinusitis in children of more than 6 months was not a predictor of success of endoscopic sinus surgery in these children. Although there seemed to be a trend toward having a more successful procedure in children who had surgery between 6 and 12 months of medical treatment versus those who had surgery after more than 12 months of medical treatment, this did not reach statistical significance. A prospective study with more patients may shed more light on this subject.     

Plain radiographic evaluation of the nasopharynx: Do raters agree?

Background

Subjective plain radiographic evaluation of the nasopharynx has been a widely adopted technique. Although it has its own limitations, its ease of interpretation and simplicity are some of its advantages.

Aim

To investigate the reliability, using kappa, in subjectively reporting plain nasopharyngeal radiographs in children with symptoms suggestive of enlarged adenoids.

Methods

This was a retrospective study of the clinical records, and plain X-rays of the nasopharynx of paediatric patients with clinical features of adenoid hypertrophy in a Nigerian Tertiary Health Institution from January 2008 to December 2008.

Results

Fifty-one children with a mean age of 3.4 years; standard deviation of 2.772 was studied. They had an age range of 2 months to 12 years. Most (66.6%) of the children studied were in the age bracket 0-4 years. The inter-rater reliability between the two Otolaryngologists, and that between an Otolaryngologist and a Radiologist using kappa statistics were 0.6696, 95% CI (0.5035-0.8357; p < 0.05) and 0.8182, 95% CI (0.7073-0.9291; p < 0.05) respectively. While the kappa intra-rater reliabilities for the two Otolaryngologists were 0.6931, 95% CI (0.5473-0.8389) and 0.9591, 95% CI (0.9033-1.000).

Conclusion

There was a high level of agreement among trained raters, in subjectively interpreting plain nasopharyngeal radiographs in children with suspected adenoidal obstruction.     

Endoscopic medial maxillectomy with preservation of inferior turbinate: how do we do it?

The aim of this study was to describe the endoscopic medial maxillectomy technique with preservation of the inferior turbinate in patients affected by maxillary sinonasal inverted papilloma. We retrospectively reviewed the clinical charts and surgical technique in six patients with paranasal sinus inverted papilloma. There were five males and one female, whose mean age at diagnosis was 60?years ranging between 57 and 65?years. No recurrences were diagnosed, and no nasal crusting was evidenced postoperatively. Nasal breathing was satisfying in all cases. Postoperative epistaxis was not observed, and none of the patients refereed to have epiphora after the surgery. This technique has been successfully performed, showing no recurrence to the present and allowing the preservation of a functional inferior turbinate.     

Failures of Adenoidectomy for Chronic Rhinosinusitis in Children: For Whom and When Do They Fail?

OBJECTIVES: To determine which children who are treated with adenoidectomy for chronic rhinosinusitis (CRS) will ultimately undergo endoscopic sinus surgery (ESS) and the length of time between adenoidectomy and ESS. STUDY DESIGN: Retrospective chart review of prospectively collected data in a tertiary pediatric otolaryngology service. METHODS: One hundred forty-three children had adenoidectomy for CRS over a 10-year period. Follow-up was available on 121 children. Sixty-one children failed the procedure. Data were available on 55 children who underwent ESS after failing adenoidectomy for the treatment of CRS. Mean time from adenoidectomy to ESS was determined. Factors such as age, allergic rhinitis, asthma, computed tomography (CT) score, and sex were evaluated for effects on this time. RESULTS: With use of Cox regression analysis, the mean time from adenoidectomy to ESS was 24 months, ranging from 4 to 77 months. The presence of asthma (P < .04) and age less than 7 years (P < .01) were predictors of earlier failure. Allergic rhinitis (P < .3), CT score (P < .9), and sex (P < .3) showed no effect. CONCLUSIONS: Those who fail adenoidectomy for CRS who require ESS are mainly children who are younger than 7 years of age and have asthma. They appear to require a salvage ESS at a mean of 24 months after the adenoidectomy.     

Endoscopic and combined external–transnasal endoscopic approach for the treatment of inverted papilloma: analysis of 110 cases

The aim of the study was to evaluate the effectiveness of the endoscopic approach for the management of inverted papilloma (IP) of the nose and paranasal sinuses and the possible factors associated with its recurrence. One hundred and forty-one patients affected by an IP originating at the level of the sinonasal tract were treated surgically using an endoscopic technique alone or a combined external–endoscopic approach at the ENT Department of the University of Bologna between January 1994 and December 2012. Of these patients, 110 were selected for the recurrence analysis. Univariate and multivariate analyses were performed to detect risk factors for IP recurrence. The patients had a mean follow-up of 56.7 months (24–167 months). Seven cases (6.3 %) of recurrence were observed in patients treated with the endoscopic approach for the primary or recurrent tumor. Previous surgery (p = 0.005) and number of previous surgical procedures (p = 0.003) were associated with higher recurrence rate. The number of previous operations was associated to recurrence-free survival at Cox regression analysis. In our study, the endoscopic approach showed itself to be a useful tool for the radical resection of an IP. The endoscopic approach should be tailored for the different extensions of IP. Recurrent cases showed an increased risk of further recurrence. Therefore, these should be treated paying particular attention to the boundaries of the primary tumor.     

Facial soft tissues of mouth-breathing children: Do expectations meet reality?

Objective

To quantify the differences between the facial soft tissue morphology of severely obstructed mouth breathing (MB) and that of predominantly nasal breathing (NB) children.

Methods

Soft tissue measurements were performed in the lateral cephalograms of 64 severely obstructed MB children (mean age 6.7 ± 1.6) compared with 64 NB children (mean age 6.5 ± 1.3). Groups were paired by age, gender, skeletal maturation status and sagittal skeletal pattern. Based on the assumption of normality and homoscedasticity, comparison of the means and medians of soft tissue measurements between the two groups was performed.

Results

The facial convexity and anterior facial height ratio of MB were similar to NB children. The upper lip of MB children was protruded, and its base was thinner compared with NB; however, the length was not affected. The lower lip was shorter and more protruded in MB children. The nasolabial angle, nasal prominence, and chin thickness were smaller in MB children.

Conclusions

The facial soft tissue of severely obstructed MB children is different than in NB children. Changes in lips, nasolabial angle, nasal prominence, and chin thickness are associated with severe airway obstruction in children.