Biomedical subjects
Publications and source records attributed to B Kotton.
We describe a patient who had two unusual complications of prolonged mechanical ventilation-tracheoesophageal fistula and pneumoperitoneum-with a fatal outcome. Recurrent pulmonary aspirations and massive abdominal distention in the setting of longstanding artificial ventilation should alert the physician to these possibilities.
Suppurative mediastinitis following neck infection is an uncommon entity that carries a 40% mortality. It is most commonly associated with esophageal perforation or odontogenic abscess. The rapidity of spread has been attributed to dependent drainage from the neck into the mediastinum, negative intrathoracic pressure, and synergistic necrotizing bacterial growth. Cultures obtained usually grow streptococci and/or Bacteroides. We report the case of a 34-year-old woman with an upper respiratory infection who subsequently was found to have a para-/retropharyngeal and mediastinal abscess. Septic shock, respiratory failure, and death ensued, despite aggressive treatment with broad-spectrum antibiotics (for both aerobes and anaerobes), surgical drainage of the neck and mediastinum, and cardiorespiratory support. The danger of a rapid downhill clinical course with mortality due to suppurative mediastinitis makes early diagnosis of critical importance. All clinicians evaluating a "sore throat" should consider neck edema or gas on neck radiograms as evidence of cervical abscess, and subsequent widening of the mediastinum on chest x-ray as an ominous sign suggesting mediastinal abscess.
Laryngeal stenosis can present with recurrent lower respiratory tract infections, hoarseness, stridor or decreased exercise tolerance. Asphyxia and death may follow. One accepted method of treatment is to perform a tracheostomy, dilate the stricture and insert an obturator for 6 to 9 mo. Ten children with a subglottic stenosis were treated by this technique and 7 completed the treatment. Results in 5 of these children were good, 1 was improved and 1 restenosed. These results compare favorably with those reported by others. This form of treatment is indicated for unyielding but dilatable strictures which have failed to respond to other approaches. The choice, therefore, lies between resection and plastic repair or prolonged dilatation. Results are generally quite good for strictures near the vocal cords, but are variable for those well below the cords. The manufacture and insertion of a prosthesis used in the above cases are described.
A Silastic prosthesis anchored to a tracheostomy tube was used in the treatment of 5 children with subglottic stenosis. It did not cause any significant tissue reaction and obviated the problems of transfixion sutures. We treated 3 children successfully. Another died from complications owing to the tracheostomy. In the fifth patient the prosthesis was replaced by a Silastic T-tube. The use of the Silastic prosthesis is advocated for tough, dilatable laryngeal strictures, for which a T-tube is unsuitable. The advantages, disadvantages, method of manufacture and technique of insertion are discussed.
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