Index of suspicion. Case 1. Diagnosis: Ventricular myxoma with pulmonary outflow tract obstruction.
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Airway Obstruction↗
Biomedical subjects
E M Friedman
Publications and source records attributed to E M Friedman.
Laser therapy for lymphatic malformations of the upper aerodigestive tract. An evolving experience.
Lymphatic malformations of the upper aerodigestive tract can present therapeutic challenges. Symptoms associated with these lesions include bleeding, dysphagia, changes in speech, and dyspnea. Surgical therapy is recommended, which often leads to functional interference and cosmetic deformities. Laser photocoagulation of these malformations can control symptoms and may be repeated as necessary, preserving tissue and function. The results in four patients treated with the carbon dioxide laser and in five patients treated with the neodymium-YAG laser were reviewed. Reduction of bulk and improvement of symptoms were achieved in all patients, most of whom required multiple treatments. The average duration of each procedure was 30 minutes. All patients were discharged from the hospital on the same day or 1 day after laser therapy with minimal morbidity. The indications, evolving technique, and results of laser therapy are discussed.
Adolescent↗
Vincristine-induced recurrent laryngeal nerve paralysis.
Vincristine-sulfate-related vocal cord paralysis has been reported infrequently in the literature. The neurotoxicity of the vinca alkaloids is well-known; however, the potential for cranial nerve involvement is not widely recognized. Given the complexity of the typical patient receiving such a chemotherapeutic agent, the potential for misdiagnosis is high. Many patients have primary tumors or metastatic lesions in sites that could cause the clinician to overlook this reversible cause of neurologic dysfunction. This study describes the first three reported pediatric cases of vincristine-induced vocal cord paralysis. Two patients developed increasing stridor secondary to bilateral vocal cord paralysis; the third developed a unilateral vocal cord paralysis. All resolved spontaneously upon withdrawal of the vincristine. Vinca-alkaloid-induced vocal cord paralysis is a potentially dangerous but reversible lesion. Otolaryngologists should be aware of the association between these agents and cranial nerve neuropathies.
Adolescent↗
Thyroglossal duct remnants. Preoperative evaluation and management.
Midline cervical cysts arising from the thyroglossal duct are one of the most common causes of anterior neck swelling in children. The potential for confusion between the thyroglossal duct cyst and the ectopic thyroid gland is well documented and may result in serious complications. A retrospective chart analysis was therefore undertaken to determine the relative importance of clinical evaluation, thyroid function testing, and radioisotope scanning in distinguishing these two entities preoperatively. A combined study was carried out by The Children's Hospital, Boston, Mass, and Rainbow Babies Hospital, Cleveland, Ohio. The hospital records, including nuclear scans, were reviewed. A total of 229 patients were taken to the operating room between January 1, 1978, and December 31, 1987. Nuclear scanning was performed in 30% of these patients. This subgroup of patients forms the basis for our guidelines of preoperative assessment. The absolute need for a preoperative scan is reexamined.
Adolescent↗
Time-dependent effects of peer separation on lymphocyte proliferation responses in juvenile squirrel monkeys.
This study evaluated the immunological, hormonal, and behavioral responses of juvenile squirrel monkeys to repeated social separations of varying length. Following a 3-hr separation, lymphocyte responses to stimulation with the mitogen concanavalin A (Con A) declined significantly, and these alterations were sustained after a 24-hr separation period. The responses to Con A and to a second mitogen, phytohemagglutinin (PHA), were suppressed after 2 days. At the end of a 7-day separation period, immune responses were not significantly different from basal values. Plasma cortisol levels were elevated above basal levels in all animals after the 3-hr, 24-hr, and 2-day separations, but were not elevated after the 7-day separation. While we observed no statistically significant changes in locomotor activity or calling behavior during any of the separations, the monkeys tended to be most active and to call most immediately following separation. Our findings concur with earlier reports indicating that social stressors can influence lymphocyte proliferation in nonhuman primates and that certain cell types might be differentially sensitive to stress, but also indicate that these influences are transient.
Animals↗
Congenital cholesteatoma of the middle ear in children: a clinical and histopathological report.
Forty-one children with congenital cholesteatoma of the middle ear seen from 1978 through 1989 are reviewed. The most common presentation was that of an asymptomatic white mass behind a normal intact tympanic membrane. Computed tomography (CT) scan was useful in documenting extension beyond the mesotympanum. Surgical removal was performed using an extended tympanotomy for lesions in the middle ear and tympanomastoidectomy for those that had extended into attic and mastoid air cells. Observation over an average 3.1-year period indicated that 80% of children were free of disease after initial surgery. Residual disease that required further surgery was present in 20%. The importance of early diagnosis of congenital cholesteatoma is strongly advocated. The prognosis is better when the cholesteatoma is confined to the anterosuperior quadrant of the middle ear. Seventeen patients in this study had such a lesion, and extended tympanotomy allowed removal of an encapsulated closed cholesteatoma with normal postoperative hearing and no residual cholesteatoma. The average age was 2.3 years. Temporal bone histopathological studies of three cases of congenital cholesteatoma demonstrate two distinct pathological types of congenital cholesteatoma. A "closed" keratotic cyst in the anterior mesotympanum, which is easily removed, and an "open" infiltrative type in which there is no containment of the keratotic debris and the cholesteatoma matrix is in direct continuity with middle ear mucosa. Surgical extirpation of the "open" type is difficult and more likely to be associated with residual disease.
Adolescent↗
Tympanoplasty in children. The Boston Children's Hospital experience.
Considerable controversy surrounds the subject of tympanoplasty in children. Conflicting opinions about the indications, patient selection, timing, and technique of surgery are supported by various published series of cases. The records of 64 consecutive tympanoplasty procedures performed at the Boston (Mass) Children's Hospital over a recent 6-year period were reviewed. The study was limited to cases of repair of uncomplicated perforation of pars tensa that did not require ossiculoplasty or mastoidectomy. Surgery was successful in 73% of cases. A number of factors that are postulated to affect the outcome of surgery have been analyzed to assess their utility in selecting successful surgical candidates. Only patient age at the time of surgery was found to have statistical significance. We conclude that tympanoplasty for repair of perforation is warranted for children 8 years of age and older.
Age Factors↗
Airway complications in CHARGE association.
The association between catastrophic airway events and developmental delay was examined in patients with CHARGE (coloboma, heart disease, atresia choanae, retarded growth and/or development, genital hypoplasia, and ear anomalies and/or deafness) association. A retrospective chart analysis was performed from The Children's Hospital in Boston, Mass. Sixteen patients were identified with CHARGE association. Nine patients had at least one respiratory arrest, and 7 had no airway difficulties. Some degree of developmental delay was seen in 14 patients, but was most severe in those patients who suffered a respiratory arrest. We conclude that children with CHARGE association have a propensity for airway instability and that cerebral hypoxia contributed to the developmental delay in some of our patients. We recommend early tracheotomy rather than early choanal atresia repair in these patients to protect the central nervous system.
Abnormalities, Multiple↗
Central nervous system complications associated with acute otitis media in children.
The purpose of this article is to review a subset of pediatric patients with otitis media occurring simultaneously with meningitis and other central nervous system diseases. Of the 92 cases reviewed, 61.3% involved patients under 12 months of age. Meningitis associated with otitis media involved 91% of the patients; the remainder had nonmeningitic central involvement. The most striking finding was the high incidence of Haemophilus influenza type-B, a relatively uncommon pathogen of the middle ear. This finding highlights the need to select antibiotic coverage to adequately treat Haemophilus influenza type-B.
Acute Disease↗
Chronic pediatric stridor: etiology and outcome.
Stridor in children is usually acute. This paper represents a chart review and telephone survey of 60 patients with chronic pediatric stridor. The most common etiology was laryngomalacia, which required airway intervention in 22% of the patients. The symptoms persisted beyond 18 months of age in 17% of the patients. Twelve percent of the patients had multiple lesions; 65% of the second lesions were below the vocal cords. It appears that the presence of cyanosis should increase physician suspicion of multiple lesions. There was not a higher risk of recurrent upper respiratory infections with any of the diagnoses.
Child, Preschool↗
Caustic ingestions and foreign bodies in the aerodigestive tract of children.
Caustic ingestions, both accidental and intentional, continue to cause significant morbidity and mortality. This article recommends the best methods of managing caustic ingestion and the related problems of foreign bodies in the digestive tracts of small children, and also stresses the need for prevention as the best defense.
Burns, Chemical↗
Foreign bodies in the pediatric aerodigestive tract.
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Airway Obstruction↗
Melanotic neuroectodermal tumor of infancy.
A case of melanotic neuroectodermal tumor of infancy has been presented, and the etiology, clinical presentation, and management of this rare tumor have been discussed. The tumor may not be familiar to most otolaryngologists and should be included in the differential diagnosis of pediatric head and neck neoplasms.
Female↗
Computed tomography in the evaluation of choanal atresia in infants and children.
While traditional confirmatory clinical tests are helpful in establishing the diagnosis of choanal atresia, they give little useful information concerning the composition, position, and thickness of the atresia plate. Surgeons experienced in the repair of choanal atresia have recognized that detailed anatomic assessment is valuable in the preoperative selection of the method of repair and design of the repair once undertaken. The utilization of high-resolution computerized tomography to provide such information in a group of infants and children with choanal atresia forms the basis for this report. The application of computed tomography in the evaluation of choanal atresia and preoperative surgical planning is discussed. Based on this experience, we feel that the introduction of high-resolution computerized tomography is a significant advance in the diagnostic and therapeutic approach to choanal atresia and should be the single radiographic procedure of choice.
Child↗
Bacterial tracheitis--two-year experience.
Inflammatory illnesses of the pediatric airway cause significant morbidity and mortality. Bacterial tracheitis is a distinct entity with features common to both croup and epiglottitis. Ten patients between the ages of 3 months and 12 years were treated at Children's Hospital, Boston, MA., for bacterial tracheitis. The clinical presentation and medical management is discussed. Seven of the patients required both direct laryngoscopy and bronchoscopy; one patient required urgent intubation; and one patient required indirect laryngoscopy. In one patient the diagnosis was based on clinical and radiographic findings in conjunction with tracheal aspirates. Seven of the 10 patients did well with aggressive medical management. Three patients required endotracheal intubation. No patient required tracheotomy, and there were no cardiopulmonary arrests. It is of particular interest that although the patients in this series presented in a manner similar to that of patients in other published series, the management is significantly different and the overall outcome is significantly better.
Bacterial Infections↗
The emergency management of caustic ingestions.
In the emergency department, any patient who is suspected of having sustained a caustic ingestion must be handled in a serious manner. All patients should be initially stabilized with regard to airway and circulatory status. Initial questioning concerning the type and quantity of agent ingested will be most helpful. Signs and symptoms of shock, impending perforation, or airway distress take precedence over any further work-up. Patients who have a known history of ingestion require admission to the hospital. Complete physical examination should be carried out, bearing in mind that the lack of oropharyngeal involvement or other symptoms does not rule out the possibility of esophageal burns. One should avoid emesis and should begin early dilutional therapy. Water may be used initially to dislodge adherent solid particles, as well as to dilute the caustic ingestion. It is important not to be excessively aggressive with dilution, as this may cause nausea, vomiting, and possible aspiration. Early otolaryngologic evaluation will be most helpful. The role of early esophagoscopy has been demonstrated to aid greatly in determining the further management. This diagnostic procedure should be carried out within 48 hours after ingestion. Based on the information obtained with esophagoscopy, patients who have had moderate esophageal burns should receive 20 mg methylprednisone intravenously every eight hours if under the age of two and 40 mg intravenously every eight hours if over the age of two. When oral preparations can be used, 2 mg per kg of prednisone should be continued for three to four weeks. Antibiotic coverage should be reserved until the first sign of infection occurs.
Acids↗
Laser surgery in the pediatric airway.
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Carbon Dioxide↗
Carbon dioxide laser management of subglottic and tracheal stenosis.
The carbon dioxide laser has been used in a variety of otolaryngologic conditions. Its specific advantages have particularly lent themselves to its use in the airway. The role of laser endoscopic treatment in subglottic and tracheal stenosis will continue to expand and aid in the successful management of these difficult cases.
Carbon Dioxide↗