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Biomedical subjects

F D Burstein

Publications and source records attributed to F D Burstein.

At least 19 recordsLinked to original sources
PubMed1999

Alternatives to tracheostomy in infants and children with obstructive sleep apnea.

PURPOSE: Since 1989, 70 children have been treated surgically with varying degrees of obstructive sleep apnea (OSA). Of these, 29 patients had completely failed conventional medical and surgical treatment and were considered tracheostomy (T) candidates, whereas five had previously undergone T for severe OSA as infants and did not respond to standard decannulation protocols. The preoperative diagnoses were cerebral palsy (n = 5), Down's syndrome (n = 5), hemifacial microsomia (n = 4), Pierre Robin sequence (n = 6), and a mixed group of craniofacial disorders (n = 14). The patients ranged in age from 2.5 weeks to > or =18 months (mean, 7.32 years). Preoperatively, four patients were on ventilators and one suffered a cardiac arrest, attesting to the severity of OSA. METHODS: To enlarge the caliber of the airway, each patient underwent an aggressive surgical treatment protocol. All sites of upper airway obstruction were treated simultaneously by a combination of craniofacial skeletal expansion and soft-tissue reduction. RESULTS: Tracheostomy was avoided in 90.4% of patients. Temporary or "permanent T" were required in three patients (9.6%). One patient with cerebral palsy had recurrent OSA and died. A second patient with severe laryngotracheomalacia and retrognathia who did not respond to apnea surgery underwent a tracheostomy and ultimately died of pulmonary causes. Four patients (7.8%) required supplemental home oxygen or continuous positive airway pressure. The average preoperative respiratory disturbance index, defined as the average number of apneic and hypopneic events per hour of sleep, dropped from 25.9 to 4.4 after surgery. The average lowest recorded oxygen saturation during overnight polysomnography rose from 61% to 92% after surgery. Of the five patients with permanent T, four had thus far been decannulated. Complications occurred in 10 patients, 50% of which were related to minor problems with mandibular distraction devices. CONCLUSION: Our results confirm the efficacy of an aggressive surgical approach to the treatment of OSA in children, avoiding the necessity for tracheostomy or permitting decannulation of permanent T in the majority of cases.

Child↗
PubMed1999

Airway disorders in hemifacial microsomia.

The anatomic components of hemifacial microsomia have been classified previously, but their relevance to functional abnormalities has not been stressed. In a recent review of the literature, we found that the frequency and severity of airway disorders, especially those leading to upper airway obstruction and/or obstructive sleep apnea, had not been reported. Accordingly, a retrospective study of 38 patients (21 male, 17 female), aged 6 months to 22 years (mean, 8 years 3 months) with hemifacial microsomia was undertaken to ascertain the frequency and severity of airway disorders in hemifacial microsomia. Upper airway disorders fell broadly within three categories: group I (n = 22, 58 percent) was asymptomatic for airway disturbances; group II (n = 7, 18 percent) had a medical history suspect for intermittent obstructive sleep apnea or had a perioperative apneic event; and group III (n = 9, 24 percent) had a definite history of obstructive sleep apnea or upper airway obstruction requiring tracheotomy or apnea surgery. Group III versus groups II and I had a higher incidence of bilateral involvement (33 percent versus 14 percent and none), a greater percentage of M2, M2a, M2b, and M3 mandibular deformities (88.9 percent versus 28.6 percent and 18.2 percent), more severe orbital involvement (33 percent O2 and O3 versus none in group II and 9 percent in group I), and more severe soft-tissue involvement (89 percent S2 and S3 versus 29 percent and 23 percent). Patients with more severe mandibular and orbital deformities, but not ear or vertebral abnormalities, appear at a greater risk for obstructive sleep apnea. The relationship of OMENS-Plus (extracraniofacial anomalies) to apnea was variable but was found more commonly in group II (86 percent) and group III (56 percent) than in group I (32 percent) patients. Group III patients had a higher frequency of cardiac anomalies (44 percent versus 29 percent in group II and 23 percent in group I). The incidence of obstructive sleep apnea in our population of patients with hemifacial microsomia approaches 24 percent. Patients with hemifacial microsomia should undergo routine screening for obstructive sleep apnea: a positive history warrants polysomnographic and anatomic workup.

Adolescent↗
PubMed1998

Skeletal expansion combined with soft-tissue reduction in the treatment of obstructive sleep apnea in children: physiologic results.

Twenty consecutive children, ranging in age from 6 days to 18 years, were treated with skeletal expansion, in addition to soft-tissue reduction, for medically refractory obstructive sleep apnea. The underlying diagnoses were craniofacial microsomia (n = 6), Down syndrome (n = 3), Pierre Robin syndrome (n = 3), cerebral palsy (n = 3), Nager's syndrome (n = 1), Treacher Collins syndrome (n = 1), cri du chat syndrome (n = 1), juvenile rheumatoid arthritis (n = 1), and temporomandibular joint ankylosis (n = 1). Fourteen children had severe medically refractory sleep apnea and were tracheostomy candidates; in the remaining six, tracheostomies were placed shortly after birth and could not be decannulated. Overnight, 12-channel polysomnography was obtained before and after surgery. The mean apnea index improved from 7.42 to 1.26, the mean respiratory disturbance index improved from 25.24 to 1.72, and the mean lowest apnea-related oxygen saturation improved from 68% to 88%. Of the 14 children with medically refractory obstructive sleep apnea, two required tracheostomies. Of the six patients with tracheostomies, five have been decannulated at the time of this writing. Skeletal expansion in conjunction with soft-tissue reduction in the pediatric population permits substantial increases in the volume of both the nasopharynx and oropharynx. Creative use of conventional osteotomies and the application of distraction osteogenesis have enabled surgeons to apply maxillofacial and craniofacial techniques in treating children with obstructive sleep apnea.

Adolescent↗
PubMed1998

Endoscopic surgical treatment for congenital muscular torticollis.

Muscular torticollis, if untreated, may result in significant permanent craniofacial deformities. Surgical release of the sternocleidomastoid muscle is recommended for patients who fail to respond to physical therapy. Current surgical techniques all leave noticeable scars, and provide limited exposure. These limitations make complete muscular release and visualization of the spinal accessory nerve difficult. We have applied a new technique of endoscopic release of the sternocleidomastoid muscle in 12 infants and children ages 4 to 18 months and one adolescent with muscular torticollis. Complete muscular release was achieved in all patients with one minor complication. The spinal accessory nerve was preserved in all cases. Our endoscopic approach allows precise division of the muscle fibers and preservation of neurovascular structures, leaving an inconspicuous scar in the scalp.

Adolescent↗
PubMed1998

Mandibular distraction osteogenesis in the treatment of upper airway obstruction in children with craniofacial deformities.

Over the past 3 years, 16 patients (12 males, 4 females) have undergone mandibular distraction osteogenesis in conjunction with soft-tissue procedures to treat medically refractory obstructive sleep apnea. Thirty distraction devices were placed for bilateral distraction in 14 children and unilateral distraction in 2. The mean age of treatment was 4 years and 8 months (range 14 weeks to 12 years and 8 months). Eight of the patients had failed conventional medical and surgical treatment of obstructive sleep apnea and were considered tracheostomy candidates, whereas the remaining eight had tracheostomies placed shortly after birth for upper airway obstruction. These eight children could not be decannulated by standard protocols. The average distraction distance was 25 mm (range 18 to 35 mm). To date, seven of the eight patients with tracheostomies have been decannulated, and one is still in progress. Clinical improvement in the signs and symptoms of sleep apnea and reduction or elimination of preoperative oxygen requirements occurred in seven of the eight children with medically refractory sleep apnea. Twelve-channel polysomnograms were obtained preoperatively and postoperatively in each of the eight patients without tracheostomies. Respiratory disturbance index decreased from a mean of 7.1 to 1.7 after surgery. Lowest oxygen saturation rose from a mean of 0.70 to 0.89 after surgery. Application of mandibular distraction osteogenesis is an important component in the treatment of obstructive sleep apnea and permits mandibular advancement in the younger child. As more experience is gained with distraction osteogenesis in the treatment of children with obstructive sleep apnea, the role of distraction will become better defined.

Airway Obstruction↗
PubMed1998

Applications of endoscopic surgery in pediatric patients.

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been few reports of the use of this technology in the pediatric population. Because of their minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal for this age group. Here we present our experience with endoscopic pediatric plastic surgery. From February of 1995 to August of 1997, 104 patients underwent 139 procedures utilizing 5- and 10-mm endoscopes. There were 58 male and 46 female patients. The mean age at surgery was 5.6 years (range, 3 weeks to 19 years). The most common type of procedures performed were insertion of tissue expanders (n = 34), excision of benign head and neck masses (n = 27), torticollis release (n = 20), excision of vascular lesions (n = 13), and miscellaneous procedures, (n = 10). There were 26 complications in 139 procedures (19 percent). Seventeen (65 percent) were in the tissue expander group. The rest were scattered among the groups with other diagnoses. Although there did not appear to be a specific type of complication associated with endoscopy, 77 percent occurred in the first 2 months of our study. This suggests a relatively steep technical learning curve. These results demonstrate that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds, with complication rates that are comparable with those of conventional open surgical treatment.

Adolescent↗
PubMed1998

Sleep apnea surgery versus tracheostomy in children: an exploratory study of the comparative effects on quality of life.

Successful surgery for medically refractory obstructive sleep apnea in children has prevented tracheostomy in many cases. However, sleep apnea surgery requires postoperative ventilatory support and intensive care, and the magnitude of the surgery may be substantial. Tracheostomy, in contrast, is a simple procedure that is considered the standard of care for relief of upper airway obstruction. To determine their relative benefits, the posttreatment quality of life in children with airway obstruction who underwent either sleep apnea surgery or tracheostomy was evaluated and compared in this exploratory study. A 76-item questionnaire was developed to assess the quality of life in this population, including an investigation of physical symptoms, psychosocial function, and costs. Forty-four parent questionnaires were returned; 16 of these parents had children who had had clinically successful sleep apnea surgery and 6 had children who had had tracheostomies placed for obstructive sleep apnea. Results revealed that the parents of children in the tracheostomy group ranked 95 percent of all items on the questionnaire as worse than the parents of children in the surgery group. These rankings included statistically significant group differences (p < 0.05) on number of hospital, emergency room, and physician visits, and hours per day spent on their child's respiratory care. In addition, parents of the successful sleep apnea surgery group reported significant improvement (p < 0.05) in 100 percent of symptom variables (i.e., choking, snoring, and daytime sleepiness), 75 percent of parental care variables (i.e., assisting with their child's breathing, suctioning), 67 percent of medical visit items, and 75 percent of the stress and coping variables (i.e., perception of child's distress, worrying about their child's breathing, level of family stress), indicating substantial gains in quality of life. Despite initially higher costs, successful surgery for obstructive sleep apnea was associated with substantial benefits in quality of life, health, and psychosocial outcomes when compared with tracheostomy.

Adaptation, Psychological↗
PubMed1998

Multiple suture synostosis and increased intracranial pressure following repair of single suture, nonsyndromal craniosynostosis.

OBJECTIVE: Increased intracranial pressure, frequently associated with closure of multiple cranial sutures, has been reported to occur in 36% of cases following correction of syndromal craniosynostosis. Although much less common, multiple suture closure may occur following repair of single suture, nonsyndromal craniosynostosis and we present cases that concern two such children. RESULTS: Two children with nonsyndromal craniosynostosis, one metopic and one left-coronal, underwent fronto-orbital advancement at age 3 months. At age 19 months and at age 5 years, respectively, both patients re-presented with headaches, decrease in head circumference percentile, and acceptable cosmetic outcome. Both had computerized tomographic evidence of multiple closed cranial sutures and increased intracranial pressure (ICP) (determined by monitoring). Both patients improved following a cranial expansion procedure. CONCLUSION: Delayed closure of multiple sutures and resultant increased ICP may occur following correction of nonsyndromal, single suture craniosynostosis. This may be more likely when the initial suture is contiguous with the facial sutures. Children should be followed for many years following craniosynostosis repair with cranial, neurologic, and possibly funduscopic examinations as well as head circumference measurements to detect delayed closure of cranial sutures.

Age Factors↗
PubMed1997

Endoscopic pediatric plastic surgery.

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been to date no reports of its use in the pediatric population. Because of its minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal in this age group. Herein we present our initial experience with endoscopic pediatric plastic surgery. From February 1995 to December 1995, 41 patients were treated utilizing 5-mm and 10-mm endoscopes at Scottish Rite Children's Medical Center, Atlanta, GA. There were 19 males and 22 females. The mean age at surgery was 5.6 years (range, 7 months-15 years). The most common types of procedures performed were insertion of tissue expanders (N = 19), excision of facial dermoids (N = 7), torticollis release (N = 5), and excision of vascular lesions (N = 4). The remaining 6 patients underwent a variety of reconstructive procedures. The complication rate in the tissue expander group was 3 out of 39 expanders inserted (9.5%), and consisted of infection (N = 2) and rupture (N = 1). In the dermoid group, complications consisted of wound infection requiring reoperation (N = 1), and transient frontal paresis (N = 1). One patient in the hemangioma group had an incomplete resection necessitating open excision. The remaining patients all had satisfactory outcomes with no complications. The majority of the procedures were done on an outpatient basis. These results suggest that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds with complication rates that are comparable to those of conventional surgical treatment.

Adolescent↗
PubMed1997

Age-related outcomes of sleep apnea surgery in infants and children.

This study was designed to determine whether age at the time of surgery is an important influencing factor on outcomes following surgical correction of severe refractory obstructive sleep apnea (OSA) in infants and children. Data were collected prospectively on 55 children, all with severe OSA refractory to conservative medical and surgical measures, who underwent combinations of soft-tissue and skeletal procedures aimed at relieving their airway obstruction. The study population was subdivided for analysis into three groups based on age at the time of surgery (> 36 months, > 12 to < 36 months, and < or = 12 months). Each child was assessed for clinical outcomes, polysomnography results, and complications. Children in the > 36 months group demonstrated a significant improvement in respiratory disturbance index (RDI), apnea index, and lowest overnight oxygen saturation postoperatively. Only RDI improved significantly in the > 12 to < 36 months group. Although there was a trend toward improvement in the respiratory indices for the children < or = 12 months of age, they had a significantly longer intensive care and hospital stay, a greater mean number of extubation attempts, and the highest surgical failure rate (29%). Other complications such as infection, atelectasis, or temporary postoperative nasopharyngeal tube dependence occurred most frequently in the > 36 months group. Surgical management of severe refractory OSA in children age < or = 12 months is more difficult and less likely to succeed. The reasons for this are discussed and recommendations for management are given.

Adolescent↗
PubMed1997

Down syndrome: identification and surgical management of obstructive sleep apnea.

To date, a paucity of information is available on the optimal management of obstructive sleep apnea in Down syndrome, which may have particularly important implications in this already vulnerable patient population. The objective of this study was to evaluate prospectively the results of a new surgical approach for the treatment of obstructive sleep apnea. Patients with Down syndrome and obstructive sleep apnea underwent preoperative and postoperative polysomnography and clinical and radiologic evaluation to determine prospectively the efficacy of sleep apnea surgery. Statistical testing of apnea index, respiratory disturbance index, and lowest oxygen saturation were compared by means of paired t tests. Seven children (five boys, two girls) from 3 to 12 years of age were subjected to a management protocol that included an aggressive surgical approach to the treatment of obstructive sleep apnea. Clinical symptoms and signs of obstructive sleep apnea, apnea index, respiratory disturbance index, lowest oxygen saturation, and surgical morbidity were the main outcome measures. Surgical treatment consisted of a combination of soft-tissue and skeletal alterations including tongue reduction (n = 6), tongue hyoid advancement (n = 4), uvulopalatopharyngoplasty (n = 7), and maxillary or midface advancement (n = 2). Polysomnography was obtained preoperatively and postoperatively in six patients. One patient was intubated preoperatively. Mean preoperative apnea index and respiratory disturbance index were 34.00 and 52.46 compared with mean postoperative values of 1.62 and 6.46, respectively. Clinically, all patients were improved symptomatically in terms of snoring, noisy breathing, and oxygen requirements. The one patient who had been intubated preoperatively for respiratory failure was extubated successfully but later developed recurrent tricuspid regurgitation and was found to have fixed pulmonary hypertension with cor pulmonale. This patient represented the only treatment failure and underwent tracheostomy. An aggressive surgical approach aimed at correcting all anatomic abnormalities associated with upper airway obstruction was applied successfully to the treatment of obstructive sleep apnea in Down syndrome. We suggest periodic polysomnography in patients with Down syndrome, especially if there is unexplained deterioration in mental capacity or other signs and symptoms of obstructive sleep apnea. Surgical treatment should address both the soft-tissue abnormalities and the skeletal deformities such as midface retrusion. Preoperative cardiac ultrasonography is important to determine the presence of right-sided heart failure, which may be an indication for cardiac catheterization to determine pulmonary venous pressures.

Child↗
PubMed1997

Surgical treatment of obstructive sleep apnea in neurologically compromised patients.

Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.

Adenoidectomy↗
PubMed1997

Maxillary-midface distraction in children with cleft lip and palate: a preliminary report.

A miniature system of distraction devices has been employed for maxillary-midface advancement in two children with cleft lip and palate, class III malocclusion, and associated midfacial hypoplasia. The devices are made with commercially available palatal expansion screws linked to rigid fixation plates. A midfacial osteotomy is used, and distraction is begun on the third postoperative day. In the first child, a 7-year-old boy, the midface was distracted 11 mm sagittally and 4 mm inferiorly. In the second patient, a 4 1/2-year-old girl with unilateral cleft lip and palate and midfacial retrusion, an 11-mm distraction was carried out in the vertical and sagittal direction. There were no complications, and none of the devices failed. Maxillary-midfacial distraction osteogenesis to correct severe maxillary-midfacial hypoplasia in children with clefts and other craniofacial disorders permits early intervention with potentially less invasive techniques than are currently available.

Bone Lengthening↗
PubMed1997

A longitudinal, statistical study of reoperation rates in craniosynostosis.

A prospective, statistical study of reoperation rates was done in the treatment of 167 consecutive children with nonsyndromic and syndromic craniosynostosis over a 6-year period at Scottish Rite Children's Medical Center in Atlanta, Georgia. Mean length of follow-up was 2.8 years, with a range of 3 months to 6 years. Reoperation equal to or exceeding the magnitude of the original procedure occurred in 7 percent of cases. Multiple regression analysis revealed several factors associated with reoperation: Females and children with syndromic synostoses were more likely to require reoperation. Total reoperation rates for syndromic and nonsyndromic synostoses were 27.3 and 5.9 percent, respectively. Age at initial surgery, length of operation, and estimated blood loss did not predict a higher reoperation rate.

Child↗
PubMed1997

The use of porous granular hydroxyapatite in secondary orbitocranial reconstruction.

The search for the ideal bone-graft substitute has been the focus of many research and clinical studies. Hydroxyapatite is one such material that combines osseointegration with maintenance of implant volume and excellent durability. We present our experience in 29 patients ranging in age from 3 to 22 years (mean age 10.5 years) who underwent secondary orbitocranial reconstruction of large contour defects utilizing porous granular hydroxyapatite. Follow-up ranges from 6 to 72 months (mean 30 months). Indications for secondary surgery included residual bony contour defects of the frontal bone, temporal areas, and superior orbital rims that were present 12 months or more after initial surgery. There was one infection secondary to a chronic seroma necessitating removal of the porous hydroxyapatite, and one patient required revision for underfilling and another for overfilling. Excellent permanent contour improvement was obtained with a smooth skin surface in the remainder of our patients. The contour corrections have been long lasting, without evidence of porous hydroxyapatite resorption or migration.

Biocompatible Materials↗
PubMed1997

Velopharyngeal incompetence as the presenting symptom of malignant brainstem tumor.

OBJECTIVE: When a patient presents with velopharyngeal incompetence (VPI) without an obvious structural or neurologic cause, the clinician is faced with a diagnostic challenge. We present an 11-year-old male with a long history of VPI who had been referred to our institution for evaluation and treatment. RESULTS: Detailed clinical examination and work-up revealed a malignant brainstem tumor. The presenting symptoms of breathiness associated with VPI had been overlooked by several different clinicians in the past. The patient successfully underwent a sphincter pharyngoplasty. CONCLUSIONS: A careful neurologic examination with special attention to the cranial nerves is necessary to identify subtle neurologic deficits and avoid delay in diagnosis. Differential diagnosis of neurogenic VPI is discussed.

Brain Neoplasms↗
PubMed1997

Secondary management of congenital and acquired craniomaxillofacial deformities. Individualized treatment planning.

Late treatment of craniofacial disorders with concomitant abnormalities of the jaw are the most challenging cases a craniofacial surgeon faces. This article details the principles of preoperative, individualized treatment planning using anthropometric guidelines in a simple but systematic scheme for facial analysis. Seventeen skeletally mature patients without cleft lip and palate or hemifacial microsomia, aged 15 to 65 years, underwent simultaneous orthognathic and craniofacial surgery for a variety of complex craniofacial disorders. The basic clinical approaches outlined in this article permit the surgeon to develop a flexible but accurate treatment plan and proceed with confidence in the management of patients with widespread craniomaxillofacial deformities.

Adolescent↗