Biomedical subjects
Publications and source records attributed to Michael J Cunningham.
Parapharyngeal space masses are rare in the pediatric population and have a higher incidence of malignancy than those in adults, although the differential diagnosis is similar. We present the work-up and treatment of a child with a parapharyngeal space mass discovered incidentally on CT imaging.
OBJECTIVE: We hypothesized that resident fatigue error should improve, related to well-rested trainees as a direct cause/effect benefit. However, patient hospital care quality is multifactorial, so impact on patient care quality by changing only one variable for a single caregiver group was unknown. DESIGN AND PARTICIPANTS: Convenience samples of 156 residents from three surgical specialties were administered a questionnaire in early 2004 addressing perceptions of patient care quality before and after the 80-h workweek. Additionally, residents recently under work-hour restrictions (Newly Restricted, NR) were compared to New York state trainees already regulated by work-hour restrictions (Previously Restricted, PR). SETTING: Surgical residency training venues. MAIN OUTCOME MEASURE: Survey results; the level of significance for all tests was 0.05. RESULTS: The participation response rate was 94.5%. Eighty-eight percent of respondents indicated by survey subjective impression that patient care quality was either unchanged (63%) or worse (26%) due to work-hour restrictions (P = 0.003). PR residents were more likely than NR residents to report unchanged or worse quality of care (P = 0.015). Residents overall did perceive improvement in some types of error with fewer fatigue-related errors (P < 0.001), e.g., medication (P < 0.001), judgment (P = 0.001), and dexterity (P = 0.013), subsequent to work-hour restrictions. However, more errors were perceived related to continuity of care (P < 0.001), miscommunication (P = 0.001), and cross-coverage availability (P = 0.001). CONCLUSIONS: Despite an expected perception of improvement in fatigue-related errors, most participants (particularly PR residents) reported impressions that patient care quality had remained unchanged or had declined under the work-hour restrictions. Unresolved challenges with continuity of care, miscommunication, and cross-coverage availability are possible explanations. Mere work-hour reduction does not appear to improve patient care quality automatically nor to decrease the possibility for some types of error. Process interventions that specifically target trainee sign-out coverage constraints as part of a global reassessment will be important for future attempts to enhance quality hospital patient care.
OBJECTIVES: To assess the incidence of symptomatic tubal tonsil hypertrophy (TTH) after adenoidectomy and to attempt to differentiate the clinicoradiographic presentation of TTH from that of recurrent or residual adenoid. DESIGN: Retrospective case series review. SETTING: Pediatric otolaryngology practice in a tertiary care hospital. PATIENTS: The charts of all patients scheduled to undergo revision adenoidectomy or nasopharyngeal examination under anesthesia over a 5-year period in 1 pediatric otolaryngologist's practice were reviewed. MAIN OUTCOME MEASURE: Presence of TTH in patients with recurrent symptoms after previous adenoidectomy. RESULTS: Forty-two patients were identified, 24 of whom satisfied the established criteria of recurrent symptoms after previous adenoidectomy. Ten (42%) of these patients were identified as having TTH. The average age at presentation was 7 years 2 months, at an average time interval of 4 years 2 months after adenoidectomy. The comparative incidence of recurrent or residual adenoid was 54%. The symptomatic manifestations of TTH included nasal obstruction, obstructive sleep disorder, rhinosinusitis, recurrent otitis media, and otitis media with effusion. Preoperative radiographic evaluation was not useful in distinguishing TTH from recurrent or residual adenoid; nasopharyngoscopy appears to have better diagnostic potential. Thermal ablation with suction cautery was therapeutically effective. CONCLUSIONS: Tubal tonsil hypertrophy is a significant clinical entity as a cause of recurrent symptoms after adenoidectomy. The study patients demonstrated the entire spectrum of signs and symptoms seen in patients with adenoid hypertrophy. Operative nasopharyngeal examination is required to definitively distinguish TTH from recurrent or residual adenoid.
OBJECTIVE: To examine whether microdebrider intracapsular tonsillotomy (MT) results in less postoperative pain compared with electrosurgical extracapsular tonsillectomy (ET). DESIGN: Prospective, randomized, double-blind, matched pair, clinical trial. SETTING: Specialty care hospital. Patients Twelve male (48%) and 13 female (52%) children aged 5 to 15 years, with obstructive tonsillar hyperplasia were randomized to have one tonsil removed by MT and the other by ET. INTERVENTIONS: An angled endoscopic microdebrider was used to perform MT, and ET was performed by standard monopolar cautery technique. Parents and children were blinded to the side of MT and ET. Children rated the pain 0 to 5 by side using the Faces Pain Scale-Revised. Blinded data collection was via telephone daily for 2 weeks by a study nurse. MAIN OUTCOME MEASURES: Primary: postoperative pain as recorded by Faces Pain Scale-Revised; secondary, presence or absence of otalgia and postoperative bleeding. RESULTS: Twenty-two children (88%) had tonsillectomy and adenoidectomy, while 3 children (12%) had tonsillectomy alone. On postoperative days 1 to 9, children reported significantly less pain on the MT side compared with the ET side (paired t test; P<.01). By postoperative days 10 to 14, the difference between sides disappeared. Twenty children (80%) reported otalgia, and it was always unilateral. For those children reporting otalgia, there was a 100% correlation between the side of otalgia and the side of ET. There was no posttonsillectomy bleeding among the 25 children. CONCLUSION: Microdebrider intracapsular tonsillotomy is significantly less painful compared with electrosurgical ET in children undergoing surgical intervention for obstructive tonsillar hypertrophy.
OBJECTIVE: To validate the Pediatric Voice-Related Quality-of-Life (PVRQOL) survey, which was designed to assess voice changes over time in the pediatric population. DESIGN: Prospective longitudinal study. SETTING: Outpatient pediatric otolaryngology office practice. PARTICIPANTS: One hundred twenty parents of children aged 2 through 18 years having a variety of otolaryngological diagnoses including disorders that affect the voice. INTERVENTIONS: The previously validated Pediatric Voice Outcomes Survey and the PVRQOL were jointly administered to the parents of the study participants. Test-retest reliability was accomplished by having 70 caregivers repeat the instrument 2 weeks after the initial visit. The Cronbach alpha value was calculated to determine reliability. Instrument validity was determined by examining convergent and discriminant validity. MAIN OUTCOME MEASURE: Correlation of PVRQOL scores with Pediatric Voice Outcomes Survey scores. RESULTS: Reliability of the PVRQOL was established by evaluating the Cronbach alpha value (.96; P<.001) and by test-retest reliability (weighted kappa value, 0.8). Validity of the PVQROL was tested by evaluating its ability to show significant change in voice-related quality-of-life after adenoidectomy (discriminant validity) (P<.001). The PVQROL also proved valid when the overall score was correlated with the previously validated Pediatric Voice Outcomes Survey (r = 0.7; P<.001). CONCLUSION: The PVRQOL is a more comprehensive survey than the previously validated Pediatric Voice Outcomes Survey and is another valid instrument to examine the health-related quality-of-life issues in pediatric voice disorders.
Developmental anomalies of the nasolacrimal drainage system typically manifest early in childhood with epiphora and occasionally infection. Although the majority of cases of congenital nasolacrimal obstruction resolve spontaneously with conservative medical management, certain anomalies require operative intervention. Included in this latter group are dacryocystoceles or nasolacrimal duct cysts. The application of endoscopic sinus surgical techniques to children with persistent symptomatic nasolacrimal obstruction provides an alternative to external dacryocystorhinostomy that appears to be equally efficacious and concurrently allows for the potential correction of any predisposing intranasal pathology. Endonasal endoscopic dacryocystorhinostomy is best performed as a joint otolaryngologic-ophthalmologic procedure.
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OBJECTIVE: To discuss the clinical and histopathologic features of cervical bronchogenic cysts. METHODS: Retrospective case series. RESULTS: A 22-year pathology database search identified 24 patients 18 years of age and younger with bronchial/bronchogenic cysts, four of which presented in the cervical region. CONCLUSION: Cervical bronchogenic cysts are rare in the pediatric population but deserve inclusion in the differential diagnosis of cystic neck masses. Such cysts result from abnormal tracheobronchial tree development with characteristic pathology including respiratory-type epithelium, mural cartilage, smooth muscle, and seromucinous glands. Definitive treatment requires surgical excision.
OBJECTIVE: To evaluate the incidence, sites of presentation, and treatment outcome of non-orbital pseudotumor of the head and neck in the pediatric population. METHODS: 10-year retrospective case series at a tertiary care center. All patients 18 years of age and younger with non-orbital pseudotumor of the head and neck evaluated and treated at our institution over the study period (1990-2000) were identified through the Systematic Nomenclature of Medicine (SNOMED) database with the keyword 'pseudotumor'. RESULTS: Among 146 patients identified with head and neck pseudotumor at our institution, 15 (10%) were pediatric patients, only three (20%) of whom had pseudotumor in non-orbital sites (the infratemporal and pterygopalatine fossae, submandibular gland, and masseter space). Four (27%) of the 15 had pseudotumor limited to the lacrimal gland, with the remaining eight (53%) being orbital pseudotumor cases. CONCLUSIONS: Similar to cases of orbital pseudotumor, long term systemic steroid therapy proved effective in the management of non-orbital pseudotumor in all three children with eventual disease resolution.
OBJECTIVE: We present the application and initial results of a CO(2) laser technique for the treatment of medically refractory chronic granular myringitis (CGM). STUDY DESIGN AND SETTING: Retrospective case series of 15 treated ears in 13 consecutive patients between the ages of 6 and 14 years (median age, 9.0 years) cared for in a tertiary care specialty hospital. RESULTS: Eleven of 15 treated ears had total resolution of CGM and associated symptoms; median follow-up time was 10 months. Three ears were improved, and 1 ear remained unchanged. Three of 5 preoperative tympanic membrane perforations healed after laser treatment; 1 patient developed a postoperative, dry perforation. Hearing was not impaired in any patient tested. CONCLUSION: Preliminary results suggest that CGM, when refractory to medical treatment, can often be treated effectively by a single laser treatment.
The diagnosis of atypical cervicofacial lymphadenitis is often not readily clinically apparent. Parents may bring a child to the physician's attention long before the development of the classic findings. When assessing the child with acute-onset cervicofacial lymphadenitis, there are 2 imperative clinical determinations: Is the lymphadenitis of viral, bacterial, or mycobacterial etiology? If of mycobacterial etiology, is it an atypical or tuberculous mycobacterial process? The goal in management is to avoid misdiagnosis and lengthy duration of symptoms before appropriate therapy is instituted. This paper includes a case study-based review of the evaluation, diagnosis, and management of cervicofacial lymphadenitis in children due to atypical mycobacterial organisms.