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Biomedical subjects

Michael J Rutter

Publications and source records attributed to Michael J Rutter.

At least 19 recordsLinked to original sources
PubMed2006

Salivary gland surgery for chronic pulmonary aspiration in children.

INTRODUCTION: Chronic aspiration in the neurologically impaired child has a considerable morbidity and occasional morbidity. Hospitalization, physician visits and health costs associated with the sequelae of aspiration are considerable. AIM: To assess the efficacy of salivary gland surgery to treat chronic aspiration in children. SETTING: Tertiary pediatric center. STUDY DESIGN: A 6 year retrospective chart review of all patients undergoing salivary gland surgery to treat chronic aspiration. OUTCOME PARAMETERS: (1) Rate of lower respiratory tract infection (LRTI); (2) baseline oxygen saturation pre- and post-surgery. RESULTS: Sixty-two patients aged 7-279 months (mean 68 months) underwent four duct ligation or bilateral submandibular gland excision with unilateral or bilateral parotid duct ligation. The mean rate was 1.2/year pre-operatively and 0.7/year post-operatively (p=0.6). There was, however, a significant improvement in the baseline post-operative oxygen saturation (mean 94.3%) when compared to the pre-operative baseline oxygen saturation (mean 92.8%, p=0.003). Analysis of the cerebral palsy subgroup was performed (n=13). In this group there was no difference between mean pre- and post-operative LRTI rate (p=0.5) nor change in baseline oxygen saturation (p=0.83). Children under 3 years of age showed a reduction in the LRTI rate (mean of 2.1 versus 0.7 episodes per year, p=0.04) and an improvement in the post-operative baseline oxygen saturation (p=0.001) following surgery. CONCLUSIONS: Unlike a previous publication from this institution, when evaluating the population sample as a whole, there was no significant improvement in the rate of LRTI following salivary gland surgery, however, there was an improvement in baseline oxygen saturation, possibly reflecting an improvement in lung function. There was an improvement in neither outcome parameter in children with cerebral palsy and improvements in both outcome measures in children under the age of 3.

Adolescent↗
PubMed2006

Combined retrograde and anterograde hypopharyngeal puncture and dilatation in a child with complete hypopharyngeal stenosis.

The management of complete hypopharyngeal stenosis is a complex task, and various methods of re-creating a lumen and maintaining its patency have been described in both the adult and pediatric literature. We present our experience using a modification of the combined anterograde-retrograde endoscopic technique for managing a 15-year-old child who developed complete hypopharyngeal and upper esophageal obliteration following successful treatment of a parapharyngeal rhabdomyosarcoma. During an 18-month period following initial cannulation of the aerodigestive tract, we performed 17 dilatations using a double-balloon technique that combined anterograde and retrograde approaches to the stenosis. Initially, Kenalog injections and topical Mitomycin-C were used as adjunctive treatments. We observed no major complications following dilatations. At 33 months follow-up the patient was asymptomatic, tolerating a near normal diet, had not required dilation for more than 18 months, and no longer required a gastrostomy tube.

Administration, Topical↗
PubMed2006

Deficient tracheal rings.

Deficient cartilaginous rings are an extremely rare intrinsic tracheal defect. To our knowledge, only two cases have previously been reported in the literature. We describe our experience with three patients presenting with this unusual defect causing severe tracheomalacia who were successfully managed with slide-tracheoplasty. With respect to correction of the stenotic tracheal segment, our clinical outcomes were excellent. Dissimilarities in medical history suggest that the origin of deficient tracheal rings can be either congenital or acquired.

Child, Preschool↗
PubMed2006

Open excision of subglottic hemangiomas to avoid tracheostomy.

OBJECTIVE: To assess the efficacy of open excision as an alternative to tracheostomy in the management of subglottic hemangioma. DESIGN: A retrospective review of patients undergoing open surgical excision of subglottic hemangiomas over a 10-year period. SETTING: A tertiary pediatric center. PATIENTS: The study included 22 children ranging in age from 2 to 42 months (median age, 5 months) who underwent open excision of subglottic hemangioma over a 10-year period. RESULTS: Twenty-one patients were treated with single-stage procedures, with postoperative endotracheal intubation for an average of 5 days. One patient who had a preexisting tracheostomy was treated with a 2-stage procedure and underwent decannulation 2 months after excision. Seven other patients were tracheostomy dependent at the time of excision and underwent decannulation at the time of the procedure. Cartilage grafts were inserted in 10 patients. There were no problems with subglottic stenosis. Twenty-one patients reported good voice and no airway symptoms after a mean follow-up period of 42 months. Five patients had significant postoperative problems. Three patients required further endoscopic procedures for removal of granulation tissue, and 1 patient, who remains minimally symptomatic, developed an anterior glottic web. One patient required a 6-month course of steroids after surgery to treat residual glottic hemangioma. CONCLUSIONS: Open surgical excision of subglottic hemangiomas can be performed as a single procedure, avoiding a tracheostomy, when modern surgical techniques developed for laryngotracheal reconstruction are incorporated. This approach can avoid repeated endoscopic procedures, prolonged treatment with corticosteroids, and years spent with a tracheostomy waiting for spontaneous involution of the hemangioma.

Child, Preschool↗
PubMed2006

Down syndrome and complete tracheal rings.

Tracheal stenosis caused by complete tracheal rings has previously not been associated with Down syndrome. We identified 7 children with Down syndrome and complete tracheal rings. We found the clinical presentation and airway anatomy to be variable, advocating a heightened level of suspicion when evaluating a child with Down syndrome.

Child, Preschool↗
PubMed2006

Lymphatic malformations of the tongue base.

PURPOSE: In light of the paucity of literature on lymphatic malformations of the tongue base, our aim was to present our experience and long-term outcomes of patients with this rare and challenging pathologic entity. METHODS: Medical records of 25 patients treated by the 3 senior authors (RGA, MTC, and RTC) between 1974 and 2003 were retrospectively reviewed, and comprehensive clinical data were collected and analyzed. RESULTS: Twenty-one patients (13 female and 12 male infants) were diagnosed either prenatally or at birth. Of these patients, 18 required early airway stabilization; 17 required tracheotomy. Four patients were diagnosed after 1 year of age and had no airway problems. Follow-up ranged from 2 days (owing to death) to 28 years, with a mean of 10 years. In 21 patients, pathology was extensive, involving contiguous anatomical areas such as the anterior tongue, larynx, pharynx, and floor of mouth. Multiple resections and debulking procedures were performed to restore function and improve cosmesis. Four patients died, all with laryngeal involvement. Of the 14 survivors who had tracheotomies, only 5 are decannulated. Normal oral feeding has been achieved in 14 patients and normal speech, in 8 patients. Cosmesis has improved with time. Orthodontic and dental problems are common, and 9 patients have significant macrognathia. CONCLUSIONS: Although most patients with lymphatic malformations of the tongue base achieve normal oral feeding, airway, speech, and cosmesis issues remain problematic throughout life. Laryngeal involvement signifies extensive disease and is the most significant risk factor for serious complications and death.

Airway Obstruction↗
PubMed2006

Evaluation and management of upper airway disorders in children.

Upper airway disorders in children may be divided into those that are congenital in origin and those that are acquired. The presentation and management of these disorders is significantly influenced both by the anatomic location of the pathology, which is usually obstructive in nature, and by the severity of the obstruction. This discussion provides an overview of the presentation, diagnosis, management, and potential complications of the most commonly seen upper airway disorders. These disorders are presented within an anatomic framework, progressing from proximal at the nares to distal at the carina.

Airway Obstruction↗
PubMed2005

Management of incidental thyroglossal duct cysts during laryngotracheal reconstruction.

Thyroglossal duct cysts originate from trapped elements of the thyroglossal duct tract during embryological descent of the thyroid gland. The incidental finding of a thyroglossal duct cyst during cervical surgery has not been described previously. We present four cases of small asymptomatic thyroglossal duct cysts discovered as an incidental finding during laryngotracheal reconstruction. In each case, the cyst was removed using a Sistrunk procedure. In all four cases the patient was successfully decannulated, and there were no cases of cyst recurrence. We also consider the implications that these four cases may have on the perceived incidence of the thyroglossal duct cysts and their management.

Child, Preschool↗
PubMed2005

Pediatric cricotracheal resection: surgical outcomes and risk factor analysis.

OBJECTIVE: To identify risk factors for operation-specific outcomes of pediatric cricotracheal resection (CTR). DESIGN: We identified the first 100 consecutive children undergoing CTR at our institution from January 1, 1993, to December 31, 2004. Retrospective review of medical records provided data on demographics, operation dates, decannulation dates, and proposed risk factors, including age, stenosis grade, vocal cord function, Down syndrome, history of distal tracheal surgery, history of open laryngotracheal surgery, presence of tracheotomy at the time of operation, use of suprahyoid release, extended CTR, and use of chin-to-chest sutures. Complete data sets were available for 93 patients. We performed multivariable logistic regression analysis to identify significant independent risk factors. SETTING: A tertiary care children's hospital. PATIENTS: All patients younger than 18 years who underwent CTR at our institution. MAIN OUTCOME MEASURES: Operation-specific and overall decannulation rates. RESULTS: Results of the preoperative evaluation showed grade III or IV stenosis in 89 patients (96%). The overall decannulation rate included 87 patients (94%); the operation-specific decannulation rate, 66 patients (71%). The only significant risk factor for failure to decannulate after 1 operation was the presence of unilateral or bilateral vocal cord paralysis (P = .007). CONCLUSIONS: Cricotraceal resection may be safely performed in patients with multiple airway lesions. Patients with a history of vocal cord paralysis who undergo CTR often require more than 1 open airway procedure for decannulation and should be counseled appropriately. This study represents the largest reported series of pediatric CTR.

Adolescent↗
PubMed2005

Aspiration in children with CHARGE syndrome.

UNLABELLED: Patients with Coloboma, Heart defect, choanal Atresia, Retarded development, Genitorenal and Ear abnormalities (CHARGE) syndrome have been reported to be at high risk for aspiration and swallowing difficulties. Aspiration has been implicated as the most common cause of mortality in these patients. To date, however, aspiration and swallowing disorders in CHARGE patients have not been independently studied. OBJECTIVE: To determine the prevalence of aspiration and swallowing dysfunction in children with CHARGE syndrome. METHODS: A retrospective chart review of 30 children with CHARGE syndrome was performed. RESULTS: Eighteen (60%) children had aspiration observed on video swallow study (VSS), flexible endoscopic evaluation of swallowing (FEES), and/or had otherwise unexplained bronchiectasis noted on CT scan of the chest. Twenty-four children (80%) had evidence of abnormal swallowing such as laryngeal penetration, dyscoordination, poor bolus mobility, or pooling of secretions. CONCLUSION: Aspiration and swallowing dysfunction are common in children with CHARGE syndrome. Formal evaluation of swallowing function should be part of the standard otolaryngologic examination for these patients.

Abnormalities, Multiple↗
PubMed2005

Airway reconstruction in pediatric burn patients.

OBJECTIVE: Reconstruction of the laryngotracheal airway in pediatric burn victims has been described anecdotally as less successful than reconstruction performed in other populations. To evaluate this clinical impression, outcomes of laryngotracheal reconstruction (LTR) in pediatric burn victims were compared with a randomly selected, matched control population of children receiving LTR. DESIGN: Retrospective case control study. SUBJECTS: The records of 34 pediatric burn victims undergoing LTR were reviewed. A control group of 48 children undergoing LTR for acquired stenosis was randomly selected from a population matched for age and grade of stenosis. RESULTS: Decannulation rate after 1st procedure, number of open airway procedures required, and length of time after 1st procedure until decannulation were not significantly different between the 2 groups. Two deaths (both tracheostomy tube related) occurred in the burn group; 1 occurred in the control group. Two patients in the burn group and 3 patients in the control group remain tracheostomy tube dependent at least 1 year after the initial reconstructive attempt. CONCLUSIONS: Long-term outcomes of LTR in burn patients are not significantly different from outcomes of LTR in the pediatric acquired airway stenosis population.

Burns↗
PubMed2005

Primary cricotracheal resection with thyrotracheal anastomosis for the treatment of severe subglottic stenosis in children and adolescents.

Severe subglottic stenosis in children is best managed by laryngotracheal reconstruction or cricotracheal resection (CTR). We describe clinical outcomes with CTR and end-to-end anastomosis in pediatric patients with severe subglottic stenosis in a tertiary-care pediatric teaching hospital in Mexico City. We prospectively followed up all consecutive patients younger than 18 years of age with a Myer-Cotton grade 3 or 4 subglottic stenosis who underwent CTR between May 1, 2000, and March 31, 2003. The frequency of each clinical outcome was calculated. Twenty-two patients (16 boys [72.7%] and 6 girls [27.3%]) were included. The mean age at operation was 4.6 years (range, 11 months to 16 years). Eighteen patients (81.8%) required primary CTR, and 4 (18.2%) required extended CTR. Seventeen (77.3%) had grade 3 stenosis, and 5 (22.7%) had grade 4 stenosis. Six (27.3%) had associated clinical conditions, and 3 (13.6%) had associated vocal cord mobility defects. All were tracheostomy-dependent at presentation, and none had undergone previous airway surgery. Ten (45.5%) underwent one-stage surgery, and 12 (54.5%) had a concomitant temporary tracheotomy. No intraoperative complications occurred. Seventeen patients (77.3%) developed postoperative granulation tissue requiring endoscopic resection. The mean follow-up was 1.2 years (range, 2 months to 2.8 years). No deaths occurred. Fifteen children (88.2%) with grade 3 stenosis and 5 (100%) with grade 4 stenosis were decannulated, for an overall decannulation rate of 90.9%. Partial cricoid resection with end-to-end anastomosis has been a feasible procedure with reproducible successful results among our patients. We conclude that CTR performed as a primary procedure is an effective treatment for the management of severe subglottic stenosis in children.

Adolescent↗
PubMed2005

Altered laryngeal sensation: a potential cause of apnea of infancy.

Delayed maturation of respiratory control of breathing and the laryngeal adductor reflex (LAR) are commonly implicated in infant apnea. A swallow response occurs to remove the stimulus from the pharynx to prevent aspiration once the glottis reopens. Induction of apnea by poorly cleared endogenous upper airway secretions has been postulated to be a potential cause of infant apnea. Our purpose was to determine whether alteration in the LAR, an indicator of laryngeal sensation, and the presence of secretions influenced the responsiveness of the LAR in infants with apnea. The LAR was induced in 20 infants with apnea (median gestational age, 36.5 weeks) by application of air pulses of controlled duration (50 ms) and intensity (2.5 to 10 mm Hg) to the aryepiglottic fold. Twenty infants evaluated for upper respiratory tract anomalies were used as a comparison group (median gestational age, 39 weeks). The infants with apnea required higher-intensity stimuli (p < .001) to induce the LAR (6.2 +/- 1.6 mm Hg) than did the comparison group (4.3 +/- 1.0 mm Hg) and demonstrated poorer clearance of secretions (p < .001). These findings were significant even when we adjusted for postconceptional age at the time of the test (p = .007). The findings of this study suggest that decreased laryngeal sensitivity results in poor endogenous secretion clearance and that it may induce a prolonged glottic closure event to prevent aspiration. This closure may play a role in infant apnea.

Air Movements↗
PubMed2005

Acquired subglottic cysts in preterm infants.

OBJECTIVES: Acquired subglottic cysts (SGCs) are a recognized complication of intubation in preterm infants. A brief window of our experience is reviewed to determine the demographics and outcomes of therapy. DESIGN: A retrospective review encompassing patients diagnosed and treated from 2001 to 2002 inclusively. SETTING/METHODS: A case series of 11 patients evaluated at a tertiary care pediatric institution over a 2-year period is presented. RESULTS: Eleven patients evaluated for symptoms of severe airway distress were diagnosed with SGC by microlaryngoscopy and bronchoscopy. All had a history of prematurity with intubation in the perinatal period. All but one became symptomatic many months following intubation. Two patients presented for assessment with tracheotomies, whereas a third received a tracheotomy during therapy owing to a large obstructive bilateral SGC. Large unilateral SGCs were the most common finding on endoscopy. Treatment consisted of cyst marsupialization or direct excision on laryngotracheoplasty. Twenty-six procedures were performed. Four patients required single procedures for complete resolution of symptoms. Two patients had staged procedures with the use of endoscopic diathermy. An element of subglottic stenosis was present in 10 of the 11 patients; however, only 3 patients required laryngotracheoplasty for definitive treatment. CONCLUSION: SGCs are associated with intubation in premature infants and may develop many months following extubation. The duration of intubation does not appear to be a predictive risk factor. Subglottic stenosis is commonly an underlying finding in patients with SGC. Staging procedures with endoscopic diathermy is a highly effective modality, minimizing the need for more invasive procedures.

Cysts↗
PubMed2004

Nonoperative management of complete tracheal rings.

BACKGROUND: Children with complete tracheal rings are often challenging to manage. Most children will present early with a severely compromised airway and will require tracheal reconstruction. OBJECTIVE: To show that a small number of minimally symptomatic patients with complete tracheal rings experience airway growth over time and do not require tracheoplasty. DESIGN: A retrospective medical chart review over a 10-year period. SETTING: A tertiary care pediatric hospital. PATIENTS: Children (N = 10) with a diagnosis of complete tracheal rings, confirmed on bronchoscopy, who were observed for a minimum of 1 year prior to determining the need for tracheoplasty. MAIN OUTCOME MEASURES: Patient symptoms, bronchoscopic findings, airway size, and the progression of these over time. Other congenital anomalies, the reason for initial diagnosis, and the need for tracheoplasty were documented. RESULTS: The 10 patients in our series fell into the following 3 categories: 5 patients were minimally symptomatic or asymptomatic, showed bronchoscopic evidence of progressive airway growth, and did not require tracheoplasty; 2 patients had worsening symptoms of exercise intolerance, showed minimal airway growth, and ultimately required tracheoplasty; and 3 patients are still being clinically observed and may eventually require tracheoplasty. Periods of observation have varied from 1 year to over 12 years. CONCLUSIONS: Not all patients with complete tracheal rings require tracheoplasty. Some have satisfactory airway growth and do not require airway reconstruction. A period of observation to monitor airway growth and clinical symptoms is safe and may spare some patients from undergoing unwarranted airway reconstruction.

Airway Obstruction↗
PubMed2004

The use of posterior cricoid grafting in managing isolated posterior glottic stenosis in children.

OBJECTIVE: To review our experience using posterior cricoid grafts to manage pediatric patients with isolated posterior glottic stenosis (PGS). DESIGN: Retrospective review over a 12-year period. SETTING: Tertiary care pediatric hospital. PATIENTS: All patients with isolated PGS treated between 1990 and 2002, in whom PGS was the dominant airway lesion and laryngotracheoplasty was required. Patients with concomitant vocal cord paralysis, a history of posterior laryngeal clefting, a Bogdasarian type I stenosis, or subglottic stenosis worse than grade I were excluded. MAIN OUTCOME MEASURES: Cause, operative intervention, decannulation rate, failure rate, and requirement for secondary procedures. RESULTS: A total of 29 patients ranging in age from 2 to 8 years were treated (21 with a history of prolonged intubation and 8 with a history of laryngeal trauma). Twenty patients had tracheotomies in place at the time of airway reconstruction and the remainder had stridor. Costal cartilage was the preferred graft material and was used in 27 patients. Six patients were referred with a diagnosis of bilateral vocal cord paralysis, but on evaluation were found to have PGS and mobile vocal cords. In 12 patients, repair was accomplished in a single-stage procedure; a suprastomal stent was placed in 17 patients. Overall decannulation rate was 97%, though a second procedure was required in 4 patients. One patient remained tracheotomy dependent; 4 had poor voice, including 2 with a history of laryngeal fracture; and 2 had late arytenoid prolapse. CONCLUSIONS: Isolated PGS in children is effectively managed with costal cartilage grafting of the posterior cricoid. This series has seen an evolution in management, with shorter stenting periods, placement of flanged posterior grafts without sutures, and graft placement without complete laryngofissure.

Adolescent↗
PubMed2004

Single-stage tracheal resection for severe tracheal stenosis in older children.

OBJECTIVE: While tracheal resection for management of tracheal stenosis is an effective technique that has been well described in adults, the results in children have been less encouraging, as children tolerate anastomotic tension less well than adults. We describe our current technique for the management of severe tracheal stenosis in older children. METHODS: Four teenagers, 16-17 years of age, presented with severe tracheal stenosis. A 16-year-old girl had sustained tracheal stenosis following prolonged intubation, and presented with a severe Grade III stenosis having had 25 endoscopic procedures, and a failed resection at another institute. Two 17-year-old boys and a 17-year-old girl presented with Grade IV stenosis at the suprastomal area following previous intubation injuries. All four children had an identical procedure with tracheal resection over a Hood tracheal stent. RESULTS: All four children were extubated in the operating room. Chin-to-chest sutures were removed between 7 and 10 days, as was the Hood stent. All four are currently asymptomatic with no airway stenosis. CONCLUSIONS: Although tracheal resection for tracheal stenosis in children is associated with a higher failure rate than is seen in the adult population, even severe stenosis and long segment resection may achieve excellent results. We feel that important factors influencing outcome in this series included anastomosis to an intact cricoid ring, and support of the anastomosis with a tracheal stent.

Adolescent↗