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Biomedical subjects

R T Cotton

Publications and source records attributed to R T Cotton.

At least 19 recordsLinked to original sources
PubMed2001

Topical mitomycin application after laryngotracheal reconstruction: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To explore the effect of mitomycin treatment on the pediatric airway following laryngotracheal reconstruction. DESIGN: Randomized, double-blind, placebo-controlled trial. PATIENTS: Children aged 2 to 17 years with subglottic or upper tracheal stenosis undergoing laryngotracheal reconstruction at a single, tertiary care, children's hospital. INTERVENTION: At the time of extubation or stent removal, the children underwent bronchoscopy and 0.4 mg/mL (2 mL of a 0.2-mg/mL solution of either mitomycin or an equal volume of isotonic sodium chloride was directly applied to the subglottic region for a single application of 2 minutes. These children then underwent interval endoscopy at 2 weeks, 6 weeks, and 3 months postoperatively for assessment of their airways. RESULTS: Granulation tissue was graded on a scale of 0 (none) to 4 (near-total or total occlusion). Videotapes of endoscopies were independently observed and graded by 3 pediatric otolaryngology fellows with a subsequent interobserver agreement of 91.6%. The results were then dichotomized to represent a single cohort in which further surgical intervention would be required and another separate cohort in which further surgery would not be required. At the 1-year mark, interim analysis was performed by a Data Safety and Monitoring Committee. At this time, 13 children had been randomized to the mitomycin-treated arm of the study and 11 children to the placebo-treated arm. A 2-tailed Fisher exact test revealed a value of 1.00. The Data Monitoring and Safety Committee advised that the trial should be stopped because the distributions between the 2 populations were almost identical. CONCLUSION: We cannot reject the null hypothesis that a single topical dose of mitomycin exerts an equal benefit as does isotonic sodium chloride when applied to the pediatric airway after laryngotracheal reconstruction.

Administration, Topical↗
PubMed2001

Posttonsillectomy hemorrhage: what is it and what should be recorded?

OBJECTIVES: To report on our incidence of posttonsillectomy hemorrhage and to define what constituted posttonsillectomy bleeding. DESIGN: Retrospective study. SETTING: Tertiary care children's hospital and a local satellite facility. PATIENTS: A series of 1438 consecutive patients who had undergone either tonsillectomy or adenotonsillectomy between January 1, 1999, and December 31, 1999. INTERVENTION: During this period, parents were instructed to return with their children for clinical evaluation if any blood was seen in the postoperative period. MAIN OUTCOME MEASURES: Postoperative day of evaluation, age, sex, location of bleeding, management strategy, length of hospital admission, and any bleeding disorders were noted for each patient. RESULTS: A total of 112 patients underwent evaluation 134 times. Of these patients, 96 required only 1 evaluation and 16 required more than 1 evaluation. All patients who had more than 1 evaluation required intervention. The total number of children requiring intervention for posttonsillectomy hemorrhage was 51 (3.5%) of the 1438 patients. Female patients were more likely than male patients to return for evaluation. Patients who were 12 years and older were the most likely and those 3 years and younger were the least likely to have posttonsillectomy hemorrhage. The most common time from surgery to initial evaluation for hemorrhage was 6 days. CONCLUSIONS: By reviewing our own criteria for defining and recording posttonsillectomy hemorrhage, we conclude that posttonsillectomy hemorrhage is defined differently in the literature. This supports the need for a standard definition to allow for direct comparisons.

Adenoidectomy↗
PubMed2001

Cricotracheal resection in children.

OBJECTIVE: To review our experience with cricotracheal resection in a pediatric population. DESIGN: Prospective case review of a cohort of patients undergoing cricotracheal resection. SETTING: Tertiary care pediatric hospital. PATIENTS: Forty-four consecutive patients undergoing cricotracheal resection between January 1, 1993, and December 31, 1998. MAIN OUTCOME MEASURES: Decannulation rates. RESULTS: Thirty-eight (86%) of the 44 children are decannulated. The ultimate decannulation rate was independent of the presenting grade of subglottic stenosis. Fourteen children (100%) had a primary cricotracheal resection; all are decannulated. Twenty-one children had a salvage cricotracheal resection, and 19 (90%) are decannulated. Nine children had an extended cricotracheal resection, of whom 5 (56%) are decannulated. A primary cricotracheal resection was performed on a child on whom no previous open airway procedure had been performed. A salvage cricotracheal resection was performed on a child on whom previous open airway reconstruction had not resulted in an adequate airway. An extended cricotracheal resection was performed on a child on whom the cricotracheal resection was combined with a second procedure, either additional expansion cartilage grafting or an open arytenoid procedure. Most of these children had complex airway pathologic conditions. CONCLUSION: Cricotracheal resection complements standard laryngotracheal reconstruction techniques in a pediatric population.

Adolescent↗
PubMed2001

Laryngotracheoplasty for subglottic stenosis in Down Syndrome children: the Cincinnati experience.

Previous studies from our institution have noted difficulties in the surgical repair of subglottic stenosis (SGS) in children with Down Syndrome. The objectives of this paper were to update our 15 year experience in the Down Syndrome patient population, compare our results with our overall series of laryngotracheoplasty for SGS, and to report on the increased incidence of posterior glottic stenosis (PGS) within this group of patients. Medical records of all children with SGS and Down Syndrome evaluated between 1982 and 1997 were reviewed for history of prior intubation, tracheotomy, gastroesophageal reflux disease (GERD), pre-operative SGS grade, and decannulation. From this review several conclusions have been drawn. First, the risk factors for SGS appear to be the same in the Down Syndrome group as the general population. Second, SGS continues to be more prevalent among children with Down Syndrome than among children in the general population. Third, we have now found a higher rate of PGS within these patients when compared to our overall series. Finally, it now seems that our decannulation rates in Down Syndrome children are approaching our overall series results.

Down Syndrome↗
PubMed2001

Postoperative management of children after single-stage laryngotracheal reconstruction.

OBJECTIVE: To report the safety and efficacy of a postoperative approach that avoids pharmacologic and physical restraints and allows liberal physical activity after single-stage laryngotracheal reconstruction in children. DESIGN: Retrospective study. SETTING: Tertiary care pediatric intensive care unit. PATIENTS: One hundred thirty-three children who underwent single-stage laryngotracheal reconstruction, including laryngotracheoplasty, tracheal resection, and cricotracheal resection. INTERVENTIONS: Five-year period of data collection regarding postoperative care and complications. MEASUREMENTS AND MAIN RESULTS: The medical records of all patients (age range, 2-336 months; mean age +/- SEM, 66 +/- 5 months) who underwent single-stage laryngotracheoplasty, tracheal resection, or cricotracheal resection between 1993 and 1998 were reviewed. Tracheally intubated, awake, and unrestrained patients (group 1, n = 54; mean age, 113 +/- 8 months) were compared with tracheally intubated, sedated, and restrained patients (group 2, n = 79; mean age, 33 +/- 3 months). Pediatric intensive care unit length of stay was less in group 1 in comparison with group 2 patients (11.2 +/- 0.5 days vs. 13.7 +/- 0.6 days; p = .007). Hospital length of stay was less in group 1 than group 2 patients (16.7 +/- 1.0 days vs. 21.1 +/- 1.1 days; p = .01). Adverse events were fewer in group 1 compared with group 2 patients: atelectasis, 44% vs. 73% (p < .001); postextubation stridor, 22% vs. 53% (p < .001); and withdrawal syndromes, 0% vs. 43% (p < .001). The occurrence of pneumonia, airleak syndromes, unplanned extubation, and aspiration events was not different between groups. CONCLUSIONS: For developmentally appropriate children, postoperative management after single-stage laryngotracheal reconstruction does not require the use of physical and pharmacologic restraints. Older children who are not sedated or restrained and who are allowed liberal physical activity have shorter pediatric intensive care unit and hospital lengths of stay, and a decreased incidence of postoperative adverse events. Centers performing single-stage laryngotracheal reconstruction should consider a postoperative management strategy that avoids sedatives, muscle relaxants, and physical restraints, and allows liberal bedside physical activity in developmentally appropriate children.

Adolescent↗
PubMed2001

Acquired total (grade 4) subglottic stenosis in children.

Pediatric acquired total subglottic stenosis (SGS) is a challenging problem. The management of these patients has evolved at our institution over the past 25 years. We conducted a retrospective study to evaluate the surgical management and outcomes of children with grade 4 SGS. Fifty-six patients have presented with acquired grade 4 SGS since 1981. The causes included previous surgery (34), prolonged intubation (15), bums (1), and unknown causes (6). Of the 56 patients, 44 (79%) were decannulated; 120 total procedures were performed, and 39 patients (70%) required more than 1 procedure for decannulation. The decannulation rate has risen from 67% in the 1980s to 86% in the 1990s. Patients who underwent cricotracheal resection (CTR) had a higher decannulation rate than patients who underwent laryngotracheal reconstruction (LTR) with anterior and posterior costal cartilage grafting (CCG) (92% versus 81%), and were less likely to need additional open procedures to achieve decannulation (18% versus 46%). The decannulation rate for children with grade 4 SGS has improved because of advances in surgical technique. Currently, the principal operations used at our institution are 1) CTR and 2) LTR with anterior and posterior CCG. There was a trend toward a higher decannulation rate in patients who underwent CTR, and they were less likely to require further reconstructive surgery before decannulation.

Adolescent↗
PubMed2001

Arytenoid prolapse as a consequence of cricotracheal resection in children.

Cricotracheal resection (CTR) is a technique introduced comparatively recently for treating severe laryngotracheal stenosis in children. The recognized complications of CTR include recurrent laryngeal nerve damage, anastomotic dehiscence, and restenosis. We describe a further complication of CTR, namely, prolapse of the arytenoid cartilage. The presentation may be late, with symptoms of shortness of breath on exertion and nocturnal stertor with a poor sleep pattern, or the prolapse may be an asymptomatic incidental finding. The diagnosis is performed with flexible nasopharyngoscopy with the patient unanesthetized, or with rigid endoscopy with the patient lightly anesthetized and spontaneously ventilating. The affected arytenoid cartilage is noted to prolapse anteriorly and medially with inspiration, partly obstructing the airway. If treatment is required, endoscopic laser partial arytenoidectomy is effective. In a series of 44 children who underwent CTR, 20 were noted to develop arytenoid prolapse after operation. Twelve were asymptomatic, and 8 required laser arytenoidectomy, 2 of whom now require continuous positive airway pressure for moderate supraglottic collapse.

Adolescent↗
PubMed2001

Role of laryngoscopy, dual pH probe monitoring, and laryngeal mucosal biopsy in the diagnosis of pharyngoesophageal reflux.

There is no standard for determining significant pharyngoesophageal reflux. This prospective blind comparison study compared dual pH probe studies, direct laryngoscopy, and mucosal biopsy in children without symptoms of gastroesophageal reflux who underwent airway evaluation. Significant reflux to the lower esophageal probe did not correlate with statistical significance with reflux to the upper probe. In this group of asymptomatic patients, a positive lower pH probe finding did not correlate with upper or lower esophageal mucosal inflammation. Eosinophilia in the esophageal mucosa is diagnostic of gastroesophageal reflux disease, and was seen in 5 of the laryngeal biopsies. A weak correlation was seen between positive findings at laryngoscopy and positive posterior cricoid biopsy in this group. There may be no consistent way to predict significant pharyngoesophageal reflux in asymptomatic patients. Single-probe pH testing will not predict significant pharyngoesophageal reflux with mucosal changes. Laryngoscopy and upper pH probe findings only weakly correlate with significant histologic findings. Laryngeal and posterior cricoid biopsy may be the only sensitive test for mucosal injury. Clinical trials of empiric antireflux therapy should be used to determine whether the laryngeal changes seen in these patients are reversible.

Biopsy↗
PubMed2001

Duration of stenting in single-stage laryngotracheal reconstruction with anterior costal cartilage grafts.

In single-stage laryngotracheal reconstruction (ss-LTR), the endotracheal tube is used as a stent. The optimal duration of stenting is not known. The stenting period requires a stay in the intensive care unit, as the patient is intubated. Sedation and, rarely, paralysis may be required. An analysis from a prospectively collected database was performed to investigate the effect of length of stenting on the outcome of ss-LTR. The outcomes used were reintubation rate and postoperative tracheostomy rate. Patients with anterior costal graft ss-LTR were selected, as they had undergone similar procedures and have similar stenosis types and grades. In 101 patients, the duration of stenting ranged from 2 to 14 days (mean, 7 days; SD, 2.6 days). No significant correlation was found between the number of days stented and the reintubation rate or the postoperative tracheostomy rate. Patients stented for longer than I week were an average of 15 months younger than those stented for less than 1 week; however, the stenosis grades for the two populations were equivalent. The differences in rates of reintubation (p = .68) and postoperative tracheostomy (p = .52) in these 2 groups were not significant. For patients undergoing ss-LTR with anterior costal cartilage grafts, no correlation was found between the number of days stented (intubated) and the reintubation rate or the postoperative tracheostomy rate.

Adolescent↗
PubMed2001

Surgery for pediatric subglottic stenosis: disease-specific outcomes.

To set the foundation to develop a disease-based, operation-specific model to predict the outcome of pediatric airway reconstruction surgery, we performed a retrospective database review of children operated on at a single, tertiary-care children's hospital. Over the 12-year period 1988 to 2000, a total of 1,296 airway reconstruction procedures were performed. Out of these, charts were identified for 199 children who underwent laryngotracheal reconstruction for a sole diagnosis of subglottic stenosis. Children were excluded from the study if their disorder included supraglottic, glottic, or upper tracheal disease. The main outcome measures were Myer-Cotton grade-specific decannulation and extubation rates, including both operation-specific and overall results. There were 101 children who underwent double-stage laryngotracheal reconstruction. The operation-specific decannulation rates for Myer-Cotton grades 2, 3, and 4 were 85% (18/21), 37% (23/61), and 50% (7/14) (chi2 analysis, p = .0007). The overall decannulation rates were 95% (20/21), 74% (45/61), and 86% (12/14) (chi2 analysis, p = .04). There were 98 children who underwent single-stage laryngotracheal reconstruction. The operation-specific extubation rates for Myer-Cotton grades 2, 3, and 4 were 82% (37/45), 79% (34/43), and 67% (2/3) (chi2 analysis, p = .63). The overall extubation rates were 100% (45/45), 86% (37/43), and 100% (3/3) (chi2 analysis, p = .03). Logistic regression analysis showed no effect of age (less than or greater than 2 years of age) on operation-specific or overall outcome parameters. We conclude that laryngotracheal reconstruction for pediatric subglottic stenosis remains a challenging set of procedures in which multiple operations may be required to achieve eventual extubation or decannulation. Children with Myer-Cotton grade 3 or 4 disease continue to represent a significant challenge, and refinements of techniques are being examined to address this subset of children. Disease-based, operation-specific outcome statistics are the first step in the development of a meaningful predictive model.

Adolescent↗
PubMed2000

Cricotracheal resection as a primary procedure for laryngotracheal stenosis in children.

OBJECTIVE: Cricotracheal resection (CTR) is being increasingly used in the treatment of children with severe laryngotracheal stenosis. In this institution the majority of children are treated with CTR as a salvage procedure having undergone previous unsuccessful laryngotracheal reconstruction (LTR). Selected children have undergone CTR as a primary procedure (without previous LTR). The objective of this study is to examine the outcome for children undergoing cricotracheal resection as a primary procedure for severe laryngotracheal stenosis. METHOD: analysis from prospectively collected database. RESULTS: 17 patients underwent CTR without previous LTR or anterior cricoid split between October 1994 and September 1998. All the patients had grade 3 or 4 stenosis. After a minimum of 1 year follow up 15 children are decannulated. Five children required further surgery to achieve this. Two children still have tracheostomies. Both had extended procedures. One included bilateral arytenoid abduction for bilateral vocal cord paralysis in a patient with quadraparesis following transverse myelitis. The other child, who suffered from multiple congenital anomalies, underwent a concurrent posterior cricoid cartilage graft. Nine patients had good voice post-operatively, five had acceptable voice and three had weak or no voice. CONCLUSION: the early experience for CTR in children as a primary procedure achieved an overall decannulation rate of 88% after 1 year follow up in children with severe laryngotracheal stenosis. Five children required further surgery to achieve this. The voice outcome was variable. CTR is an alternative primary procedure to LTR for severe laryngotracheal stenosis in children. The relative indications for these procedures are discussed.

Child↗
PubMed2000

Spiral CT versus MRI in neonatal airway evaluation.

Magnetic resonance imaging has become the standard means of imaging pediatric airway obstruction due to vascular anomalies. However, magnetic resonance imaging requires a long acquisition time and is prone to motion artifacts. The development of spiral or helical computed tomography provides an alternative imaging modality for evaluating pediatric airway obstruction. We present the case of a neonate with a double aortic arch which initially was not identified on magnetic resonance imaging but was visualized with spiral computed tomography. If suspicion of an intra-thoracic abnormality is high, spiral computed tomography may be a useful adjunct or replacement to magnetic resonance imaging.

Airway Obstruction↗
PubMed2000

Management of subglottic stenosis.

Evaluation and management of pediatric subglottic stenosis is complex and technically challenging. Laryngotracheal reconstruction has become the standard of care for symptomatic subglottic stenosis in children. Careful preoperative planning, meticulous surgery, and dedicated postoperative care are essential for a successful outcome. Early recognition and management of intraoperative and postoperative complications minimize their impact.

Child↗
PubMed2000

Congenital laryngeal anomalies. Laryngeal atresia, stenosis, webs, and clefts.

Congenital laryngeal anomalies may occur as a result of defects in normal prenatal development. They are associated with a broad spectrum of symptoms and require treatment ranging from observation alone to complex open airway surgery. The treating otolaryngologist must organize a management strategy focused on timely diagnosis, ensuring a safe airway, and maximum conservation of respiratory, phonatory, and swallowing ability.

Humans↗
PubMed2000

Potential role of growth factors and extracellular matrix in wound healing after laryngotracheal reconstruction.

Laryngotracheal reconstruction (LTR) has been used for more than 20 years to treat infants and children with subglottic stenosis. Results after pediatric LTR have been satisfactory; however, approximately 10% of children have recurrent airway narrowing after LTR. The purpose of our study was to determine whether a correlation existed between specific growth factors and extracellular matrix in patients with adequate wound healing capability as compared with patients with poor wound healing capability. Histologic sections from 27 patients who underwent LTR were cut, and immunohistochemical staining was performed for transforming growth factor-beta, platelet-derived growth factor, fibronectin, tenascin, transforming growth factor-alpha, and vascular endothelial growth factor. Results showed that patients with adequate wound healing capability had a positive correlation with vasculature fibronectin, vasculature tenascin, and stromal fibronectin. Patients with poor wound healing capability had a positive correlation with stromal vascular endothelial growth factor.

Child↗
PubMed2000

Expression of Ki-67, tumor suppressor proteins, growth factor, and growth factor receptor in juvenile respiratory papillomatosis: Ki-67 and p53 as predictors of aggressive disease.

The enhanced proliferation of epithelial cells is a typical feature of respiratory papilloma. The mechanism or mechanisms leading to abnormal epithelial proliferation remain unclear. Overexpression of growth factors and their receptors and inactivation of tumor-suppressor proteins are known to cause cell transformation and proliferation. The objectives of this study were to evaluate the expression of these factors in juvenile respiratory papillomas with correlation to cellular proliferation activity, and to determine whether such expression is associated with the clinical course of the disease. The expression of transforming growth factor-alpha, epidermal growth factor receptor, p53 protein, retinoblastoma proteins and Ki-67 was quantified by immunohistochemistry in paraffin-embedded biopsy specimens taken at the initial surgical excision from children in whom respiratory papillomatosis was diagnosed. Clinical information regarding the number of disease sites, tracheobronchial spread, malignant transformation, and frequency of recurrences was reviewed. Thirty-five specimens were suitable for immunohistochemical evaluation. Ki-67 expression was significantly higher in patients with multiple sites of disease and frequent recurrences. High p53 expression was significantly associated with malignant transformation. We concluded that Ki-67 and p53 expression may be predictive of the clinical course in children with respiratory papillomatosis.

Adolescent↗
PubMed2000

Paediatric airway stenosis: laryngotracheal reconstruction or cricotracheal resection?

Modern surgical management of paediatric laryngotracheal stenosis includes a wide variety of surgical procedures. These can broadly be divided into two groups. First, laryngotracheal reconstruction (LTR) procedures in which the cricoid cartilage is split and the framework is expanded with various combinations of cartilage grafts and stents; and second, cricotracheal resection (CTR) where a segmental excision of the stenotic segment is done and an end-to-end anastomosis is performed. In this article we review the literature and our experience and discuss the relative indications for CTR and LTR in children. High decannulation rates have been reported for CTR; however, it remains a more extensive procedure than LTR involving extensive tracheal mobilization. If the tracheostomy site is included in the resection then a significant length of trachea is excised. Alternatively, LTR with cartilage grafting can precisely correct a specific stenosis with minimum morbidity and high decannulation rates for grade 2 and selected grade 3 stenosis. For the more severe stenosis treatment with LTR has been less successful. Retrospective data from this institution suggests that the children with grade 4 stenosis treated with LTR are more likely to require a subsequent open procedure to achieve decannulation than those treated with CTR. LTR is a less extensive procedure and is preferred for grade 2, selected grade 3 stenosis. CTR is the preferred option for grade 4 and severe grade 3 stenosis with a clear margin between the stenosis and the vocal cords.

Child↗