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Nasal obstruction in children: Evaluation of common assessment methods
Otolaryngology– Head and Neck Surgery Volume 131 Number 2
Scientific Session—Wednesday P227
9:30 AM to 10:30 AM Room JJCC 1A07 •
Scientific Sessions: Pediatric Otolaryngology Moderators: Amelia F. Drake, Hotlel, MD
MD,
Michael R.
9:30 AM Conductive Hearing Loss and Otopathology in Cleft Palate Patients Steven L Goudy, MD; John W Canady, MD; Richard J H Smith, MD Iowa City IA; Iowa City IA; Iowa City IA
Objectives: To assess incidence of conductive hearing loss, ear pathology, and associated communicative disorders in cleft palate patients. Methods: Retrospective chart review of 100 patients all treated at a tertiary facility since birth. Results: The median patient age was 19 years old (range, 7–25) at last follow up. Girls comprised 35% of group. The median age of cleft palate repair was 16 months (range, 12– 60). Median number of myringotomy tubes placed was 3 (range, 1–7). Conductive hearing loss(CHL) ⬎20 db PTA was found in 25% of patients at last follow-up. Severity of CHL was mild in 75%, moderate in 21%, and severe in 4%. Middle ear surgery was performed on 13%. Cholesteatoma was identified in 6%. The mean age at resolution of CHL was 5 years (range, 3–19). Developmental learning disorders were identified in 8%. Speech difficulties requiring surgical treatment occurred in 27%. Risk factors associated with CHL at last follow-up included middle ear surgery (P ⫽ 0.016), cholesteatoma (P ⫽ 0.003), and increased number of myringotomy tubes (P ⫽ 0.030). Associations between CHL and age at cleft repair, speech impairment, or learning disabilities were not found. Conclusions: Otopathology in cleft palate patients continues to be a problem despite close observation. Children requiring increased number of myringotomy tubes, middle ear surgery, and found to have cholesteatoma are at increased risk for long-standing CHL. The impact of hearing on speech and developmental learning also underscore the importance of close audiologic monitoring in cleft palate patients.
9:38 AM Gastric Reflux and Acute Posttympanostomy Otorrhea Kristen Mary Lloyd, MD (presenter); James Lee; Patrick J Antonelli, MD Gainesville FL; Gainesville FL; Gainesville FL
Objectives: Acute posttympanostomy otorrhea (APTO) is a common complication of tympanostomy tube placement. APTO has been related primarily to viral upper respiratory infections and external ear contamination. Recently, elevated levels of gastric enzymes have been found in a large proportion of chronic middle ear effusions, implicating gastric reflux (GR) in its pathogenesis. The purpose of this study was to determine if GR may be a contributing factor in the development of APTO. Methods: Otorrhea samples were collected from children with APTO. Total pepsinogen concentrations were measured using a commercial, enzyme-linked immunosorbent assay (ELISA) kit, utilizing a pepsinogen I specific capture antibody, and horseradish peroxidase detection antibody. Results: Twenty-six samples from 24 patients were collected and analyzed. Only 17 of 26 samples demonstrated measurable pepsinogen I, and the concentration ranged from less than 0.002– 0.017 mg/mL, well below the normal serum reference ranges for pepsinogen I (0.044 – 0.086 mg/mL). Conclusions: GR does not seem to play an important role in the etiology of APTO in children.
9:46 AM Nasal Obstruction in Children: Evaluation of Common Assessment Methods Mohamed A Bitar, MD (presenter); Ghina Birjawi, MD; Marwan Youssef, MD; Nabil S Fuleihan, MD New York NY; New York NY; New York NY; Beirut Lebanon
Objectives: To evaluate the commonly used methods in assessing nasal obstruction in children. Methods: Children with chronic nasal obstruction were enrolled. All patients had anterior rhinoscopy. The tonsils were graded on a 4-point scale. The adenoid pad size was rated on endoscopy using a 3-grade scale (grade 1, ⬍50%; grade 2, 50%75%; grade 3, ⬎75%). The degree of obstruction on true lateral soft tissue roentgenograms was reported as mild, moderate, or severe. Each method was evaluated based on the treatment outcome. Results: We enrolled 213 patients aged 6 months to 13 years (mean, 5.1 years). The clinical picture directed the approach to the patient, occasionally pinpointing the definite diagnosis. Grade 1 adenoids had associated abnormalities causing the nasal obstruction. Grade 2 adenoids required surgery only in 33.3%. All grade 3 adenoids required removal. Patients with mild obstruction on x-rays had some
WEDNESDAY
Operative time was reduced as compared with standard skin flaps. Postoperative pain was minimal and no surgical complication occurred. To date no movement of the devices have been noted. Conclusions: This minimally invasive technique is a safe convenient method for implanting this device. Early hospital discharge is achieved and no postoperative care is needed prior to “switch on.”
Scientific Session—Wednesday
false-negative results. Those with moderate to severe obstruction required surgery in more than 85%. There was a significant interobserver agreement only in the extremes. Conclusions: The clinical picture helps orient the assessment of children with nasal obstruction. Nasal endoscopy offers the best evaluation method. In case of an uncooperative child or refusing parents, a true lateral soft tissue film may be useful. 10:00 AM Ultracision Scissors: An Alternative Method in Tonsillectomy, 400 Cases Joao Paco, MD PhD (presenter); Carlos Stapleton Garcia, Diogo Oliveira E Carmo, MD Lisbon Portugal; Lisbon Portugal; Lisbon Portugal
MD;
Objectives: To show that the ultracision curved shears for tonsillectomy is a less hemorrhagic and significantly faster and safer technique than monopolar techniques Methods: A total of 400 patients, 240 children and 160 adults, of which 86 associated with UPP were subjected to tonsillectomy with Ultacision Harmonic Scalpel curved shears shaft length 14 cm CS-14C-Ethicon Endo Surgery in the last 48 months. Results: We divided the patients into 3 groups: 240 children, 74 adults, and 86 adults with UPP. In these groups we present the (1) age distribuition, (2) operating time, (3) pain control, (4) return to work, and (5) complications. Ultracision shears are safer and permit a more blodless and significantly faster dissection in comparisson with bipolar and monopolar surgery. The tissue surrounding the capsule is conserved. The fact that there is practically no blood in the operating field gives the surgean a great sense of security and makes it possible to carry out a very accurate dissection. This combined with the inexistence of blood in the operating fiel makes it the technique of choice in the case of patients with sleep apneia with large tonsils and for UPP. Complications: 4 hemorrhages in 400 cases (1%). Conclusions: Cutting and dissecting with scissors is a very natural gesture for the surgeon. Ultracision scissors offer a safe, efficient, and clean technique that makes tonsilectomy a neat and easy surgical action. The time saving aspect is also important in surgical anaesthetic and cost effectiveness. 10:08 AM Longevity of Micronized Alloderm in Pediatric Augmentation Laryngoplasty Nalin J Patel, MD (presenter); Joseph E Kerschner, Merati, MD Milwaukee WI; Milwaukee WI; Milwaukee WI
MD;
Albert L
Objectives: To report the outcomes of augmentation laryngoplasty using micronized alloderm for the management unilateral vocal fold paralysis in children. Indications for
acute management and the observed longevity of micronized alloderm is discussed. Methods: Retrospective chart review of patients with unilateral vocal fold paralysis surgically managed at a tertiay care hospital between July 2002 and December 2003. Results: Eight children with unilateral vocal fold paralysis were identified. Age range at the time of surgical management was 3 weeks to 17 years. Follow-up ranged from 6 months to 14 months. Etiologies included cardiac surgery, idiopathic, and brainstem ependymoma. Five of 8 (62.5%) patients were managed in the acute setting; 4 of 8 (50%) of the augmentation laryngoplasty procedures were performed for significant aspiration, and the other 4 patients were managed for dysphonia. The clinically observed longevity of the micronized alloderm was 3 to 6 months. All patients managed for aspiration had significant objective improvement, and 3/4 (75%) were discharged home feeding orally. Three of 5 (60%) of the children managed in the acute setting had recovery of vocal fold function. No airway complications were observed. Conclusions: Augmentation laryngoplasty using micronized alloderm is a safe option for the acute management of aspiration associated with a unilateral vocal fold paralysis in children. The clinically observed longevity of the collagen in children is 3 to 6 months.
10:16 AM Management of Pediatric Dysphagia and Cricopharyngeal Dysfunction Using Botulinum Toxin Joseph E Kerschner, MD (presenter); Nalin J Patel, MD Milwaukee WI; Milwaukee WI
Objectives: To report the management of cricopharyngeal achalasia and cricopharyngeal discoordination using botulinum toxin in children. As this treatment strategy in children has not been previously reported, appropriate diagnostic methods and indications for management are discussed. Methods: Retrospective chart review of patients who underwent cricopharyngeal botulinum toxin injection for dysphagia between January 2002 and October 2003 at a tertial care children’s hospital was performed. All patients underwent a preoperative esophageal monometry and a preoperative and postoperative video-swallow study. Results: Four children were identified during the study period. Age range was 2 years to 9 years. Etiology of the cricopharyngeal disorder was achalasia in 2 patients and discoordinated relaxation of the cricopharyngeus associated with a vagal or recurrent laryngeal nerve injury in the other 2 patients. The patients with achalasia had significantly elevated pressures across the cricopharyngeus on esophageal manometry testing. The other 2 patients did not have elevated pressures but did show a restricted flow across the cricopharyngeus. Follow-up swallow studies noted improved tran-
WEDNESDAY
P228
Otolaryngology– Head and Neck Surgery August 2004
Scientific Session—Wednesday P227
9:30 AM to 10:30 AM Room JJCC 1A07 •
Scientific Sessions: Pediatric Otolaryngology Moderators: Amelia F. Drake, Hotlel, MD
MD,
Michael R.
9:30 AM Conductive Hearing Loss and Otopathology in Cleft Palate Patients Steven L Goudy, MD; John W Canady, MD; Richard J H Smith, MD Iowa City IA; Iowa City IA; Iowa City IA
Objectives: To assess incidence of conductive hearing loss, ear pathology, and associated communicative disorders in cleft palate patients. Methods: Retrospective chart review of 100 patients all treated at a tertiary facility since birth. Results: The median patient age was 19 years old (range, 7–25) at last follow up. Girls comprised 35% of group. The median age of cleft palate repair was 16 months (range, 12– 60). Median number of myringotomy tubes placed was 3 (range, 1–7). Conductive hearing loss(CHL) ⬎20 db PTA was found in 25% of patients at last follow-up. Severity of CHL was mild in 75%, moderate in 21%, and severe in 4%. Middle ear surgery was performed on 13%. Cholesteatoma was identified in 6%. The mean age at resolution of CHL was 5 years (range, 3–19). Developmental learning disorders were identified in 8%. Speech difficulties requiring surgical treatment occurred in 27%. Risk factors associated with CHL at last follow-up included middle ear surgery (P ⫽ 0.016), cholesteatoma (P ⫽ 0.003), and increased number of myringotomy tubes (P ⫽ 0.030). Associations between CHL and age at cleft repair, speech impairment, or learning disabilities were not found. Conclusions: Otopathology in cleft palate patients continues to be a problem despite close observation. Children requiring increased number of myringotomy tubes, middle ear surgery, and found to have cholesteatoma are at increased risk for long-standing CHL. The impact of hearing on speech and developmental learning also underscore the importance of close audiologic monitoring in cleft palate patients.
9:38 AM Gastric Reflux and Acute Posttympanostomy Otorrhea Kristen Mary Lloyd, MD (presenter); James Lee; Patrick J Antonelli, MD Gainesville FL; Gainesville FL; Gainesville FL
Objectives: Acute posttympanostomy otorrhea (APTO) is a common complication of tympanostomy tube placement. APTO has been related primarily to viral upper respiratory infections and external ear contamination. Recently, elevated levels of gastric enzymes have been found in a large proportion of chronic middle ear effusions, implicating gastric reflux (GR) in its pathogenesis. The purpose of this study was to determine if GR may be a contributing factor in the development of APTO. Methods: Otorrhea samples were collected from children with APTO. Total pepsinogen concentrations were measured using a commercial, enzyme-linked immunosorbent assay (ELISA) kit, utilizing a pepsinogen I specific capture antibody, and horseradish peroxidase detection antibody. Results: Twenty-six samples from 24 patients were collected and analyzed. Only 17 of 26 samples demonstrated measurable pepsinogen I, and the concentration ranged from less than 0.002– 0.017 mg/mL, well below the normal serum reference ranges for pepsinogen I (0.044 – 0.086 mg/mL). Conclusions: GR does not seem to play an important role in the etiology of APTO in children.
9:46 AM Nasal Obstruction in Children: Evaluation of Common Assessment Methods Mohamed A Bitar, MD (presenter); Ghina Birjawi, MD; Marwan Youssef, MD; Nabil S Fuleihan, MD New York NY; New York NY; New York NY; Beirut Lebanon
Objectives: To evaluate the commonly used methods in assessing nasal obstruction in children. Methods: Children with chronic nasal obstruction were enrolled. All patients had anterior rhinoscopy. The tonsils were graded on a 4-point scale. The adenoid pad size was rated on endoscopy using a 3-grade scale (grade 1, ⬍50%; grade 2, 50%75%; grade 3, ⬎75%). The degree of obstruction on true lateral soft tissue roentgenograms was reported as mild, moderate, or severe. Each method was evaluated based on the treatment outcome. Results: We enrolled 213 patients aged 6 months to 13 years (mean, 5.1 years). The clinical picture directed the approach to the patient, occasionally pinpointing the definite diagnosis. Grade 1 adenoids had associated abnormalities causing the nasal obstruction. Grade 2 adenoids required surgery only in 33.3%. All grade 3 adenoids required removal. Patients with mild obstruction on x-rays had some
WEDNESDAY
Operative time was reduced as compared with standard skin flaps. Postoperative pain was minimal and no surgical complication occurred. To date no movement of the devices have been noted. Conclusions: This minimally invasive technique is a safe convenient method for implanting this device. Early hospital discharge is achieved and no postoperative care is needed prior to “switch on.”
Scientific Session—Wednesday
false-negative results. Those with moderate to severe obstruction required surgery in more than 85%. There was a significant interobserver agreement only in the extremes. Conclusions: The clinical picture helps orient the assessment of children with nasal obstruction. Nasal endoscopy offers the best evaluation method. In case of an uncooperative child or refusing parents, a true lateral soft tissue film may be useful. 10:00 AM Ultracision Scissors: An Alternative Method in Tonsillectomy, 400 Cases Joao Paco, MD PhD (presenter); Carlos Stapleton Garcia, Diogo Oliveira E Carmo, MD Lisbon Portugal; Lisbon Portugal; Lisbon Portugal
MD;
Objectives: To show that the ultracision curved shears for tonsillectomy is a less hemorrhagic and significantly faster and safer technique than monopolar techniques Methods: A total of 400 patients, 240 children and 160 adults, of which 86 associated with UPP were subjected to tonsillectomy with Ultacision Harmonic Scalpel curved shears shaft length 14 cm CS-14C-Ethicon Endo Surgery in the last 48 months. Results: We divided the patients into 3 groups: 240 children, 74 adults, and 86 adults with UPP. In these groups we present the (1) age distribuition, (2) operating time, (3) pain control, (4) return to work, and (5) complications. Ultracision shears are safer and permit a more blodless and significantly faster dissection in comparisson with bipolar and monopolar surgery. The tissue surrounding the capsule is conserved. The fact that there is practically no blood in the operating field gives the surgean a great sense of security and makes it possible to carry out a very accurate dissection. This combined with the inexistence of blood in the operating fiel makes it the technique of choice in the case of patients with sleep apneia with large tonsils and for UPP. Complications: 4 hemorrhages in 400 cases (1%). Conclusions: Cutting and dissecting with scissors is a very natural gesture for the surgeon. Ultracision scissors offer a safe, efficient, and clean technique that makes tonsilectomy a neat and easy surgical action. The time saving aspect is also important in surgical anaesthetic and cost effectiveness. 10:08 AM Longevity of Micronized Alloderm in Pediatric Augmentation Laryngoplasty Nalin J Patel, MD (presenter); Joseph E Kerschner, Merati, MD Milwaukee WI; Milwaukee WI; Milwaukee WI
MD;
Albert L
Objectives: To report the outcomes of augmentation laryngoplasty using micronized alloderm for the management unilateral vocal fold paralysis in children. Indications for
acute management and the observed longevity of micronized alloderm is discussed. Methods: Retrospective chart review of patients with unilateral vocal fold paralysis surgically managed at a tertiay care hospital between July 2002 and December 2003. Results: Eight children with unilateral vocal fold paralysis were identified. Age range at the time of surgical management was 3 weeks to 17 years. Follow-up ranged from 6 months to 14 months. Etiologies included cardiac surgery, idiopathic, and brainstem ependymoma. Five of 8 (62.5%) patients were managed in the acute setting; 4 of 8 (50%) of the augmentation laryngoplasty procedures were performed for significant aspiration, and the other 4 patients were managed for dysphonia. The clinically observed longevity of the micronized alloderm was 3 to 6 months. All patients managed for aspiration had significant objective improvement, and 3/4 (75%) were discharged home feeding orally. Three of 5 (60%) of the children managed in the acute setting had recovery of vocal fold function. No airway complications were observed. Conclusions: Augmentation laryngoplasty using micronized alloderm is a safe option for the acute management of aspiration associated with a unilateral vocal fold paralysis in children. The clinically observed longevity of the collagen in children is 3 to 6 months.
10:16 AM Management of Pediatric Dysphagia and Cricopharyngeal Dysfunction Using Botulinum Toxin Joseph E Kerschner, MD (presenter); Nalin J Patel, MD Milwaukee WI; Milwaukee WI
Objectives: To report the management of cricopharyngeal achalasia and cricopharyngeal discoordination using botulinum toxin in children. As this treatment strategy in children has not been previously reported, appropriate diagnostic methods and indications for management are discussed. Methods: Retrospective chart review of patients who underwent cricopharyngeal botulinum toxin injection for dysphagia between January 2002 and October 2003 at a tertial care children’s hospital was performed. All patients underwent a preoperative esophageal monometry and a preoperative and postoperative video-swallow study. Results: Four children were identified during the study period. Age range was 2 years to 9 years. Etiology of the cricopharyngeal disorder was achalasia in 2 patients and discoordinated relaxation of the cricopharyngeus associated with a vagal or recurrent laryngeal nerve injury in the other 2 patients. The patients with achalasia had significantly elevated pressures across the cricopharyngeus on esophageal manometry testing. The other 2 patients did not have elevated pressures but did show a restricted flow across the cricopharyngeus. Follow-up swallow studies noted improved tran-
WEDNESDAY
P228
Otolaryngology– Head and Neck Surgery August 2004