Tracheostomy in childhood

86

INTERNATIONAL ABSTRACTS

between 11 months and 15 years, one of whom, a 31/2-year-old boy, died with fulminant hepatic failure. All the children had received multiple halothane anaesthetics (range 2 to 6, median 3). In all cases other causes of liver disease were excluded, and in all but one the diagnosis was confirmed serologically by antibodies to halothane altered liver cell membrane antigens. These findings suggest that halothane hepatitis occurs in children, and the risk of halothane hepatitis should therefore be considered when choosing which agents to use in children who require multiple anesthetics.--Prem Puri Bupivicaine Squirting. J.H. Cook. Ann R Coil Surg Engl 69:4,

(January), 1987. A concise description of a useful technique where pain relief in a freshly closed surgical wound can be obtained for several hours is described. The subcutaneous tissues are sprayed with a 0.5% solution of bupivicaine just before the wound is closed. The solution should be in contact with the raw area for about ten seconds to be effective. It presumably acts on the nerve endings exposed by the surgeon.--B.A. Madarikan Measurement of Carbon Dioxide Production Rate in Sick Ventilated Premature Infants. A. Lucan, Y. Nohria, and S.B. Roberts.

Biol Neonate 51:138-143, (April), 1987. A new method is described for measuring the rate of carbon dioxide production, and hence for estimating energy expenditure, in preterm infants receiving assisted ventilation. In a validation study, the mean error in carbon dioxide measurement was 1.9%. Measurements were made over a 45-minute period on 11 sick, ventilated subjects and carbon dioxide production rate was 5.2 _+ 0.7 (SD) mL/min/kg body weight. The authors suggest that continuous monitoring of carbon dioxide output will contribute to the clinical assessment of the effects of different ventilator settings on pulmonary gas exchange and that estimated values for energy expenditure will be of value in nutritional studies on sick ventilated infants.-Prem Puri INTEGUMENT AND CONNECTIVE TISSUE Congenital Malignant Melanoma, N.S. Prose, T.A. Laude, E.R. Heilman, et al. Pediatrics 79:967-970, (June), 1987.

The authors report a 6-week-old girl with congenital malignant melanoma of the midepigastric area. Treatment consisted of surgical excision with 1 cm margin, and included the underlying portion of rectus sheath. Follow-up at 1 year revealed no evidence of residual disease. Childhood melanoma is discussed briefly. A literature review of seven similar cases suggests that the diagnosis is frequently delayed, but regional or distant metastatic disease does not rule out long-term survival following surgery and, in selected cases, chemotherpy.--J.L. Zitsman Congenital Epidermal Cyst in the Foot. L.R. Priaulx and A.H.M.E. Moustafa. J R Coil Surg (Ed) 32:120-121, (April), 1987.

A 3-year-old boy presented with a discharging sinus and swelling on the lateral aspect of his left foot that had been present since birth. X-ray showed fusion of the base of the fourth and fifth metatarsals. A sinogram revealed a subcutaneous tract extending from the base of the little toe along the lateral border of the foot, passing medially deep to the Achilles tendon, ending just above the medial malleolus. The sinus, which was mainly superficial, was completely removed. It was lined by squamous epithelium with inflammatory changes. The authors discuss other causes of cystic swellings on the foot and suggest the reported lesion is analogous to cutaneous sinuses seen in relation to the central nervous system. This is the first report of such a case. A sinogram is essential to outline the tract preoperatively. Complete excision of the sinus is necessary.--W.G. Scobie

HEAD A N D NECK CHARGE Association in Neonates Presenting With Choanal Atre-

sia. G. Stewart, D.G. Young, and A.F. Azmy. Z Kinderchir 42:12-

13, (February), 1987. The spectrum of this association of multiple anomalies includes coloboma (C), heart disease (H), atresia choanae (A), retarded growth development and/or CNS anomalies (R), genital anomalies (G), and ear anomalies/deafness (E). From this evolved the term CHARGE association. Ten consecutive patients admitted to the hospital because of nasal airway obstruction have been reviewed. Four showed four or more components of the CHARGE association, three of whom died before the age of 2 months. Infants with choanal atresia but not having other features of CHARGE association survived. In particular, the combination of choanal atresia and heart disease carries a very high risk.--Thomas A. Angerpointner Three Dimensional Imaging in Craniofacial Disorders. D.C. Hemmy. Aust N Z J Surg 57:101-104, (February), 1987.

This article describes the role of computerized tomography in the management of craniofacial disorders. It shows by pictures and diagrams how the CT scan can be used to plan the operative procedure. The author presents and discusses one patient and shows how CT scanning was used to achieve a satisfactory cosmetic outcome.--Alasdair Mackellar Midfacial Osteotomies in Patients With Cleft Lip, Alveolus, and

Palate. W.J. Holtje. Aust N Z J Surg 57:89-99, (February), 1987.

Surgical/orthodontic strategies in patients with hypoplastic midfaces and cleft of lip, alveolus, and palates after completion of skeletal growth are guided by cephalometric data, with the soft tissue profile playing the most important role. The Le Fort 1, the extended Le Fort 1, and less frequently the Le Fort II procedure depend on the extent of midfacial hypoplasia. Osteotomy planning should consider that in a cleft patient's maxilla, the anterior nasal spine and A point need to be advanced and caudally rotated to a larger extent than is necessary in noncleft patients. A slight overcorrection of ANB angle is necessary to achieve a harmonious and attractive soft tissue since upper lip and nasal soft tissue require more bony support. In severe bimaxillary disturbances the midfacial advancement has to be combined with mandibular osteotomies. Stabilization after midfacial osteotomies should be done by corrosion-resistant vitallium or titanium miniplates. This technique provides sufficient stability to restore early function immediately after surgery. Intermaxillary fixation following surgery is no longer necessary. Several decisive advantages are provided by this technique over the previously applied wire suspension concepts or wire suturing techniques. The most advantageous points are (1) no intermaxillary fixation is required immediately postoperatively; (2) normal soft food intake is resumed after eight to ten days when wound healing is completed; (3) rigid plate fixation leads to considerable improvement in bone healing, while "pumping-effects" induced by micromovements from the masticatory muscles are avoided; (4) plate fixation allows immediate functional "antirelapsetreatment" against relapse tendencies, using soft intermaxillary elastic.--Alasdair MacKellar Tracheostomy in Childhood. J.H. Dempster, E.H. Dykes, W.C. Brown et al. J R Coil Surg (Ed) 31:359-363, (December), 1986.

Sixty-five children, 50% under 1 year of age, underwent tracheostomy during a 12-year period at the Royal Hospital for Sick Children, Glasgow. Thirty-one had mechanical obstruction due to infection, congenital anomaly, or tumor. Twenty-one had impaired respiration after major surgery or respiratory distress syndrome.

INTERNATIONAL ABSTRACTS Seven had a neurological problem. All procedures were performed under general anesthesia, 47 electively. The technique varied with the speciality of the surgeon (pediatric, ENT, or cardiac). A transverse skin incision was used in most cases, the trachea being opened either vertically or transversely. Early complications occurred in a third of patients. These included tube obstruction, pneumothorax, emphysema, hemorrhage, granulations, extubation difficulty, tube in bronchus, and pneumomediastinum. Seven developed late complications after extubation. These were stenosis, strider, tracheomalacia, and cutaneous fistula. There were 26 deaths due to the primary condition, none due to the tracheostomy. The technique of tracheostomy did not influence the results. The authors conclude that the increased use of mechanical ventilation in small babies with respiratory impairment is a major factor in influencing the use of tracheostomy.--W.G. Scobie

87 eight patients had normal forced expiratory volume of 72% of vital capacity and were included in the study. The patients were divided into groups by age at pneumonectomy. The ventilatory capacity was not dissimilar from that predicted for two lungs in those patients undergoing surgery from 0 to 5 years of age, confirming that near complete compensation had occurred. This may be due to continuing alveolar multiplication. The compensatory ability of the lung decreases with age. Hyperplasia or simple hypertrophy may be responsible for postoperative growth in the older age groups (>6 years of age). These compensatory changes have extended into the long-terra. Of note is the finding that normal growth in height occurred in children following pneumonectomy.--Marleta Reynolds

Pleural Empyema in Children: A Nationwide Retrospective Study. Plunging Ranula: A Report of Three Cases and Review of the Literature, D. Parekh, M. Stewart, C. Joseph, et al. Br J Surg

74:307-309, (April), 1987. Three patients (aged 15 to 20 years) with plunging ranulas who were successfully treated by excision of the sublingual and submandibular glands using a cervical incision are reported. In a review of the literature, the high recurrence rate (70%) following various procedures is noted. The authors conclude that the cervical component is due to high pressure causing extravasation of the saliva in an oral ranula through a hiatus in the mylohyoid muscle, and that intraoral excision of the sublingual gland with intraoral drainage is adequate treatment; this contrasts with the surgical approach used in the three cases they report.--N.P. Madden THORAX Aggressive Surgical Approach for Drug-Free Remission From Myasthenia Gravis, J.E. Fischer, H.T. Grisvalski, M.S. Nussbaum,

et al. Ann Surg 205:490-503, (May), 1987 Myasthenia gravis is believed to be an autoimmune disease in which antibodies to acetylcholine receptors are produced by subsets of T-lymphoeytes. It affects all ages and both sexes, with peaks in the second and fifth decades, with younger females and older males being the most commonly affected. Transsternal wide thymectomy is now considered the treatment of choice. Twenty-seven p~tients aged 6 to 75 years treated by sternal split and extended thymectomy and radical mediastinal dissection are reported. The overall drug-free remission rate was 63% with a projected 74% drug-free remission rate. Of the remaining patients, all but three improved and required decrease medication for an improvement rate of approximately 90%. The mean taper time from start of tapering medications to drug-free remission was 283 days. Thymomas was present in three patients, six patients were believed to have thymic hyperplasia, nine patients had an involuted thymus, two patients a normal thymus, and in seven there was disagreement as to whether thymic hyperplasia was present. There was no relationship between perioperative and postoperative antibodies to acetylcholine receptor levels and the clinical course, nor was there any relationship between the clinical course, the final outcome, and drug-free remission. The results suggest that an aggressive radical surgical approach to myathenia gravis, even in a group of patients considered somewhat less favorable because of a relatively long duration of disease, can result in a high percentage of drug-free remissions.--Richard J. Andrassy Dilatation, Compensatory Growth, or Both After Pneumonectomy During Childhood and Adolescence. A Thirty Year Follow-up

Study. C.D. Lares and C.J.J. Westerman. J Thorac Cardiovase Surg 93:570-576, (April), 1987. Ventilatory function was evaluated in a total of 230 patients who had undergone pneumonectomy more than 30 years ago. Ninety-

J.E. Fajardo and M.J. Chang. South Med J 80:593-596, (May), 1987. The most common causative agents in the production of empyema in the 1940s were Streptococcus pneumoniae and Streptococcus pyogenes. In the 1950s Staphylococcus aureus became the causative agent of 92% of cases of empyema in childhood. Military hospitals across the United States provided data for this retrospective study on pediatric patients with empyema. No organism was isolated either from blood or pleural fluid in 49 of the 104 (47%) patients reviewed. Of the remaining 55 children, a positive blood culture provided the etiologic diagnosis in 14% and pleural fluid culture was positive in 27%. In 9%, organisms grew from both the blood and the pleural fluid cultures. In 3% the etiologic diagnosis was based on positive counterimmunoelectrophoresis. Hemophilus influenzae type b (17%), Streptococcus pneumoniae (14%), and Staphylococcus aureus (11%) were the most common etiologic agents. Pneumonia was the most common predisposing factor, occurring in 62%. Empyema was related to an operation in 12 patients. There were no cases of primary staphylococcal pneumonia, and all patients who developed staphylococcal empyema did so as a result of abscesses, osteomyelitis, surgery, physical trauma, or burns.--George Holcomb, Jr

Management of Tracheomalacia by Aortopexy. E.M. Kiely, L. Spitz, and R. Brereton. Pediatr Surg Internal 2:13-15, (January), 1987.

Over a 6.5-year period, 25 infants and children with symptomatic tracheomalacia underwent aortopexy. Seventeen of the patients had immediate and dramatic relief of symptoms and five others were greatly improved. The operation failed in one patient who required two subsequent procedures. Early recourse to aortopexy is recommended when symptoms of tracheomalacia become evident.--Prem Purl

HEART AND GREAT VESSELS Operative Closure of Patent Ductus Arteriosus in Premature Infants in the Neonatal Intensive Care Unit, R.L. Taylor, F.L.

Gover, P.K. Harman, et al. Am J Surg 152:704-708 (December), 1986. Operative closure of a PDA may still be the therapy of choice at certain institutions due to increasing recognition of complications associated with the use of indomethaein. There were 52 consecutive infants who underwent thoracotomy and ductus closure on the MICU with a ligaclip. There were no deaths and only nine operative complications. Operative closure was effected in a mean time of three days after diagnosis. Early operative closure is recommended.--Thomas V. Whalen