Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 2014
Objective. The aim of this study was to compare the agreement between cone beam computed tomograp... more Objective. The aim of this study was to compare the agreement between cone beam computed tomography (CBCT) and panoramic radiographs for initial orthodontic evaluation. This study was not meant to test differences between imaging modalities or to indicate superiority of one technique. Study Design. Thirty-eight subjects with both panoramic and CBCT images were retrospectively collected. Eight observers answered 14 observational questions. The observation was repeated after 4 weeks. Results. CBCT images yielded better agreement between 2 observer groups (orthodontic residents and radiologists) and better inter-and intraobserver agreement. The agreement between panoramic radiographs and CBCT scans was moderate. Conclusions. If CBCT is a priori present in a case with justified indications, it has the potential to provide valuable diagnostic information for initial orthodontic evaluation and extra information for treatment planning. The moderate agreement between panoramic and CBCT images may indicate that the nature and amount of information gained from both imaging sources is deviant.
We have made a retrospective analysis on 70 prelingually deaf children (78% congenital; age range... more We have made a retrospective analysis on 70 prelingually deaf children (78% congenital; age range 2-15 years) followed for up to 5 years post-implant during which both closed set speech perception tests (TAC, WIPI) and open set tasks (PBK, GASP) were administered. We used a binary partitioning algorithm to optimally divide our dataset on the basis of age at implantation This technique achieves an optimal split when the heterogeneity of the data is most reduced (maximal drop in deviance). For the closed set speech perception tests (TAC and WIPI) partitioning best divided-out data at age 4.4 years. For the open set tests optimal division was at a higher age of implantation (GASP word, 5.6 years; PBK word, 8.4 years). Using these partitioning values, we have found statistically signi cant differences between rate of improvement of scores in the younger implanted children compared with those implanted later.
Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study ... more Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study was to compare rigid versus flexible endoscopy in esophageal FB extraction in children. In a retrospective cohort study with consecutive data, children with esophageal FB impaction who were admitted between January 2005 and December 2008 to the Stollery Children's Hospital, Edmonton, Canada, were included. Nature of the procedure for FB removal (flexible vs. rigid endoscopy), duration of the procedure, complications, and associated pathology were documented. A total of 140 children were included (81 boys; mean age, 59.8 ± 48.6 (range, 4-203) months). More than half (54%) of patients were aged 3 years or younger. Coins were the most common foreign body (77.9%). Flexible endoscopy was used in 89 patients, rigid in 49, and both in 2 patients. The mean duration of the endoscopic procedure was 10.50 ± 12.2 minutes for FE (95% confidence interval (CI), 7.94-13.08) and 16.49 ± 21.1 minutes for RE (95% CI, 13.75-22.45; p = 0.04). Biopsies were taken in 19% of patients undergoing FE and in 6% of RE (p = 0.04). Both rigid and flexible endoscopy techniques appear to be equally safe and effective in esophageal foreign body extraction. However, performing flexible endoscopy for esophageal foreign body takes a substantial shorter duration compared with rigid endoscopy. Flexible endoscopy would probably allow a better and more thorough examination and, hence, biopsying esophageal mucosa compared with rigid endoscopy.
Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It ... more Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It is now accepted as a safe and effective means of treating sinonasal disease. The purpose of this study was to determine whether post-operative debridement is necessary after ESS. Seventeen patients undergoing bilateral primary ESS were randomized to receive debridement of either the left or right ethmoid cavity. All patients included in the study had symmetrical disease. Saline douches and all other concomitant treatments were delivered bilaterally. Outcome measures were based on regular symptom scores and surgeons' semi-quantitative assessment of the debrided and non-debrided cavities, over a three-month period. Analysis of adhesion rates, healing and symptom scores showed no statistically signi cant difference between the two groups. In conclusion, this study did not demonstrate signi cant bene t from post-operative ESS cavity debridement, at least with regard to cavity healing. This should be considered a pilot study and therefore limited conclusions can be drawn. Further work is needed to determine the optimum post-operative care for ESS.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2012
To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large con... more To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large consecutive series of atypical croup. Case series with chart review. Tertiary pediatric referral center. A surgical database was searched for all children who underwent full airway endoscopy to investigate atypical croup. The primary outcome measure was the prevalence of large airway lesions in patients with atypical croup undergoing endoscopy. Demographics, secondary diagnoses, and rate of positive findings were documented. Age and atopy were correlated using Spearman's correlation coefficient, and multivariate analysis identified predictors of large airway lesions. Eighty patients were identified over a period of 8 years (58 boys; mean [SD] age 4.8 [3.8] years; range, 46 days to 13.7 years). Of the 80 children, 31 had positive airway findings, with 33 large airway lesions demonstrated, including 10 subglottic stenosis, 7 laryngeal clefts, 6 subglottic hemangiomas, 4 tracheomalacia, an...
International Journal of Pediatric Otorhinolaryngology, 2014
To document the mode and age of primary aerodigestive presentation of Pierre Robin sequence/compl... more To document the mode and age of primary aerodigestive presentation of Pierre Robin sequence/complex (PRS/C) children to the otolaryngologist and to explore predictive factors of upper airway type and management. This is a retrospective cohort study conducted in a tertiary pediatric referral center. A prospective surgical database was searched for children who were diagnosed with PRS/C. Demographics, presenting complaint, secondary diagnoses, type of upper airway obstruction, secondary airway lesions, presence of cleft palate, and airway interventions were collected. Multiple linear regression analysis was performed to predict upper airway obstruction type and intervention. Seventy-seven potentially eligible patients were identified. Forty-six were included (20 females). Mean age at presentation was 20.4±36.9 months (range 1-191.25 months). Twenty-three primarily presented with respiratory failure, 14 with sleep disordered breathing, and nine with swallowing dysfunction. Children with presentations other than respiratory failure were older (p=0.004). Nineteen were syndromic. Overt cleft palate was more common in those presenting with respiratory failure (p=0.01). The type of airway obstruction encountered and use of tracheostomy were positively predicted by the primary presenting feature of respiratory failure (p<0.05) and male gender (p<0.05). A substantial number of PRS/C patients present later than the neonatal period with presentations other than respiratory failure. Both male gender and presentation with respiratory failure predicted a more severe airway obstruction type and the need for trachesotomy.
International Journal of Pediatric Otorhinolaryngology Extra, 2009
ABSTRACT Pyogenic granuloma is a polypoidal capillary hemangioma that occurs on the skin and muco... more ABSTRACT Pyogenic granuloma is a polypoidal capillary hemangioma that occurs on the skin and mucosal surface. Trauma, hormonal changes seen in pregnancy and use of the oral contraceptive pill have a role in its pathogenesis. Except for the oral cavity, involvement of gastrointestinal tract is quite rare and there are no reports of hypopharyngeal involvement. We report a case of hypopharyngeal pyogenic granuloma most likely secondary to prolonged nasogastric tube insertion in an immuno-compromised host.
International Journal of Pediatric Otorhinolaryngology, 2009
To compare bleeding after partial intracapsular tonsillectomy (PIT) and bipolar diathermy tonsill... more To compare bleeding after partial intracapsular tonsillectomy (PIT) and bipolar diathermy tonsillectomy (BDT). Design: Retrospective chart review. Setting: Stollery Children's Hospital, tertiary pediatric referral centre. Patients: All children (17 years of age) who had tonsillectomy. Patients who had incomplete information or less than 2-weeks follow-up were excluded. Main outcome measure: (1) Post-tonsillectomy bleeding, (2) other data collected included demographics, length of follow-up, indication(s) for surgery, other procedures performed, and co-morbidities. Results: Over a 4.5-year period 677 patients (333 BDT, 344 PIT) were identified in our search, and 77 (38 BDT, 39 PIT) were excluded. The mean age was 7.7 AE 3.8 years in the BDT group and 6.5 AE 3.2 years in the PIT group. Sex distribution was similar in the 2 groups (chi square p = 0.61). Twenty (6.8%) BDT patients experienced post-tonsillectomy bleeding, compared to three (0.98%) of PIT patients (p = 0.0001, 95% CI 1.52-2.18, OR = 7.32). Over 3 times as many PIT patients (153) had co-morbid conditions than BDT patients (44); this was statistically significant (chi square p < 0.00001, 95% CI 1.78-2.38). Conclusion: PIT results in significantly less post-tonsillectomy bleeding than BDT. These findings favor partial over total techniques with respect to reducing this important complication.
IMPORTANCE Laryngomalacia (LM) classically presents with stridor in early infancy but can present... more IMPORTANCE Laryngomalacia (LM) classically presents with stridor in early infancy but can present atypically with snoring and/or sleep-disordered breathing (S-SDB) or swallowing dysfunction (SwD). The epidemiology of these atypical presentations has not been established in the literature. OBJECTIVE To document the primary modes of presentation for LM in a consecutive series of children and to compare the characteristics of each subgroup. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series in a single tertiary pediatric otolaryngology practice. Outpatient and surgical records were searched for patients diagnosed as having LM from 2002 to 2009. We included all children with endoscopically confirmed LM without prior documentation of the diagnosis (n = 88). INTERVENTIONS Patients were investigated and managed according to the routine practice pattern of the senior author. MAIN OUTCOMES AND MEASURES The primary outcome measure was the proportion of the various primary presentations of LM. Age, sex, type of LM, management, and secondary diagnoses were also collected. Subgroup analysis was performed. RESULTS Of 117 potentially eligible patients identified, 88 children had a confirmed diagnosis of LM and were thus included (1.9:1 male to female sex ratio; mean [SD] age, 14.5 [23.0] months; age range, 0.2-96.0 months). Fifty-six children (64%) presented primarily with awake stridor and variable respiratory distress; 22 (25%) with S-SDB; and 10 (11%) with SWD. The difference in mean (SD) age for each group was statistically significant by analysis of variance: stridor, 3.5 (2.8) months; S-SDB, 46.0 (27.2) months; and SwD, 4.8 (4.6) months (P < .001). By χ 2 analysis, sex distribution was not significantly different between subgroups (P = .29), nor was the proportion of children who underwent supraglottoplasty (P = .07). The difference in proportion of types of LM between the stridor and atypical presentations was statistically significant (χ 2 P < .05), with type 1 LM predominating in children presenting with S-SDB. CONCLUSIONS AND RELEVANCE Because LM may present primarily with S-SDB and SwD in a significant proportion of children, the diagnosis must be considered in patients presenting with these upper airway complaints. The morphologic type of LM may vary by presentation.
Journal of Otolaryngology - Head & Neck Surgery, 2014
Objective: To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with ... more Objective: To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with snoring-sleep disordered breathing (S-SDB). Design: Prospective agreement diagnostic study on retrospective data. Methods: We conducted an inter-and intra-rater agreement study on video documentations of SNP performed on children (non-syndromic, complex, or operated upon) who presented with S-SDB. The videos featured various pharyngeal findings (normal, collapse, mixed or obstruction). Three 'non-expert' raters at various stages in their otolaryngological careers rated the videos independently, and on two separate occasions following an instructional session. We calculated both weighted and non-weighted linear kappa. Results: Each independent observer rated sixty-one videos (2 weeks apart). Intra-observer agreement was 0.64 ± 0.08 (95% CI 0.48-0.81), 0.74 ± 0.07 (95% CI 0.60-0.88), 0.59 ± 0.08 (95% CI 0.43-0.74), for raters 1, two and three. Weighted kappa was 0.6 ± 0.1 (95% CI 0.41-0.79), 0.8 ± 0.06 (95% CI 0.7-0.92), 0.7 ± 0.07 (95% CI 0.57-0.83), respectively. Inter-rater agreements between raters one and two, two and three, three and four were 0.83 ± 0.06 (95% CI 0.71-0.95), 0.52 ± 0.08 (95% CI 0.36-0.70), and 0.53 ± 0.08 (95% CI 0.37-0.69), respectively. Weighted kappa was 0.83 ± 0.073 (95% CI 0.69-0.98), 0.68 ± 0.06 (95% CI 0.56-0.79), and 0.64 ± 0.07 (95% CI 0.49-0.78), respectively. Conclusions: This is the first validation of pharyngeal findings on SNP in children. It is based on a four types' classification. Overall reproducibility amongst the three raters and their agreement was moderate to good. Further work should be phase four trials investigating the impact on outcome.
The purpose of this work is to review the basis and validity of sleep nasopharyngoscopy (SNP) in ... more The purpose of this work is to review the basis and validity of sleep nasopharyngoscopy (SNP) in children with sleep disordered breathing (SDB). We performed an English literature review of the effectiveness of modalities guiding surgical treatment, and the utility of SNP. Scant literature is available on SNP. Only two validation studies exist on adults, and none on children. Multiple-level pathology has been identified by several studies in children, but credible epidemiological work does not exist. Other modalities were studied but methodology flaws are substantial. In the absence of alternative validated diagnostic modalities, sleep endoscopy is emerging to identify surgical targets. This has mechanistic support, but as yet has not been accompanied by the description of a valid scheme in evaluating the upper airway.
International Journal of Pediatric Otorhinolaryngology Extra, 2006
ABSTRACT Background: Major venous thrombophlebitis and/or thrombosis in association with acute he... more ABSTRACT Background: Major venous thrombophlebitis and/or thrombosis in association with acute head and neck infection is a serious but uncommon event. The action of specific bacterial toxins causes the thrombophlebitis, which has the propensity of systemic complications and local circulatory effects. Lemierre&#39;s syndrome (LS) is a specific entity within this group, often caused by the anaerobe Fusobacterium necrophorum (FN). Objective: Review of six consecutive pediatric cases and a critical revision of diagnostic categories. Setup: Tertiary referral center. Study design: Case series of pediatric craniocervical infections complicated by internal jugular vein thrombophlebitis (IJVT). Demographics, record of anti-thrombosis management, imaging, and antimicrobial management, duration of admission, clinical picture and sequelae were retrospectively collected. Results: Six cases (three girls and three boys; age range from 7 to 16 years old) were identified over a period of 3 years. One case was a certain LS; four were probable LS cases and one possible diagnosis. Six children had IJVT diagnosed on imaging, which also demonstrated embolic seeding to the knee on one occasion and to the ankle in another. Anti-thrombosis management as outpatients was instituted for 3 months in five out of the six. None had permanent sequelae except one (unilateral high tone sensory hearing loss). In four cases, the duration of admission was 10 days or less, whereas the other two cases stayed for 2 and 5 weeks, respectively. Conclusions: Thrombogenic head and neck infections may occur in children more readily than currently believed. Failure to detect the characteristic anaerobe and the low index of suspicion of IJVT may contribute to missing cases. Modern imaging modalities represent a window of opportunity to detect the key pathogenic process to arguably the most morbid event, namely the IJVT. By incorporating their findings from the outset, the disease is categorized and its devastating complications prevented.
International Journal of Pediatric Otorhinolaryngology, 2015
To systematically review the frequency and time to spontaneous recovery in pediatric patients wit... more To systematically review the frequency and time to spontaneous recovery in pediatric patients with bilateral congenital idiopathic laryngeal paralysis (BCILP). Methods: The databases of Medline, EMBASE, Scopus, CINAHL, Cochrane Library and Proquest Dissertations were searched for English language articles reporting on laryngeal paralysis in pediatric patients. A bibliography search of the selected studies was done to identify additional articles. We included prospective or retrospective case-series studies of children and neonates diagnosed with BCILP at age <60 days and confirmed by direct laryngoscopy, with sufficient follow up and objective assessment for recovery. Two authors independently extracted the data and assessed the quality of each study. Discrepancies were resolved by consensus and adjudication by a third author. Results: Of the 4229 articles identified by the search, only one study met our inclusion criteria. The study was a retrospective case series, and was of low quality. The mean age at diagnosis was fourteen days. Sixty-five percent of the patients recovered spontaneously, and the mean time to recovery was twentyfive months. Tracheostomy was performed in 71% of the patients. Conclusions: The available literature is of low quality and provides weak evidence on the natural history of BCILP in pediatric population.
Objective: To determine the prevalence of laryngomalacia among children presenting with symptoms ... more Objective: To determine the prevalence of laryngomalacia among children presenting with symptoms of sleep-disordered breathing (SDB). Method: A retrospective observational study was conducted at a tertiary care paediatric hospital. All children presenting with SDB during a 55-month period were investigated using sleep nasopharyngoscopy (SNP). Patients who had laryngomalacia were identified. Patients who did not present primarily with SDB, or were not examined with SNP were excluded. Data for analysis was collected from a prospectively kept surgical database and medical records. This included patients' demographics, symptoms (including symptoms in infancy), diagnoses, SNP findings, overnight pulse oximetry findings, and treatment. Results: We identified 358 patients with documented primary diagnosis of SDB and who had undergone SNP. Fourteen of these also had a documented diagnosis of laryngomalacia, giving a prevalence rate of 3.9%. Three children were syndromic, and one had cerebral palsy in addition to SDB and laryngomalacia. Three children were obese, and three children had gastroesophageal reflux disease. Seven cases (50%) had symptoms of snoring and/or swallowing dysfunction and/or stridor in infancy. Twelve patients had adenotonsillar surgery. In eight cases symptoms resolved completely with adenotonsillar surgery only. In total, six patients had a supraglottoplasty. There were three failures to supraglottoplasty. Conclusion: The prevalence of laryngomalacia within children presenting with SDB is 3.9%. Our findings support full evaluation of the airway to identify the site of pathology mediating SDB symptoms.
Objectives/Hypothesis: To report on the prevalence of premature (PM) birth in a consecutive serie... more Objectives/Hypothesis: To report on the prevalence of premature (PM) birth in a consecutive series of children treated for snoring and sleep-disordered breathing (S/SDB), the parameters specific to their management and variables predictive of disease severity. Study Design: A retrospective study was undertaken at a tertiary pediatric hospital. Methods: Children with history of PM and presenting with S/SDB were identified from a prospectively kept surgical database. We set out to determine the prevalence of PM among the patients presenting with S/SDB who required airway evaluations and surgery. Pulse oximetry is overnight recordable oxygen saturation and heart rate tracing that provides information about hypoxemia during sleep. This was performed on all children preoperatively. The pulse oximetry findings were used to plan for perioperative monitoring and care. A multivariable analysis was used to identify factors predictive of abnormal pulse oximetry studies. We evaluated the associated diagnoses, surgical procedures required, and response to treatment in these selected children. Results: Fifty-seven out of 1,038 patients were PM (33 males; mean age, 62.09634.91 months; range, 4-190 months). The mean gestational age was 30.364.0 weeks. The prevalence rate of PM among patients treated surgically for SDB is 5.5% (95% CI 5.2-5.8) at our center. Comorbid pulmonary and gastrointestinal disorders were encountered on 23 (40%) and 17 (29.8%) occasions, respectively, and were the most commonly encountered comorbid diagnostic categories. Large airway abnormalities were encountered in 11 (19.3%) children, and the most common were subglottic stenosis (four) and laryngeal paralysis (four). Comorbid respiratory disease was negatively predictive of abnormal pulse oximetry (coefficient 20.35, P<.05). Postoperative respiratory outcomes correlated with abnormal pulse oximetry (coefficient 0.3; P<.05). Conclusions: Our findings suggest children with PM presenting to pediatric otolaryngology require a comprehensive evaluation for S/SDB. A significant proportion of children with S/SDB and a history of PM frequently had pulmonary and gastrointestinal comorbidities in our cohort. One-half required admission postoperatively, and these were predictable based on preoperative pulse oximetry. Respiratory comorbidity was negatively predictive of severity of SDB. Inversely, children with untreated pulmonary comorbidities are more likely to have postoperative complications.
Objective: To compare postoperative respiratory complications in obese and nonobese children foll... more Objective: To compare postoperative respiratory complications in obese and nonobese children following surgery for sleep-disordered breathing. Study Design: Case-control study. Setting: Pediatric tertiary care center. Subjects and Methods: All obese children who had undergone adenotonsillectomy for sleep-disordered breathing from 2002 to 2007 were compared with age- and gender-matched controls. Subjects were identified from a prospective surgical database. Length of hospital stay and the incidence, severity, and location of respiratory complications were compared. Multivariable analysis was performed to identify predictive factors. Results: Forty-nine obese children were identified (20:29, female:male). There were no differences in mean age or type of surgical procedures ( P > 0.05). Overall, 37 obese children (75.5%) and 13 controls (26.5%) incurred complications ( P = 0.000, OR 8.54 [95% CI 3.44-21.19]). Ten obese patients and two controls incurred major events ( P = 0.012, OR ...
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 2014
Objective. The aim of this study was to compare the agreement between cone beam computed tomograp... more Objective. The aim of this study was to compare the agreement between cone beam computed tomography (CBCT) and panoramic radiographs for initial orthodontic evaluation. This study was not meant to test differences between imaging modalities or to indicate superiority of one technique. Study Design. Thirty-eight subjects with both panoramic and CBCT images were retrospectively collected. Eight observers answered 14 observational questions. The observation was repeated after 4 weeks. Results. CBCT images yielded better agreement between 2 observer groups (orthodontic residents and radiologists) and better inter-and intraobserver agreement. The agreement between panoramic radiographs and CBCT scans was moderate. Conclusions. If CBCT is a priori present in a case with justified indications, it has the potential to provide valuable diagnostic information for initial orthodontic evaluation and extra information for treatment planning. The moderate agreement between panoramic and CBCT images may indicate that the nature and amount of information gained from both imaging sources is deviant.
We have made a retrospective analysis on 70 prelingually deaf children (78% congenital; age range... more We have made a retrospective analysis on 70 prelingually deaf children (78% congenital; age range 2-15 years) followed for up to 5 years post-implant during which both closed set speech perception tests (TAC, WIPI) and open set tasks (PBK, GASP) were administered. We used a binary partitioning algorithm to optimally divide our dataset on the basis of age at implantation This technique achieves an optimal split when the heterogeneity of the data is most reduced (maximal drop in deviance). For the closed set speech perception tests (TAC and WIPI) partitioning best divided-out data at age 4.4 years. For the open set tests optimal division was at a higher age of implantation (GASP word, 5.6 years; PBK word, 8.4 years). Using these partitioning values, we have found statistically signi cant differences between rate of improvement of scores in the younger implanted children compared with those implanted later.
Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study ... more Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study was to compare rigid versus flexible endoscopy in esophageal FB extraction in children. In a retrospective cohort study with consecutive data, children with esophageal FB impaction who were admitted between January 2005 and December 2008 to the Stollery Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital, Edmonton, Canada, were included. Nature of the procedure for FB removal (flexible vs. rigid endoscopy), duration of the procedure, complications, and associated pathology were documented. A total of 140 children were included (81 boys; mean age, 59.8 ± 48.6 (range, 4-203) months). More than half (54%) of patients were aged 3 years or younger. Coins were the most common foreign body (77.9%). Flexible endoscopy was used in 89 patients, rigid in 49, and both in 2 patients. The mean duration of the endoscopic procedure was 10.50 ± 12.2 minutes for FE (95% confidence interval (CI), 7.94-13.08) and 16.49 ± 21.1 minutes for RE (95% CI, 13.75-22.45; p = 0.04). Biopsies were taken in 19% of patients undergoing FE and in 6% of RE (p = 0.04). Both rigid and flexible endoscopy techniques appear to be equally safe and effective in esophageal foreign body extraction. However, performing flexible endoscopy for esophageal foreign body takes a substantial shorter duration compared with rigid endoscopy. Flexible endoscopy would probably allow a better and more thorough examination and, hence, biopsying esophageal mucosa compared with rigid endoscopy.
Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It ... more Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It is now accepted as a safe and effective means of treating sinonasal disease. The purpose of this study was to determine whether post-operative debridement is necessary after ESS. Seventeen patients undergoing bilateral primary ESS were randomized to receive debridement of either the left or right ethmoid cavity. All patients included in the study had symmetrical disease. Saline douches and all other concomitant treatments were delivered bilaterally. Outcome measures were based on regular symptom scores and surgeons' semi-quantitative assessment of the debrided and non-debrided cavities, over a three-month period. Analysis of adhesion rates, healing and symptom scores showed no statistically signi cant difference between the two groups. In conclusion, this study did not demonstrate signi cant bene t from post-operative ESS cavity debridement, at least with regard to cavity healing. This should be considered a pilot study and therefore limited conclusions can be drawn. Further work is needed to determine the optimum post-operative care for ESS.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2012
To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large con... more To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large consecutive series of atypical croup. Case series with chart review. Tertiary pediatric referral center. A surgical database was searched for all children who underwent full airway endoscopy to investigate atypical croup. The primary outcome measure was the prevalence of large airway lesions in patients with atypical croup undergoing endoscopy. Demographics, secondary diagnoses, and rate of positive findings were documented. Age and atopy were correlated using Spearman's correlation coefficient, and multivariate analysis identified predictors of large airway lesions. Eighty patients were identified over a period of 8 years (58 boys; mean [SD] age 4.8 [3.8] years; range, 46 days to 13.7 years). Of the 80 children, 31 had positive airway findings, with 33 large airway lesions demonstrated, including 10 subglottic stenosis, 7 laryngeal clefts, 6 subglottic hemangiomas, 4 tracheomalacia, an...
International Journal of Pediatric Otorhinolaryngology, 2014
To document the mode and age of primary aerodigestive presentation of Pierre Robin sequence/compl... more To document the mode and age of primary aerodigestive presentation of Pierre Robin sequence/complex (PRS/C) children to the otolaryngologist and to explore predictive factors of upper airway type and management. This is a retrospective cohort study conducted in a tertiary pediatric referral center. A prospective surgical database was searched for children who were diagnosed with PRS/C. Demographics, presenting complaint, secondary diagnoses, type of upper airway obstruction, secondary airway lesions, presence of cleft palate, and airway interventions were collected. Multiple linear regression analysis was performed to predict upper airway obstruction type and intervention. Seventy-seven potentially eligible patients were identified. Forty-six were included (20 females). Mean age at presentation was 20.4±36.9 months (range 1-191.25 months). Twenty-three primarily presented with respiratory failure, 14 with sleep disordered breathing, and nine with swallowing dysfunction. Children with presentations other than respiratory failure were older (p=0.004). Nineteen were syndromic. Overt cleft palate was more common in those presenting with respiratory failure (p=0.01). The type of airway obstruction encountered and use of tracheostomy were positively predicted by the primary presenting feature of respiratory failure (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) and male gender (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). A substantial number of PRS/C patients present later than the neonatal period with presentations other than respiratory failure. Both male gender and presentation with respiratory failure predicted a more severe airway obstruction type and the need for trachesotomy.
International Journal of Pediatric Otorhinolaryngology Extra, 2009
ABSTRACT Pyogenic granuloma is a polypoidal capillary hemangioma that occurs on the skin and muco... more ABSTRACT Pyogenic granuloma is a polypoidal capillary hemangioma that occurs on the skin and mucosal surface. Trauma, hormonal changes seen in pregnancy and use of the oral contraceptive pill have a role in its pathogenesis. Except for the oral cavity, involvement of gastrointestinal tract is quite rare and there are no reports of hypopharyngeal involvement. We report a case of hypopharyngeal pyogenic granuloma most likely secondary to prolonged nasogastric tube insertion in an immuno-compromised host.
International Journal of Pediatric Otorhinolaryngology, 2009
To compare bleeding after partial intracapsular tonsillectomy (PIT) and bipolar diathermy tonsill... more To compare bleeding after partial intracapsular tonsillectomy (PIT) and bipolar diathermy tonsillectomy (BDT). Design: Retrospective chart review. Setting: Stollery Children's Hospital, tertiary pediatric referral centre. Patients: All children (17 years of age) who had tonsillectomy. Patients who had incomplete information or less than 2-weeks follow-up were excluded. Main outcome measure: (1) Post-tonsillectomy bleeding, (2) other data collected included demographics, length of follow-up, indication(s) for surgery, other procedures performed, and co-morbidities. Results: Over a 4.5-year period 677 patients (333 BDT, 344 PIT) were identified in our search, and 77 (38 BDT, 39 PIT) were excluded. The mean age was 7.7 AE 3.8 years in the BDT group and 6.5 AE 3.2 years in the PIT group. Sex distribution was similar in the 2 groups (chi square p = 0.61). Twenty (6.8%) BDT patients experienced post-tonsillectomy bleeding, compared to three (0.98%) of PIT patients (p = 0.0001, 95% CI 1.52-2.18, OR = 7.32). Over 3 times as many PIT patients (153) had co-morbid conditions than BDT patients (44); this was statistically significant (chi square p < 0.00001, 95% CI 1.78-2.38). Conclusion: PIT results in significantly less post-tonsillectomy bleeding than BDT. These findings favor partial over total techniques with respect to reducing this important complication.
IMPORTANCE Laryngomalacia (LM) classically presents with stridor in early infancy but can present... more IMPORTANCE Laryngomalacia (LM) classically presents with stridor in early infancy but can present atypically with snoring and/or sleep-disordered breathing (S-SDB) or swallowing dysfunction (SwD). The epidemiology of these atypical presentations has not been established in the literature. OBJECTIVE To document the primary modes of presentation for LM in a consecutive series of children and to compare the characteristics of each subgroup. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series in a single tertiary pediatric otolaryngology practice. Outpatient and surgical records were searched for patients diagnosed as having LM from 2002 to 2009. We included all children with endoscopically confirmed LM without prior documentation of the diagnosis (n = 88). INTERVENTIONS Patients were investigated and managed according to the routine practice pattern of the senior author. MAIN OUTCOMES AND MEASURES The primary outcome measure was the proportion of the various primary presentations of LM. Age, sex, type of LM, management, and secondary diagnoses were also collected. Subgroup analysis was performed. RESULTS Of 117 potentially eligible patients identified, 88 children had a confirmed diagnosis of LM and were thus included (1.9:1 male to female sex ratio; mean [SD] age, 14.5 [23.0] months; age range, 0.2-96.0 months). Fifty-six children (64%) presented primarily with awake stridor and variable respiratory distress; 22 (25%) with S-SDB; and 10 (11%) with SWD. The difference in mean (SD) age for each group was statistically significant by analysis of variance: stridor, 3.5 (2.8) months; S-SDB, 46.0 (27.2) months; and SwD, 4.8 (4.6) months (P < .001). By χ 2 analysis, sex distribution was not significantly different between subgroups (P = .29), nor was the proportion of children who underwent supraglottoplasty (P = .07). The difference in proportion of types of LM between the stridor and atypical presentations was statistically significant (χ 2 P < .05), with type 1 LM predominating in children presenting with S-SDB. CONCLUSIONS AND RELEVANCE Because LM may present primarily with S-SDB and SwD in a significant proportion of children, the diagnosis must be considered in patients presenting with these upper airway complaints. The morphologic type of LM may vary by presentation.
Journal of Otolaryngology - Head & Neck Surgery, 2014
Objective: To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with ... more Objective: To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with snoring-sleep disordered breathing (S-SDB). Design: Prospective agreement diagnostic study on retrospective data. Methods: We conducted an inter-and intra-rater agreement study on video documentations of SNP performed on children (non-syndromic, complex, or operated upon) who presented with S-SDB. The videos featured various pharyngeal findings (normal, collapse, mixed or obstruction). Three 'non-expert' raters at various stages in their otolaryngological careers rated the videos independently, and on two separate occasions following an instructional session. We calculated both weighted and non-weighted linear kappa. Results: Each independent observer rated sixty-one videos (2 weeks apart). Intra-observer agreement was 0.64 ± 0.08 (95% CI 0.48-0.81), 0.74 ± 0.07 (95% CI 0.60-0.88), 0.59 ± 0.08 (95% CI 0.43-0.74), for raters 1, two and three. Weighted kappa was 0.6 ± 0.1 (95% CI 0.41-0.79), 0.8 ± 0.06 (95% CI 0.7-0.92), 0.7 ± 0.07 (95% CI 0.57-0.83), respectively. Inter-rater agreements between raters one and two, two and three, three and four were 0.83 ± 0.06 (95% CI 0.71-0.95), 0.52 ± 0.08 (95% CI 0.36-0.70), and 0.53 ± 0.08 (95% CI 0.37-0.69), respectively. Weighted kappa was 0.83 ± 0.073 (95% CI 0.69-0.98), 0.68 ± 0.06 (95% CI 0.56-0.79), and 0.64 ± 0.07 (95% CI 0.49-0.78), respectively. Conclusions: This is the first validation of pharyngeal findings on SNP in children. It is based on a four types' classification. Overall reproducibility amongst the three raters and their agreement was moderate to good. Further work should be phase four trials investigating the impact on outcome.
The purpose of this work is to review the basis and validity of sleep nasopharyngoscopy (SNP) in ... more The purpose of this work is to review the basis and validity of sleep nasopharyngoscopy (SNP) in children with sleep disordered breathing (SDB). We performed an English literature review of the effectiveness of modalities guiding surgical treatment, and the utility of SNP. Scant literature is available on SNP. Only two validation studies exist on adults, and none on children. Multiple-level pathology has been identified by several studies in children, but credible epidemiological work does not exist. Other modalities were studied but methodology flaws are substantial. In the absence of alternative validated diagnostic modalities, sleep endoscopy is emerging to identify surgical targets. This has mechanistic support, but as yet has not been accompanied by the description of a valid scheme in evaluating the upper airway.
International Journal of Pediatric Otorhinolaryngology Extra, 2006
ABSTRACT Background: Major venous thrombophlebitis and/or thrombosis in association with acute he... more ABSTRACT Background: Major venous thrombophlebitis and/or thrombosis in association with acute head and neck infection is a serious but uncommon event. The action of specific bacterial toxins causes the thrombophlebitis, which has the propensity of systemic complications and local circulatory effects. Lemierre&#39;s syndrome (LS) is a specific entity within this group, often caused by the anaerobe Fusobacterium necrophorum (FN). Objective: Review of six consecutive pediatric cases and a critical revision of diagnostic categories. Setup: Tertiary referral center. Study design: Case series of pediatric craniocervical infections complicated by internal jugular vein thrombophlebitis (IJVT). Demographics, record of anti-thrombosis management, imaging, and antimicrobial management, duration of admission, clinical picture and sequelae were retrospectively collected. Results: Six cases (three girls and three boys; age range from 7 to 16 years old) were identified over a period of 3 years. One case was a certain LS; four were probable LS cases and one possible diagnosis. Six children had IJVT diagnosed on imaging, which also demonstrated embolic seeding to the knee on one occasion and to the ankle in another. Anti-thrombosis management as outpatients was instituted for 3 months in five out of the six. None had permanent sequelae except one (unilateral high tone sensory hearing loss). In four cases, the duration of admission was 10 days or less, whereas the other two cases stayed for 2 and 5 weeks, respectively. Conclusions: Thrombogenic head and neck infections may occur in children more readily than currently believed. Failure to detect the characteristic anaerobe and the low index of suspicion of IJVT may contribute to missing cases. Modern imaging modalities represent a window of opportunity to detect the key pathogenic process to arguably the most morbid event, namely the IJVT. By incorporating their findings from the outset, the disease is categorized and its devastating complications prevented.
International Journal of Pediatric Otorhinolaryngology, 2015
To systematically review the frequency and time to spontaneous recovery in pediatric patients wit... more To systematically review the frequency and time to spontaneous recovery in pediatric patients with bilateral congenital idiopathic laryngeal paralysis (BCILP). Methods: The databases of Medline, EMBASE, Scopus, CINAHL, Cochrane Library and Proquest Dissertations were searched for English language articles reporting on laryngeal paralysis in pediatric patients. A bibliography search of the selected studies was done to identify additional articles. We included prospective or retrospective case-series studies of children and neonates diagnosed with BCILP at age <60 days and confirmed by direct laryngoscopy, with sufficient follow up and objective assessment for recovery. Two authors independently extracted the data and assessed the quality of each study. Discrepancies were resolved by consensus and adjudication by a third author. Results: Of the 4229 articles identified by the search, only one study met our inclusion criteria. The study was a retrospective case series, and was of low quality. The mean age at diagnosis was fourteen days. Sixty-five percent of the patients recovered spontaneously, and the mean time to recovery was twentyfive months. Tracheostomy was performed in 71% of the patients. Conclusions: The available literature is of low quality and provides weak evidence on the natural history of BCILP in pediatric population.
Objective: To determine the prevalence of laryngomalacia among children presenting with symptoms ... more Objective: To determine the prevalence of laryngomalacia among children presenting with symptoms of sleep-disordered breathing (SDB). Method: A retrospective observational study was conducted at a tertiary care paediatric hospital. All children presenting with SDB during a 55-month period were investigated using sleep nasopharyngoscopy (SNP). Patients who had laryngomalacia were identified. Patients who did not present primarily with SDB, or were not examined with SNP were excluded. Data for analysis was collected from a prospectively kept surgical database and medical records. This included patients' demographics, symptoms (including symptoms in infancy), diagnoses, SNP findings, overnight pulse oximetry findings, and treatment. Results: We identified 358 patients with documented primary diagnosis of SDB and who had undergone SNP. Fourteen of these also had a documented diagnosis of laryngomalacia, giving a prevalence rate of 3.9%. Three children were syndromic, and one had cerebral palsy in addition to SDB and laryngomalacia. Three children were obese, and three children had gastroesophageal reflux disease. Seven cases (50%) had symptoms of snoring and/or swallowing dysfunction and/or stridor in infancy. Twelve patients had adenotonsillar surgery. In eight cases symptoms resolved completely with adenotonsillar surgery only. In total, six patients had a supraglottoplasty. There were three failures to supraglottoplasty. Conclusion: The prevalence of laryngomalacia within children presenting with SDB is 3.9%. Our findings support full evaluation of the airway to identify the site of pathology mediating SDB symptoms.
Objectives/Hypothesis: To report on the prevalence of premature (PM) birth in a consecutive serie... more Objectives/Hypothesis: To report on the prevalence of premature (PM) birth in a consecutive series of children treated for snoring and sleep-disordered breathing (S/SDB), the parameters specific to their management and variables predictive of disease severity. Study Design: A retrospective study was undertaken at a tertiary pediatric hospital. Methods: Children with history of PM and presenting with S/SDB were identified from a prospectively kept surgical database. We set out to determine the prevalence of PM among the patients presenting with S/SDB who required airway evaluations and surgery. Pulse oximetry is overnight recordable oxygen saturation and heart rate tracing that provides information about hypoxemia during sleep. This was performed on all children preoperatively. The pulse oximetry findings were used to plan for perioperative monitoring and care. A multivariable analysis was used to identify factors predictive of abnormal pulse oximetry studies. We evaluated the associated diagnoses, surgical procedures required, and response to treatment in these selected children. Results: Fifty-seven out of 1,038 patients were PM (33 males; mean age, 62.09634.91 months; range, 4-190 months). The mean gestational age was 30.364.0 weeks. The prevalence rate of PM among patients treated surgically for SDB is 5.5% (95% CI 5.2-5.8) at our center. Comorbid pulmonary and gastrointestinal disorders were encountered on 23 (40%) and 17 (29.8%) occasions, respectively, and were the most commonly encountered comorbid diagnostic categories. Large airway abnormalities were encountered in 11 (19.3%) children, and the most common were subglottic stenosis (four) and laryngeal paralysis (four). Comorbid respiratory disease was negatively predictive of abnormal pulse oximetry (coefficient 20.35, P<.05). Postoperative respiratory outcomes correlated with abnormal pulse oximetry (coefficient 0.3; P<.05). Conclusions: Our findings suggest children with PM presenting to pediatric otolaryngology require a comprehensive evaluation for S/SDB. A significant proportion of children with S/SDB and a history of PM frequently had pulmonary and gastrointestinal comorbidities in our cohort. One-half required admission postoperatively, and these were predictable based on preoperative pulse oximetry. Respiratory comorbidity was negatively predictive of severity of SDB. Inversely, children with untreated pulmonary comorbidities are more likely to have postoperative complications.
Objective: To compare postoperative respiratory complications in obese and nonobese children foll... more Objective: To compare postoperative respiratory complications in obese and nonobese children following surgery for sleep-disordered breathing. Study Design: Case-control study. Setting: Pediatric tertiary care center. Subjects and Methods: All obese children who had undergone adenotonsillectomy for sleep-disordered breathing from 2002 to 2007 were compared with age- and gender-matched controls. Subjects were identified from a prospective surgical database. Length of hospital stay and the incidence, severity, and location of respiratory complications were compared. Multivariable analysis was performed to identify predictive factors. Results: Forty-nine obese children were identified (20:29, female:male). There were no differences in mean age or type of surgical procedures ( P > 0.05). Overall, 37 obese children (75.5%) and 13 controls (26.5%) incurred complications ( P = 0.000, OR 8.54 [95% CI 3.44-21.19]). Ten obese patients and two controls incurred major events ( P = 0.012, OR ...
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Papers by Hamdy Elhakim