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Biomedical subjects

C M Myer

Publications and source records attributed to C M Myer.

At least 19 recordsLinked to original sources
PubMed2003

Steroids for improving recovery following tonsillectomy in children.

BACKGROUND: Tonsillectomy continues to be one of the most common surgical procedures performed worldwide. Despite advances in anesthetic and surgical techniques, post-tonsillectomy morbidity remains a significant clinical problem. OBJECTIVES: To assess the clinical efficacy of a single intra-operative dose of dexamethasone in reducing post-tonsillectomy morbidity. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Issue 1, 2002), MEDLINE (from 1966 - February 2002), EMBASE (from 1974 - February 2002) and reference lists of relevant articles. We contacted leading experts for information on any relevant unpublished data. SELECTION CRITERIA: Randomized, double-blind, placebo-controlled trials of a single dose of intravenous, intra-operative corticosteroid for pediatric patients (age < 18 years) who underwent tonsillectomy or adenotonsillectomy were included. DATA COLLECTION AND ANALYSIS: Data regarding the primary outcome measures and measurement tools were extracted by the first author from the published studies. Data regarding study design, patient ages, procedures performed, dose of corticosteroid and method of delivery, as well as methodologic quality were also recorded by the first author. When data were missing from the original publications, the authors were contacted for more information. Data analysis was performed with a random effects model, using the RevMan 4.1 software developed by the Cochrane Collaboration. MAIN RESULTS: Children receiving a single intra-operative dose of dexamethasone (dose range = 0.15 to 1.0 mg/kg; maximum dose range = 8 to 25 mg) were two times less likely to vomit in the first 24 hours than children receiving placebo (RR = 0.54, CI95 = 0.42, 0.69; p < 0.00001). Routine use in four children would be expected to result in one less patient experiencing post-tonsillectomy emesis (RD = -0.25, CI95 = -0.37, -0.13; p = 0.00004). Additionally, children receiving dexamethasone were more likely to advance to a soft/solid diet on post-tonsillectomy day 1 (RR = 1.69, CI95 = 1.02, 2.79; p = 0.04) than those receiving placebo. Due to missing data and varied outcome measurement tools, pain could not be meaningfully analyzed as a distinct outcome measure. REVIEWER'S CONCLUSIONS: The evidence suggests that a single intravenous dose of dexamethasone is an effective, relatively safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy. No adverse events attributable to dexamethasone were reported in these trials. Additionally, in our 10-year experience of routine use of a single intravenous dose of dexamethasone during pediatric tonsillectomy, there have been no attributable, adverse events. Lastly, we found no reports in the literature of complications from use of a single intravenous dose of corticosteroid during pediatric tonsillectomy.

Adenoidectomy↗
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

Endoscopic access to the infratemporal fossa and skull base: a cadaveric study.

OBJECTIVES: To demonstrate that the regions of the infratemporal fossa and skull base at the level of the foramen ovale can be visualized endoscopically and that structures can be manipulated within these regions using endoscopic instruments. METHODS: Cadaveric dissection of 3 human cadavers using an endoscopic optical dissector. In all, 6 endoscopic infratemporal fossa and skull base approaches were performed. SETTING: Human temporal bone laboratory. RESULTS: A Gillies incision was coupled with a lateral brow incision, and then subperiosteal planes were developed. Endoscopic visualization and instrumentation was then performed. The infratemporal fossa was readily identified. The skull base at the level of the foramen ovale and the branches of the third division of the trigeminal nerve were seen distinctly. A probe was placed with ease within the foramen ovale itself. CONCLUSIONS: Endoscopic access to the infratemporal fossa is readily accomplished, with excellent visualization and instrumentation ability. This novel technique provides access to this remote region for evaluation, possible biopsy, and potential treatment of infratemporal fossa lesions.

Cadaver↗
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

Do steroids reduce morbidity of tonsillectomy? Meta-analysis of randomized trials.

OBJECTIVES/HYPOTHESIS: The study aims to reconcile conflicting published reports regarding the clinical efficacy of a single intraoperative dose of dexamethasone in reducing post-tonsillectomy morbidity. STUDY DESIGN: Systematic overview (meta-analysis). METHODS: To critically evaluate the existing evidence, we performed a formal meta-analysis of eight double-blinded, randomized, placebo-controlled studies of dexamethasone in pediatric patients undergoing tonsillectomy or adenotonsillectomy. Reduction in postoperative emesis and pain, as well as early return to soft or solid diet, were studied as distinct end points. RESULTS: Children being given a single intraoperative dose of dexamethasone (dosing, 0.15-1.0 mg/kg; maximum dose, 8-25 mg) were two times less likely to vomit in the first 24 hours than children being given placebo (relative risk [RR] = 0.55; 95% confidence interval [CI], 0.41-0.74; P < .0001). Routine use in four children would be expected to result in one less patient having post-tonsillectomy emesis (risk difference [RD] = -0.24; 95% CI, -0.38 to -0.10; P = .0006). In addition, children being given dexamethasone were more likely to advance to a soft or solid diet on post-tonsillectomy day 1 (RR = 1.69; 95% CI, 1.02-2.79; P = .04) than those being given placebo. Because of missing data and varied outcome measures, pain could not be meaningfully analyzed as a distinct end point. CONCLUSION: Given the frequency of tonsillectomy, relative safety and low cost of dexamethasone, and the reduction in postoperative morbidity, we recommend routine use of a single intravenous dose during pediatric tonsillectomy.

Adenoidectomy↗
PubMed2001

Historical perspective on the use of otic antimicrobial agents.

Treatment of otorrhea has been described in the literature since 1500 BC. A multitude of therapeutic options have been described, including the use of astringents, antiseptics, alcohol, benzoin and various powders. Since the middle of the 20th century, antibiotic usage has been promoted as the most effective means of therapy. Until recently none of the agents that were used was found to be safe for middle ear use. Since 1990 there have been publications describing the safety and efficacy of fluoroquinolone drops for acute and chronic otorrhea. This article details the transition from treatment of otorrhea with nonspecific means to an era of antimicrobial therapy based on sound scientific evidence.

Alcohols↗
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↗
PubMed2001

Is sedation safe during dynamic sleep fluoroscopy of children with obstructive sleep apnea?

OBJECTIVE: Airway compromise is considered a relative contraindication for pediatric sedation. This contraindication presents a paradoxical problem when patients require sedation in preparation for imaging performed to evaluate the cause of airway obstruction. We use dynamic sleep fluoroscopy in the evaluation of children who have obstructive sleep apnea. The purpose of this study was to evaluate the success and safety of a structured sedation program for dynamic sleep fluoroscopy. MATERIALS AND METHODS: Eighty consecutive dynamic sleep fluoroscopic studies were evaluated. The type of sedation used, success rate, complications related to the sedation, and characteristics of the children studied were reviewed. Patients were sedated in accordance with our departmental sedation program guidelines. Findings on fluoroscopy were correlated with episodes of oxygen desaturation or noisy breathing. RESULTS: In all 80 cases, dynamic sleep fluoroscopy was successfully performed. Seventy-two studies were performed, with sedation supervised by the radiologist. Four patients fell asleep without sedation. In four patients, sedation was performed by an anesthesiologist (preprocedural decision). Sixty-four children (80%) had complex medical problems, and 39 (49%) had a history of previous airway surgery. All studies were considered successful. Specific diagnoses were identified in 66 children (83%). No children suffered complications or required tracheal intubation. CONCLUSION: Children with airway compromise who are being evaluated for obstructive sleep apnea can be successfully and safely sedated for dynamic sleep fluoroscopy when a structured sedation program is used.

Child, Preschool↗
PubMed2001

Post-tympanostomy tube otorrhea.

Post-tympanostomy tube otorrhea is a common problem that is treated by both primary care physicians and otolaryngologists. Physicians should take a logical approach to managing this condition in order to prevent the development of antimicrobial resistance and to minimize healthcare expenditures. Once the diagnosis has been made, first-line therapy with fluoroquinolone drops, with or without suctioning, is preferred. If the condition does not resolve after a few days, suctioning is recommended and oral antimicrobial therapy can be initiated, depending on the clinical situation. Parenteral therapy is sometimes necessary for those very few patients who do not improve with oral and topical antimicrobial therapy and aggressive local care. The use of prophylactic drug therapy is controversial.

Cerebrospinal Fluid Otorrhea↗
PubMed2000

Subglottic stenosis associated with transesophageal echocardiography.

Transesophageal echocardiography (TEE) is used extensively to assess cardiac function and anatomical relationships in both adults and children. Although considered a noninvasive procedure, TEE in infants and small children may result in airway complications. A patient who developed subglottic stenosis after the use of TEE during a cardiac procedure is reported.

Echocardiography, Transesophageal↗
PubMed2000

Methicillin-resistant Staphylococcus aureus otorrhea after tympanostomy tube placement: an emerging concern.

OBJECTIVES: To review the treatment of pediatric patients with methicillin-resistant Staphylococcus aureus (MRSA)-positive cultures as a result of otorrhea after tympanostomy tube placement in terms of both medication and isolation strategies and to highlight an emerging problem faced by the clinician with reference to treatment options as well as to the treatment of these patients in an outpatient setting. PATIENTS: Between December 1998 and January 2000, a total of 8 children between the ages of 1 and 11 years had MRSA-positive cultures as a result of otorrhea after tympanostomy tube placement. MAIN OUTCOME MEASURES: The Department of Infectious Diseases was notified, and a variety of topical antibiotic treatments were administered. Arch Otolaryngol Head Neck Surg. 2000;126:1440-1443

Administration, Oral↗
PubMed2000

Single-stage laryngotracheal reconstruction in children: a review of 200 cases.

OBJECTIVE: We reviewed our experience with pediatric single-stage laryngotracheal reconstruction (SSLTR) to identify factors that affect postoperative outcomes, including the need for reintubation and tracheostomy. STUDY DESIGN: Retrospective chart review was done. RESULTS: In total, 190 children underwent 200 SSLTRs; 29% were reintubated, and 15% required postoperative tracheostomy. Currently, 96% are decannulated. The use of anterior and posterior costal cartilage grafting, age less than 4 years, sedation for more than 48 hours, a leak pressure around the endotracheal tube at greater than 20 cm H2O, and moderate/severe tracheomalacia significantly increased the rate of reintubation. The duration of stenting did not affect outcomes. Children with anterior and posterior grafts and those with moderate or severe tracheomalacia were more likely to need a postoperative tracheostomy. CONCLUSION: SSLTR can be effective for the treatment of pediatric laryngotracheal stenosis. Diligent preoperative assessment of the patient and the patient's airway and close postoperative care are important to the success of this operation.

Adolescent↗