Biomedical subjects
C M Myer
Publications and source records attributed to C M Myer.
Septal hematoma and abscess after nasal trauma.
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Glossoptosis (posterior displacement of the tongue) during sleep: a frequent cause of sleep apnea in pediatric patients referred for dynamic sleep fluoroscopy.
OBJECTIVE: The purpose of this study was to evaluate the frequency of glossoptosis (posterior displacement of the tongue) as a cause of sleep apnea in pediatric patients referred for fluoroscopic sleep studies. MATERIALS AND METHODS: Seventy consecutive dynamic fluoroscopic sleep studies performed to evaluate sleep apnea were reviewed. All patients had been sedated and examined with lateral fluoroscopy during sleep. Anatomic changes in the airway were correlated with episodes of oxygen desaturation. Cases of glossoptosis, in which the tongue moved posteriorly during sleep and abutted the posterior pharynx, resulting in airway obstruction and oxygen desaturation, were identified. Associated factors were reviewed. RESULTS: Of 70 sleep studies reviewed, glossoptosis was the cause of airway obstruction in 17 patients (24%). Mean age in these 17 patients was 3 years (range, 5 days to 13 years). Seven of the 17 children were younger than 1 year old. Only three patients had no underlying medical problems. Four patients had macroglossia (Down syndrome, n = 3; duplicated tongue, n = 1) as a cause, and three patients had micro- or retrognathia (Pierre Robin syndrome, n = 2; Rubinstein-Taybi syndrome, n =1) as a cause. Six patients had neuromuscular abnormalities. CONCLUSION: Glossoptosis was a cause of airway obstruction in 25% of pediatric patients referred for fluoroscopic sleep studies. Attention to this anatomic region is important when evaluating children with sleep apnea.
Gustatory sweating syndrome of the submandibular gland.
Gustatory sweating syndrome involving the submandibular gland is rare. We present a case of a patient who experienced this syndrome 5 years after undergoing submandibular gland resection. Our patient was satisfied simply with an explanation of the disorder and reassurance. But in cases where further intervention is sought, medical and surgical options are available and should be individualized for the patient.
Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children.
Retropharyngeal abscess (RPA) in children is a potentially life-threatening process which often requires immediate surgical intervention. Contrast enhanced computed tomography (CT) is utilized frequently to determine abscess versus cellulitis/phlegmon and aids in determining cases needing surgical drainage. The purpose of this retrospective study was to determine the accuracy of CT in distinguishing retropharyngeal abscess from cellulitis in children. The medical records of 32 children from 1989 to 1997 suspected of having a retropharyngeal abscess were reviewed. All patients included in the study underwent a CT scan as well as surgical exploration within 48 h of the scan. Two patients required two surgical procedures (n = 34). A comparison between CT results and operative findings was made to determine the accuracy of CT imaging in confirming the presence of RPA versus cellulitis. Suspected diagnosis of abscess or cellulitis/phlegmon on CT was confirmed at surgery in 25 of 34 cases (73.5%). The false positive rate of CT scan was 11.8% (4/34), while the false negative rate was 14.7% (5/34). Based on our results, CT is accurate in differentiating abscess from cellulitis in 73.5% of cases. Clinical findings, as well as radiologic findings, must be considered together prior to surgical drainage of a suspected retropharyngeal abscess in children.
Does the presence of a tracheoesophageal fistula predict the outcome of laryngeal cleft repair?
OBJECTIVE: To determine if the presence of a tracheo-esophageal fistula (TEF) alters outcome following laryngeal cleft repair. DESIGN: A retrospective review of patients diagnosed and treated for laryngeal clefts, with a minimum follow-up period of 1 year. SETTING: An academic tertiary care children's hospital. PATIENTS: Twenty-five pediatric patients diagnosed and surgically treated for laryngeal cleft. MAIN OUTCOME MEASURES: Each chart was reviewed to determine if patients with a laryngeal cleft had been diagnosed with TEF and had undergone a surgical TEF repair procedure. The success of the surgery was evaluated based on the resolution of symptoms and the endoscopic evaluation of the repair site. RESULTS: Twenty-five patients were reviewed for study purposes. Fourteen had a history of TEF repair and 11, no history of TEF. All 25 patients underwent surgical repair of the laryngeal cleft. Twelve of the 14 patients with a history of TEF repair experienced a breakdown of the laryngeal cleft repair. Only 1 of the 11 patients with no history of TEF experienced such a breakdown. In 8 of 9 patients with a laryngotracheoesophageal type I cleft, surgical repair was not successful. CONCLUSIONS: In our series, patients with laryngeal clefts who also had a history of TEF had a much higher incidence of breakdown of cleft repair compared with patients with no history of TEF. This finding is not conclusive and requires further investigation. The failure of cleft repair correlated with the severity of the cleft. The importance of these associations may lead to enhanced surgical planning and realistic preoperative family expectations.
Saccular cyst caused by recurrent respiratory papillomatosis.
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Use of a laryngeal micro resector system.
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Pediatric type I thyroplasty: an evolving procedure.
The treatment of vocal fold paralysis by type I thyroplasty in the pediatric age group has not been reported. From 1990 to 1998, 12 type I thyroplasty procedures were performed on 8 patients between 2 and 17 years of age. The most common cause of vocal fold paralysis was neurologic, followed by vagal injury from a cardiac procedure. The most common indications for the procedure were aspiration and dysphonia. In our early thyroplasty experience, adult techniques and measurements adapted after Isshiki or Netterville were used. Postoperative laryngoscopy showed that in most cases, the placement of the implant was too high. There were variable outcomes in aspiration and dysphonia with this technique. These findings appear to be independent of thyroplasty approach or of implant design type. We conclude that the standard approach for vocal fold medialization in the adult cannot be applied accurately in the pediatric population. In performing pediatric thyroplasty, the anatomically lower position of the vocal fold must be taken into consideration. We have since modified our technique to adjust for accurate identification of the vocal fold line and medialization. The modified approach for vocal fold medialization in the pediatric population is discussed.
The role of second-look nasal endoscopy after pediatric functional endoscopic sinus surgery.
OBJECTIVE: To determine if second-look nasal endoscopy (SLE) improves clinical outcome after pediatric functional endoscopic sinus surgery (FESS). DESIGN: A retrospective review was performed for all patients who had undergone FESS between January 1993 and December 1994. The patients were divided into 2 groups: those who underwent SLE 2 to 3 weeks after FESS (n=94) and those who did not undergo SLE after FESS (n=53). Patients with a history of cystic fibrosis, bone marrow transplantation, or isolated sphenoidal sinus disease were excluded from the study. SETTING: Pediatric tertiary care hospital. PATIENTS: All patients had a diagnosis of chronic rhinosinusitis, had failed medical therapy, and had subsequently undergone FESS. MAIN OUTCOME MEASURES: The need for revision sinus surgery was used as the definition for poor clinical outcome, indicating that sinus disease recurred or was persistent. The number of patients requiring revision sinus surgery in each group was compared. RESULTS: Revision surgery was performed in 20 of the 94 patients who underwent SLE after FESS. Revision surgery was performed in 10 of the 53 patients who did not undergo SLE after FESS. Six patients in the "no-second-look group" underwent follow-up nasal endoscopy at some time after the initial FESS. There was no significant difference in terms of clinical outcome between the 2 groups. CONCLUSIONS: The rate of revision sinus surgery was comparable in those patients who underwent SLE after FESS and those who did not. The usefulness and application of SLE need to be considered carefully.
S-phase fraction as a predictor of prognosis in juvenile respiratory papillomatosis.
OBJECTIVE: To determine whether DNA ploidy and the S-phase fraction are predictive of the clinical course in children with recurrent respiratory papillomatosis. DESIGN: Masked compression of DNA analysis findings to the clinical course of the disease. SETTING: Tertiary referral center. PATIENTS: All pediatric patients treated for recurrent respiratory papillomatosis at our institution between 1989 and 1995 who had adequate follow-up and whose primary biopsy specimen was available for examination. Fifty-five patients met these criteria. METHODS: Information was collected from the case notes on the patient's age at presentation, sex, sites of disease, duration of active disease, and frequency of operative interventions. Flow cytometric analysis was performed on the archival paraffin-embedded primary biopsy specimen obtained at the initial surgical excision, providing DNA content and percentages of S-phase cells. The investigators who performed the DNA analysis were masked to the clinical course. RESULTS: The age of the patients at presentation ranged from 3 months to 16 years. Thirty patients had involvement in more than 1 anatomical site. The disease in 10 patients had spread to the distal tracheobronchial tree. The patients underwent a total of 1124 procedures, with a frequency range of 7 to 27 per year. All cell populations studied were diploid. The percentage of S-phase cells was significantly higher in the primary biopsy specimen from patients with disease characterized by more frequent recurrences, multiple sites, and distal extension (P<.05). In multiple regression analysis, the S-phase fraction was found to be an independent and powerful prognostic factor for aggressive disease. CONCLUSIONS: The S-phase fraction may be predictive of the clinical course in patients with juvenile respiratory papillomatosis. Prospective studies are needed to assess the diagnostic and clinical value of our primary results and to determine whether DNA analysis can assist in identifying patients at increased risk for an aggressive clinical course.
Airway management in Pierre Robin sequence.
There is a great deal of controversy regarding the long-term management of airway obstruction in children with Pierre Robin sequence. All 23 pediatric otolaryngology fellowship programs were surveyed to determine their current practice patterns. Issues that were addressed included methods of evaluation of airway obstruction, including polysomnography, choices for home care in children in whom observation and positioning treatment failed, and complications of the various treatment modalities. The lack of unanimity among the respondents mirrors the controversy found in the literature. Though tracheotomy appears to be favored as the method of long-term management, responses from those surveyed often were based on emotions as much as on scientific data. This report details those findings and offers suggestions to clinicians involved with the management of patients with Pierre Robin sequence with airway compromise.
Blunt laryngotracheal trauma in children.
OBJECTIVES: To demonstrate the diverse causes and manifestations of blunt laryngotracheal trauma in children, and to recommend an appropriate treatment protocol for these patients. DESIGN: A retrospective review of the medical records of patients treated at a tertiary care children's hospital for blunt laryngotracheal trauma during the 12 years before March 1, 1995 was performed. Clinical signs and symptoms, mechanisms of injury, and the results of laryngoscopy were included. PATIENTS: The study included 23 patients ranging from 2 1/2 to 18 1/2 years of age. The medical records of patients who had sustained an injury as a result of penetrating trauma, intubation, or foreign body were excluded. RESULTS: Four patients urgently required tracheotomies; 2 of these patients required subsequent reconstructive airway procedures. One child required a microlaryngoscopy with relocation of the arytenoid cartilage. The remaining 18 patients were treated conservatively with continuous pulse oximetry, cool mist room air, and serial flexible fiberoptic laryngoscopy. The 18 patients were discharged from the hospital after 24 to 48 hours of observation without sequelae. CONCLUSIONS: The signs and symptoms of blunt laryngotracheal trauma in children are not always specific to the extent or type of injury. A prompt diagnosis and treatment plan are needed to prevent potentially catastrophic complications. Patients with obvious airway compromise require immediate intervention. Those without acute airway symptoms often can be treated conservatively, provided that flexible fiberoptic laryngoscopy confirms a safe airway.
Ventilation tube placement in a managed care population.
To date, little information is available regarding the actual incidence of ventilation tube placement in a known population of pediatric patients. We evaluated the incidence of ventilation tube placement in a known population of pediatric patients whose health coverage is provided through a large managed care organization. Epidemiological data provided by a large managed care organization on a population of 67,995 children from July 1, 1993, through June 30, 1994, were evaluated. A primary care physician referral to an otolaryngologist was required for assessment, and precertification for ventilation tube placement was obtained using explicit criteria developed by a large national health services utilization review organization. In children younger than 24 months, 30.11% underwent ventilation tube placement compared with an overall incidence of 4.49% for all children younger than 18 years. The details of this study are presented to understand better the implications of the epidemiology of otitis media and how it relates to a physician's participation in a managed care organization.
Eosinophilic ulcer of the tongue.
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Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis.
Foreign body (FB) injury from aspiration or ingestion is a common pediatric health problem. Diagnosis relies on clinical judgment plus medical history, physical examination, and radiographic evaluation. A multi-institutional review of 1269 FB events revealed that 85% were correctly diagnosed following a single physician encounter. However, 15% of the children had an elusive diagnosis (>1 week), despite previous evaluation. Delays in diagnosis were seven times more likely to occur in aspirations than in ingestions. Secondary injuries (e.g., pneumonia and atelectasis) occurred in 13% of airway FBs but in only 1.7% of esophageal FBs. Plain radiographs were used in 82% of children, and special studies (e.g., fluoroscopy) in only 7%. We conclude that diagnosis of FB injury in children is frequently achieved at the initial evaluation but that continued surveillance by follow-up visits to health care facilities from parents and other caretakers is important, to reduce pulmonary injuries.
Magnetic resonance imaging determination of tracheal orientation in normal children. Practical implications.
OBJECTIVE: To determine normative anatomical data on the pediatric upper airway. DESIGN: Anatomical study of the trachea and surrounding structures in vivo using magnetic resonance imaging. Three-dimensional positions of the hyoid bone, sternum, skin, and trachea were determined. Tracheal angulation was measured from the vertical plane. SUBJECTS: One hundred children (53 males and 47 females) undergoing magnetic resonance imaging of the brain or chest. INTERVENTION: None. RESULTS: Ages ranged from 2 days to 20.4 years, with a median of 6.05 years. Gender differences were not significant. The mean distance from the hyoid bone to the sternal notch was 63.0 mm (SD, 22.04 mm). The skin to anterior tracheal wall distance averaged 9.34 mm (SD, 3.29 mm), and tracheal diameter averaged 8.48 mm (SD, 2.88 mm). The trachea was not found to be a linear structure. An anterior angulation change of 9.9 degrees (SD, 7.89 degrees) was detected. The point of inflection was found to lie below the sternal notch in children younger than 2 years and above the notch in older children. CONCLUSIONS: Normal anatomical data of the pediatric airway have been acquired using magnetic resonance imaging. Because the trachea exhibits a previously unknown anterior angulation, current design of tracheotomy tubes may not be ideal. Rigid tracheotomy tubes that do not conform to the anatomical structure of the trachea may be responsible for suprastomal collapse or innominate artery erosion.
Selected risk factors in pediatric adenotonsillectomy.
OBJECTIVE: To evaluate the ability of a set of cost-effective criteria to identify before surgery the pediatric patients in whom perioperative respiratory compromise is most likely to develop after adenotonsillectomy. SETTING: A children's hospital medical center. DESIGN: Prospective study using preoperative parental questionnaires and perioperative respiratory status documentation. PATIENTS: All patients scheduled at the outpatient clinic were eligible. MAIN OUTCOME MEASURE: The development of respiratory compromise as defined by at least 1 of the following occurring more than 2 hours after surgery: an oxygen desaturation level of less than 90%, an obstructive breathing pattern, or respiratory distress requiring intervention. RESULTS: The risk of respiratory compromise was significantly increased in patients who were younger than 3 years (P < .001) and in those who had neuromuscular disorders (P < .05), chromosomal abnormalities (P < .005), difficulty in breathing during sleep (P < .005), restless sleep (P < .01), loud snoring with apnea (P < .05), or an upper respiratory tract infection within 4 weeks of surgery (P = .005). Respiratory compromise did not develop in any patients who did not snore (P < .05). CONCLUSIONS: A complete history that includes symptoms suggestive of sleep apnea will assist in the preoperative identification of pediatric patients most at risk for perioperative respiratory compromise after undergoing adenotonsillectomy. Such patients might benefit from overnight observation in a hospital setting. However, when snoring is absent, outpatient surgery is appropriate, as the risk of respiratory compromise is minimal.