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Craig S Derkay

Publications and source records attributed to Craig S Derkay.

At least 19 recordsLinked to original sources
PubMed2006

Prevention of recurrent respiratory papillomatosis: role of HPV vaccination.

Recurrent respiratory papillomatosis is a rare, but devastating, cause of airway lesions in children and adults. This disease is caused by human papilloma virus subtypes 6 and 11. At this time there are two vaccines in late stages of development seeking Food and Drug Administration (FDA) approval to prevent cervical cancer, which is also caused by human papilloma virus. One of these vaccines has been developed to stimulate immunity to the most common subtypes that cause cervical cancer but also includes those responsible for recurrent respiratory papillomatosis. With the possibility this could drastically reduce the incidence of RRP, the otolaryngology community should advocate for implementation of a vaccine program that provides effective prevention of HPV infection with subtypes 6 and 11.

Adult↗
PubMed2006

Four mutations in Epidermodysplasia verruciformis 1 (EVER1) gene are not contributors to susceptibility in RRP.

OBJECTIVE: Epidermodysplasia verruciformis is a skin disease characterized by abnormal susceptibility to human papilloma viruses. Recently four mutations in the Epidermodysplasia verruciformis 1 gene (EVER1, also known as TMC6) have been associated with the disease. Because of the phenotypic similarity between Epidermodysplasia verruciformis and recurrent respiratory papillomatosis, we decided to investigate whether any of these mutations accounts for the susceptibility to human papilloma viruses in subjects with recurrent respiratory papillomatosis (RRP). METHODS: Allele-specific PCR and restriction fragment length polymorphisms (RFLPs) were employed for genotyping a cohort of 101 patients with recurrent respiratory papillomatosis. RESULTS: None of these four mutations were found in the studied subjects. CONCLUSION: The absence of these mutations in RRP patients might indicate that EVER 1 alleles are not associated with susceptibility to RRP, or that other, as yet unidentified, mutations in the Epidermodysplasia verruciformis 1 gene, might account for the susceptibility to RRP.

Female↗
PubMed2006

Post-tonsillectomy morbidity and quality of life in pediatric patients with obstructive tonsils and adenoid: microdebrider vs electrocautery.

OBJECTIVE: To prospectively compare outcomes in children over age 2 with obstructive adenotonsillar hypertrophy when tonsillectomy is performed utilizing an intracapsular microdebrider technique versus low-wattage electrocautery technique. STUDY DESIGN AND SETTING: Prospective, single-blind, randomized controlled trial at a tertiary care children's hospital. RESULTS: Among the 300 children, those treated with the microdebrider resumed normal activity faster, with a median recovery of 2.5 days, and stopped taking pain medication sooner, with the median time to the last dose of 4 days. The microdebrider group were 3 times more likely to no longer need pain medications at 3 days postoperatively and 2.5 times less likely to be still needing pain medication 7 days postoperatively. They were twice as likely to be at a normal activity level by 3 days postoperatively and were less likely to still not have attained normal activity and normal diet after 7 days. There was no difference between groups in median days to return to normal diet (3.0 to 3.5 days). At 1-month follow-up, children in the microdebrider group were 5 times more likely to have residual tonsil tissue. CONCLUSIONS: Intracapsular tonsillectomy in children with obstructive adenotonsillar hypertrophy results in improved peri-operative outcomes. Residual tonsil tissue is more common with use of the microdebrider; however, the incidence of future obstruction or infection is unknown. EBM RATING: A-1b.

Adenoidectomy↗
PubMed2006

Unique challenges of obtaining regulatory approval for a multicenter protocol to study the genetics of RRP and suggested remedies.

OBJECTIVE: Investigations that seek to generalize findings or to understand uncommon diseases must be conducted at multiple centers. This study describes the process of obtaining regulatory approval for a minimal risk genetic study in a multi-center setting as undertaken by the Recurrent Respiratory Papillomatosis (RRP) Task Force. STUDY DESIGN AND SETTING: Sequential cohort of American children's hospitals. A single protocol was submitted to each Institutional Review Board (IRB). RESULTS: Documentation was prepared for 14 IRBs over 2.5 years. The median time between enlistment and approval at the first 8 sites was 15 months. Institutions varied considerably in their requirements and in the issues that were raised. Protocols were submitted sequentially and accumulated experience was used in the preparation of applications to subsequent IRBs. Nevertheless, there was no correlation between the accumulated experience and the number of issues that were raised. CONCLUSION: Despite uniform federal standards, all local IRBs required unique and individualized submissions. For multicenter studies, investigators should seriously consider the establishment of cooperative authorization agreements. On a simpler level, a standardized format for applications needs to be adopted nationwide. EBM RATING: B-3b.

Clinical Protocols↗
PubMed2006

Recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis is a frustrating and challenging disease for surgeons, patients, and patients' families. Although the voice and airway manifestations are managed surgically, a "cure" for this disease remains elusive. In this edition of the "Seminar Series," we endeavor to review the current literature regarding the epidemiology, etiology, clinical manifestations, and surgical and medical treatments of this disorder. The key to future management of recurrent respiratory papillomatosis may lie in its prevention, if current efforts to develop an effective vaccine come to fruition.

Antineoplastic Agents↗
PubMed2005

Pediatric sinusitis: when do we operate?

PURPOSE OF REVIEW: The role of surgery in the treatment of pediatric sinusitis is still in evolution. This review of recent literature highlights developments in the study of pediatric sinusitis, particularly as it pertains to surgical intervention. RECENT FINDINGS: There is growing support in the literature for adenoidectomy as a first-line surgical intervention for chronic rhinosinusitis in children when maximal medical management fails. Maxillary sinus aspiration or middle meatal culture can be performed at the same sitting to facilitate directed antibiotic therapy. Intravenous antibiotics seem to be a promising alternative to functional endoscopic sinus surgery (FESS), especially in younger children. Current literature continues to support FESS as a safe and effective treatment for pediatric sinus disease. Previous notions that FESS may inhibit midfacial growth have been challenged by several recent studies. There is no clear consensus regarding timing of FESS for chronic rhinosinusitis. However, the current literature seems to support FESS when maximal medical therapy, adenoidectomy, and culture-directed systemic antibiotics have all failed with persistence of sinonasal disease, when anatomic abnormalities predispose to chronic rhinosinusitis by obstructing normal sinonasal drainage pathways, in sinonasal polyposis to facilitate application of topical steroids, as an adjunct to desensitization in aspirin-sensitive patients, when orbital or intracranial complications of sinonasal disease occur, and in selected cystic fibrosis patients to improve quality of life and facilitate application of topical antibiotics with activity against Pseudomonas aeruginosa. SUMMARY: Although the current literature lends some additional clarity to the indications for surgical intervention in pediatric chronic rhinosinusitis, additional research is still needed to elucidate appropriate timing for surgery and more specific indications.

Adenoidectomy↗
PubMed2005

HspE7 treatment of pediatric recurrent respiratory papillomatosis: final results of an open-label trial.

OBJECTIVES: We sought to evaluate the effectiveness of HspE7, a recombinant fusion protein of Hsp65 from Mycobacterium bovis BCG and E7 protein from human papillomavirus 16, to improve the clinical course of pediatric patients with recurrent respiratory papillomatosis. METHODS: An open-label, single-arm intervention study was conducted in 8 university-affiliated medical centers. Twenty-seven male and female patients with recurrent respiratory papillomatosis, ages 2 to 18 years, were enrolled and followed up to 60 weeks. Before enrollment, these patients required surgery on average every 55 days. After a baseline debulking surgery, the patients received HspE7 500 microg subcutaneously monthly, for 3 doses over 60 days. The primary end point was the length of the interval from the last surgery during the treatment period until the first debulking surgery in the posttreatment period, compared with the median intersurgical interval (ISI) of the 4 surgeries before the treatment. RESULTS: The mean of the first posttreatment ISI increased 93% (from 55 days to 106 days; p < .02). The median ISI for all surgeries after treatment was similarly prolonged (mean, 107 days; p < .02), indicating a sustained treatment effect, and was associated with a significant decrease in the number of required surgeries (p < .003). Unexpectedly, the treatment effect was most striking in the 13 female patients, who had statistically significant increases in both the first posttreatment ISI (142%; p < .03) and the median ISI (147%; p < .03). The most common adverse events were mild-to-moderate injection site reactions. CONCLUSIONS: Treatment with HspE7 appears to significantly improve the clinical course in pediatric patients with RRP insofar as it reduces the frequency of required surgeries. These results warrant a confirmatory phase III trial.

Adolescent↗
PubMed2004

American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy.

OBJECTIVE: To evaluate how evolving treatment technologies have affected our management of recurrent respiratory papilloma (RRP) since the last comprehensive survey of pediatric otolaryngologists in 1998. DESIGN: Web-based survey of all American Society of Pediatric Otolaryngology members residing in the United States, Canada, Europe, and Australia. RESULTS: Evaluable survey results were tabulated from 74 practitioners in 62 separate practices managing 700 current children with RRP. A total of 150 (21%) of these patients presently receive adjuvant medical therapies with cidofovir and interferon, accounting for more than two thirds of the total. Sixty-one percent of patients treated with cidofovir have experienced a beneficial response. Distal spread of RRP has occurred in 94 (13%) of the 700 patients. Half of the practices surveyed have experienced a death from RRP, with 89% of deaths directly related to RRP. The laryngeal microdebrider (53%) has supplanted the carbon dioxide laser (42%) as the preferred means of surgically removing papilloma from the larynx in children. Spontaneous, apneic, and jet ventilation (88%) anesthesia techniques have replaced the use of laser-safe endotracheal tubes (10%) as the preferred anesthetic management. Routine human papillomavirus subtyping is practiced by 45% of respondents while 15% treat all their patients with antireflux medications. Half of respondents send lesions for histologic examination only if there is a change in growth pattern while one third send lesions with every surgery. CONCLUSIONS: Recurrent respiratory papilloma continues to be a frustrating disease to treat and is associated with significant morbidity and mortality. There has been an evolution in the past decade toward the increased use of antiviral adjuvant therapy and the use of microdebrider techniques for surgical management.

Antineoplastic Agents↗
PubMed2004

Analysis of a staging assessment system for prediction of surgical interval in recurrent respiratory papillomatosis.

INTRODUCTION: A staging system for assessment of recurrent respiratory papillomatosis (RRP) has been in use over the last 3 years for 17 patients at our children's hospital. OBJECTIVE: To evaluate a staging system for assessment of RRP on the basis of the predictive value on the surgical interval of: anatomic staging system score, urgency of intervention, voice quality, and stridor. To assess effect on surgical interval of the age of patient at time of surgery and use of adjuvant therapy. To develop a model based on the staging criteria to predict need for adjuvant therapy. DESIGN: Validation cohort. SETTING: Academic children's hospital. RESULTS: Estimated time to surgery decreased by "x days": "independent variable" "(95% CI)" as follows. Four days: each 1 point in total anatomical score (0.2, 8); 120 days: total anatomical score >20 (37,203); 143 days: urgent versus scheduled surgery (42, 243); 100 days: aphonic versus normal voice (-211, 343); 31 days: abnormal versus normal voice (-281, 343); 125 days: stridor at rest versus no stridor (-31, 281); 109 days: stridor with activity versus no stridor (19, 198); 26 days: each 1 year decrease in age (22, 30). Adjuvant therapy delays next surgery by 32 days (-4, 69) and average scores decreased while on adjuvant therapy. CONCLUSIONS: Elements of our proposed staging system are effective in prediction of surgical interval with statistical significance achieved for total anatomical scores, urgency of intervention and stridor with activity versus no stridor. This study is pilot in nature and provides a framework upon which future studies can be based. The analysis of a larger, more severity diverse population could yield results which lead to a model capable of effectively predicting future surgical interval based on a weighted prediction score calculated from age, comorbidities, anatomic staging score, and clinical staging score.

Child↗
PubMed2004

Multicenter initiative seeking critical genes in respiratory papillomatosis.

OBJECTIVES: To determine the host genes that govern susceptibility to recurrent respiratory papillomatosis (RRP). RRP is caused by human papillomavirus (HPV) 6 and 11. Millions of babies are exposed during the birthing process, but relatively few develop the disease and the aggressiveness of the course is highly variable. Genetically encoded host susceptibility is postulated. Determining the host genes that govern susceptibility will enhance our understanding not only of RRP but also of host-viral interaction in general. STUDY DESIGN: A genome-wide association study on familial triads consisting of an RRP-affected child and his or her parents. Using the HapMap data from the human genome project, we will identify those alleles that are over-transmitted by the parents to their affected offspring as compared to those alleles that are under-transmitted. METHODS: Approximately 400 patients and their parents will be recruited through a collaboration between the Center for Genomic Sciences and the RRP Task Force. DNA will be extracted from blood specimens and viral typing will be performed on biopsy specimens. Patients will be genotyped using single nucleotide polymorphism (SNP) markers and compared to their respective parents' genotype using the transmission disequilibrium test. Both a genome scan and a candidate gene approach will be utilized. RESULTS Institutional Review Board authorization has been obtained at three hospitals and the process is underway at 18 more. Patient and parent recruitment has begun. Specimens have been forwarded to Pittsburgh, Pennsylvania, where the DNA has been extracted and is being stored. CONCLUSIONS: A novel approach combining a nationwide patient resource and the mapping power of the sub-centimorgan human haplotype map has been developed to elucidate the biological mechanisms of RRP by determining the genetically encoded susceptibilities of host-virus interaction.

Child↗
PubMed2004

Impact of pneumococcal polysaccharide vaccine (Prevnar) on middle ear fluid in children undergoing tympanostomy tube insertion.

OBJECTIVES: The purpose of this study was to describe the bacteriology of middle ear effusions in children who have received the pneumococcal polysaccharide vaccine (Prevnar) compared with unvaccinated children. METHODS: A prospective review of medical records from July 2001 to July 2002 was conducted on children with middle ear effusion at time of tympanostomy tube insertion. Middle ear fluid was plated onto culture media immediately after acquisition, and antimicrobial resistance of cultured organisms along with serotyping of Streptococcus pneumoniae was examined. Vaccination status, demographics, and risk factors were determined from patients' medical records, parent interviews, or contact with their primary care physicians. RESULTS: After adjusting for age and number of previous infections, children vaccinated with Prevnar are two times less likely to have non-S. pneumoniae pathogenic bacteria isolated than children not vaccinated. Of those with growth, vaccinated children were almost three times more likely than nonvaccinated children to have the presence of H. influenzae. Vaccinated children with H. influenzae were 7.5 times less likely to have beta-lactamase producing H. influenzae than nonvaccinated children with H. influenzae. CONCLUSION: Because the incidence of S. pneumoniae was low, no inference could be made whether Prevnar decreased otitis media with effusion or recurrent acute otitis caused by the S. pneumoniae serotypes covered by the vaccine. However, vaccinated children did appear to have the unexpected benefit of having a certain level of protection to growth of typical acute otitis media pathogens.

Chi-Square Distribution↗
PubMed2003

Predictors of remission in juvenile-onset recurrent respiratory papillomatosis.

OBJECTIVE: To determine factors associated with remission of juvenile-onset recurrent respiratory papillomatosis (JORRP). DESIGN: Longitudinal study. SETTING: Twenty-two tertiary care centers located across the United States. STUDY PARTICIPANTS AND METHODS: The study included 165 patients diagnosed as having JORRP between January 1, 1997, and December 31, 2000. Kaplan-Meier curves and Cox proportional hazards models were used to determine associations between predictors and remission. INTERVENTIONS: Surgical excision and drug therapy. MAIN OUTCOME MEASURES: Remission of JORRP, defined as no surgical procedures for at least 1 year, as associated with age at diagnosis, drug therapy in the first year after diagnosis, number of surgical procedures in the first year after diagnosis, and number of anatomical sites of disease at diagnosis. Demographic factors (sex and race) and Medicaid status were also evaluated. RESULTS: Older age at diagnosis was positively associated with remission of JORRP (hazards ratio for every increase of 1 year in age, 1.13; 95% confidence interval, 1.03-1.23). CONCLUSIONS: Younger children were found to have persistent disease and often underwent an increased number of surgical procedures in the first year after diagnosis of JORRP. Sex and race were not important factors in determining remission.

Age Distribution↗
PubMed2003

National registry for juvenile-onset recurrent respiratory papillomatosis.

BACKGROUND: Juvenile-onset recurrent respiratory papillomatosis (JORRP) is an infrequent but debilitating disease. Because JORRP is uncommon, it has proven difficult for studies at single institutions to accurately evaluate its natural history. OBJECTIVE: To characterize the clinical spectrum of JORRP. DESIGN: Standardized retrospective and prospective medical record abstraction. SETTING: Twenty-two tertiary-care pediatric otolaryngology centers throughout the United States. Patients All patients with JORRP younger than 18 years seen between January 1, 1996, and March 31, 2002. MAIN OUTCOME MEASURES: Demographics, age at diagnosis, anatomic sites of disease, longitudinal disease course, frequency of surgery, need for tracheotomy, and medication history. RESULTS: The registry includes 603 children. The mean age at diagnosis was 4.0 years. The children underwent a mean of 5.1 surgeries annually. Current age, rather than age at diagnosis, was the primary determinant of surgical frequency. The larynx was involved at the time of diagnosis in 96.1% of children, and 87.4% had only 1 anatomic site involved. Children with 1 site involved were significantly older at diagnosis (mean age, 3.9 years) than those with 2 sites (mean age, 2.9 years). Most (74.2%) had stable disease over time, 5.8% showed progression of papillomas to new sites, and 17.9% had no evidence of disease for at least 1 year. Children with disease progression were diagnosed at a significantly younger age than those who remained stable or became disease-free. Children who required tracheotomy were significantly more likely to have progressive disease. CONCLUSIONS: The registry has established the clinical course of JORRP in a large sample representative of the United States. Young age was the most important determinant of disease severity (frequency of surgery, extent of disease at diagnosis, and progression of disease). Addressing questions of pathogenesis and disease course will require a revised data collection instrument and molecular analysis of tissues.

Adolescent↗
PubMed2003

Diagnosis and management of pulmonary metastasis from recurrent respiratory papillomatosis.

OBJECTIVE: We sought to review the current and proposed management, as well as bring about discussion, of managing the patient with distal tracheal and pulmonary parenchymal involvement by recurrent respiratory papillomatosis (RRP). DESIGN, SETTING, AND PATIENTS: We conducted a review of 6 patients with pulmonary metastasis from RRP at 3 academic tertiary care hospitals. Interventions included surgical and medical management with antiviral, chemotherapeutic, and/or immune-modulating agents. RESULTS: Although treatment with alpha-2-beta interferon, isotretinoin, and methotrexate have not proved to eradicate pulmonary involvement by RRP, possible epithelial stabilization and slowing of disease progression are noted. CONCLUSIONS: The rates of distal tracheal and pulmonary metastasis as seen in our cohort were higher than previously reported. Approximately 12% of our patients with RRP have distal tracheal spread and as many as 7% of all patients with RRP at our institutions have pulmonary dissemination. Also, high suspicion for malignant conversion to squamous carcinoma in the patient with pulmonary spread should be maintained. In addition, aggressive treatment, although not proved to eradicate the pulmonary disease, should be undertaken due to the high morbidity and mortality associated with pulmonary dissemination of RRP in our cohort.

Adolescent↗
PubMed2003

Reliability of a staging assessment system for recurrent respiratory papillomatosis.

INTRODUCTION: A staging system for the assessment of severity of disease and response to the therapy in recurrent respiratory papillomatosis (RRP) was proposed several years ago. It includes both a subjective functional assessment of clinical parameters and an anatomic assessment of disease distribution. The anatomic score can then be used in combination with the functional score to measure an individual patient's clinical course and response to the therapy over time. In using this system, it would be of benefit to know what level of variability can be expected from one surgeon to another in the assessment of an RRP patient and the assignment of a score. DESIGN: Ten videotaped recordings of endoscopic assessments of patients with RRP were reviewed by 15 pediatric otolaryngologists and scored based on the criteria of the staging assessment system. RESULTS: Analysis was conducted for 15 raters of scoring severity over 25 sites of 10 patients. The total score is the addition of scores over the 25 sites with a score equal to or greater than 20 representing high risk. For 8/10 (80%) of the subjects, there was a complete agreement about risk categorization (low risk) and agreement by 14/15 (93%) raters for categorization of one other patient. For 9/10 (90%) of subjects, the standard errors of the mean total scores were less than 1, meaning a low variance and subsequent high reliability of the total score. CONCLUSIONS: This staging system was able to achieve agreement by 15 pediatric otolaryngologists on 9 of 10 subjects in terms of degree of severity of RRP.

Humans↗
PubMed2003

Otitis media: concepts and controversies.

PURPOSE OF REVIEW: Otitis media is the most common bacterial infection among children, accounting for as many as 30 million office visits annually. Proper treatment has become critical as offending pathogens become increasingly resistant to antibiotics and the cost of managing the disorder has exceeded 3 billion dollars per year. However, data suggest that many practitioners still struggle with the diagnosis of otitis media and often recommend medical and surgical intervention inappropriately. This article presents recent advances in the otitis media literature and an evidence-based approach to its management. RECENT FINDINGS: Recent investigations have resulted in the following findings: (1) bacterial biofilms may account for the persistence of middle ear disease; (2) there is increasing evidence that heredity and reflux are risk factors for otitis media; (3) primary care providers may be receiving poor otitis media training, leading to inadequate diagnostic skills; (4) medical and surgical therapy are of limited utility in the management of acute and recurrent acute otitis media; (5) antibiotics and steroids are of limited value in the treatment of chronic middle ear effusion; (6) delayed management of effusion may not adversely affect development in children; (7) vaccination for pneumococcus may alter the serotypes responsible for otitis media; and (8) vaccine candidates for other middle ear pathogens are under investigation. SUMMARY: Management of otitis media is constantly evolving, based on research from a variety of medical subspecialties. It is incumbent on the otolaryngologist and primary care providers treating otitis media to keep pace with and synthesize these findings into a rational approach to treatment.

Humans↗
PubMed2002

Anesthetic complications of tympanostomy tube placement in children.

OBJECTIVE: To determine the incidence of perioperative anesthesia complications during bilateral myringotomy with tympanostomy tube placement (BMTT). SETTING: Tertiary care children's hospital where otolaryngology attending physicians and residents performed surgical procedures. Anesthesia providers included pediatric anesthesiologists, residents, nurse anesthetists, and students. METHODS: Medical record review was performed for a consecutive series of 3198 children undergoing BMTT (1000 prospectively, 2198 retrospectively). For the prospectively studied patients, major adverse events, which included laryngospasm and stridor, and minor adverse events, including upper airway obstruction, prolonged recovery, emesis, and persistent postprocedural agitation, were noted. Also recorded were the patient's American Society of Anesthesiologists (ASA) physical class status, age, concurrent medical conditions, and type of anesthesia provider. RESULTS: Fewer than 9% of prospectively studied pediatric patients experienced a minor adverse event, whereas a major event occurred in 1.9%. Eighty-one percent of the events experienced were attributable to agitation or prolonged recovery. Neither ASA status (P =.38), age (P =.15), nor type of anesthesia provider (P =.06) were significantly related to the occurrence of an adverse event. However, a child with an acute or chronic illness has 2.78 times the odds of experiencing an adverse event compared with a child with no illness (P<.001). CONCLUSIONS: Anesthesia administered for placement of tympanostomy tubes by physicians who specialize in the care of children in a tertiary care children's hospital is safe. The most significant predictor of a minor anesthetic event during BMTT is the presence of a preexisting medical condition or concurrent acute illness.

Acute Disease↗