Interpolation with the nucleus 22 Cochlear Implant.
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Child, Preschool↗
Biomedical subjects
R R Marsh
Publications and source records attributed to R R Marsh.
Pediatric audiologists' views on cochlear implantation.
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Adult↗
Congenital airway abnormalities in patients requiring hospitalization.
OBJECTIVE: To determine the cause of congenital airway abnormalities in pediatric patients requiring hospitalization for their respiratory status. DESIGN AND SETTING: Case series in a tertiary care center. PATIENTS: A 5-year retrospective chart review was conducted at our institution. A total of 174 patients were identified who required hospitalization for their respiratory status as a result of a congenital airway abnormality. RESULTS: Of the 174 patients, 114 (65.5%) were male and 60 (34.5%) were female. Eighty patients (47%) presented within the first 3 months of life. Forty-six patients (26%) were born prematurely, and 49 patients (28%) were diagnosed as having gastroesophageal reflux. The majority of patients (139 [80%]) had multiple presenting symptoms or signs. Stridor was the most common (129 [74%]), followed by accessory respiratory effort, cyanosis, apnea, and failure to thrive. Diagnosis was made at the time of surgical evaluation in 91% of the patients, with the remaining diagnoses made using radiological findings and/or clinical evaluation. Sixty-five patients (37%) had multiple sites of airway abnormalities; laryngeal abnormalities were noted almost 3 times as often as tracheal abnormalities (161 vs 62, respectively). Of the laryngeal abnormalities, laryngomalacia was the most common, followed by glottic web, subglottic stenosis, vocal-cord paralysis, and subglottic hemangioma. Tracheomalacia was the most common tracheal abnormality, followed by external compression and tracheal stenosis. Thirty-three patients (19%) required tracheotomy for management of recurrent respiratory decompensation. CONCLUSIONS: While congenital airway abnormalities are usually self-limited, those patients requiring hospitalization represent a group with a more severe respiratory status who have a greater chance of requiring tracheotomy. The recognizable percentage of patients with gastroesophageal reflux and prematurity accounts for comorbid factors in the need for hospitalization for respiratory issues related to congenital airway abnormalities.
Age Distribution↗
Pediatric tracheostomy: a changing procedure?
In 1982, the experience with tracheostomy at The Children's Hospital of Philadelphia was reported for 1971 through 1980. We have now reviewed 450 cases for the period from 1981 through 1992, and compared the characteristics of these cases with those in the previous review. Long-term follow-up was available on 83% of cases, and the median follow-up was 2.96 years. Patients received a tracheostomy for airway obstruction (38%), chronic ventilation (53%), or multiple indications (9%). The mean duration of tracheotomy (adjusted for death and loss to follow-up) was 2.13 years. The tracheostomy-related mortality was 0.5%, and the nontracheostomy-related mortality was 22%. Nineteen percent of patients had complications in the first postoperative week, and 58% had 1 or more late complications. In comparison with the previous study from our institution, there was a great increase in long-term tracheostomy and a continuing trend away from tracheostomy for short-term airway management. Better monitoring and improvements in parental teaching may have contributed to a decrease in tracheostomy-related mortality.
Adolescent↗
Conditional Length of Stay.
OBJECTIVE: To develop and test a new outcome measure, Conditional Length of Stay (CLOS), to assess hospital performance when deaths are rare and complication data are not available. DATA SOURCES: The 1991 and 1992 MedisGroups National Comparative Data Base. STUDY DESIGN: We use engineering reliability theory traditionally applied to estimate mechanical failure rates to construct a CLOS measure. Specifically, we use the Hollander-Proschan statistic to test if LOS distributions display an "extended" pattern of decreasing hazards after a transition point, suggesting that "the longer a patient has stayed in the hospital, the longer a patient will likely stay in the hospital" versus an alternative possibility that "the longer a patient has stayed in the hospital, the faster a patient will likely be discharged from the hospital." DATA COLLECTION/EXTRACTION METHODS: Abstracted records from 7,777 pediatric pneumonia cases and 3,413 pediatric appendectomy cases were available for analysis. PRINCIPAL FINDINGS: For both conditions, the Hollander-Proschan statistic strongly displays an "extended" pattern of LOS by day 3 (p<.0001) associated with declining rates of discharge. This extended pattern coincides with increasing patient complication rates. Worse admission severity and chronic disease contribute to lower rates of discharge after day 3. CONCLUSIONS: Patient stays tend to become prolonged after complications. By studying CLOS, one can determine when the rate of hospital discharge begins to diminish--without the need to directly observe complications. Policymakers looking for an objective outcome measure may find that CLOS aids in the analysis of a hospital's management of complicated patients without requiring complication data, thereby facilitating analyses concerning the management of patients whose care has become complicated.
Appendectomy↗
Congenital airway abnormalities requiring tracheotomy: a profile of 56 patients and their diagnoses over a 9 year period.
We reviewed the 9 year experience at the Children's Hospital of Philadelphia with patients requiring tracheotomy for a diagnosis of congenital airway abnormalities. Of the 56 patients, 28 (50%) had cardiovascular, or chromosomal abnormalities, neurologic conditions, or congenital syndromes, 24 (43%) were born prematurely, and 13 (23%) were found to have gastroesophageal reflux. Only 18 (32%) went on to eventual decannulation of their tracheotomy with a mean tracheotomy duration of 1.75 years. The majority of patients (75%) had multiple presenting signs. Stridor was the most common (54%), followed by accessory respiratory effort (39%), cyanosis (30%), apnea (29%), and failure to thrive (23%). Twenty eight patients (50%) had multiple airway abnormalities contributing to their need of a tracheotomy for airway protection orr ventilator dependence. Laryngeal abnormalities were found in 71% of patients, tracheal abnormalities in 48% of patients, bronchial abnormalities in 11%, and upper airway obstruction in 14%. Of the laryngeal abnormalities, laryngomalacia was the most common, followed by subglottic stenosis, glottic web, and vocal cord paralysis. Tracheomalacia was the most common tracheal abnormality. The relatively large percentage of patients with cardiovascular or other major malformations, and prematurity, accounts for comorbid factors in the need for prolonged tracheotomy (and low early decannulation rate). Although gastroesophageal reflux was found in a recognizable portion off the patients, it is unclear whether this represents a comorbid condition.
Abnormalities, Multiple↗
Dexamethasone in adenotonsillectomy.
Edema contributes substantially to the postoperative discomfort and morbidity of adenotonsillectomy. In a double-blind study, 58 children undergoing adenotonsillectomy were given a single intraoperative dose of either dexamethasone or saline. The steroid markedly affected the postoperative course in the first day after surgery. According to parental reports, the percentage of patients vomiting was reduced from 48 to 4%. Severe throat pain was reported in 57% of controls and only 20% of dexamethasone patients. Twice as many steroid patients as controls tolerated some soft food on the first postoperative day. It appears that dexamethasone can greatly improve patient diet and comfort after adenotonsillectomy.
Adenoidectomy↗
Tympanoplasty for the anterior-superior perforation in children.
Anterior-superior perforations of the tympanic membrane have proven more difficult to repair than other perforations, and many investigators have found such repairs to be problematic. We report a technique in which the tympanic membrane is released from the malleus, and the graft is placed medical to the remnant, lateral to the malleus, and medial to the tympanomeatal flap. In a series of 42 cases the short-term surgical success rate (represented by an intact graft at 6 months) was 98%, with 95% of ears remaining free of reperforation to the end of follow-up. Postoperatively, 90% of children had an air-bone gap of 20 dB or less and 100% of children had an air-bone gap of 30 dB or less. Eighty-seven percent of subjects demonstrated a speech reception threshold (SRT) of 20 dB or better, whereas 100% of subjects demonstrated an SRT of 30 dB or better. These results compare favorably with those reported at this institution for repair of perforations of any quadrant in children, and those of other investigators for anterior superior perforations in adults.
Adolescent↗
Type 1 tympanoplasty in children.
OBJECTIVE: To identify factors affecting the surgical success rate and reperforation rate in type 1 tympanoplasty. Controversy continues regarding the advisability of this procedure in young children, largely because of the likelihood of recurrent middle ear disease and eustachian tube dysfunction. DESIGN: Retrospective medical record review of a case series. SETTING: Pediatric hospital that serves both as a primary care and referral center. PATIENTS: All private patients younger than 18 years, undergoing type 1 tympanoplasty from 1985 through 1989, for whom at least 6 months' follow-up was available. Two hundred nine tympanoplasties on 183 patients were included; 22 patients were excluded for insufficient follow-up. MAIN OUTCOME MEASURES: Surgical success was defined by confirmation of an intact tympanic membrane at least 6 months postoperatively. Procedures were deemed long-term successes if the tympanic membrane remained free of perforation to the end of follow-up. RESULTS: The overall short-term surgical success rate was 92%, with 87% of ears remaining free of reperforation to the end of follow-up. If the perforation involved the margin, the surgical success and long-term success rates dropped to 86% and 77%, respectively. Although reperforation was more likely in patients younger than 6 years or in those with contralateral otitis media at surgery, even these groups had long-term success rates of 81% and 74%, respectively. CONCLUSIONS: Tympanoplasty may be considered at any age. Even in young children, there is a high likelihood of return to normal function.
Adolescent↗
Infant salt taste: developmental, methodological, and contextual factors.
Two studies investigated the human infant's response to salt during development. In the first study, measures of intake and sucking were obtained from two groups of infants, newborns and 4- to 8-month-olds, in response to brief presentations of two concentrations of salt (0.2 or 0.4 M) and water. For several measures of sucking and for intake, there were significant age and concentration effects. Generally, newborn infants tended to reject saline relative to water more than did 4- to 8-month-old infants. This result, consistent with previously published research, suggests a developmental change in salt acceptability and, probably, sensitivity in the human infant. In the second longitudinal study, the response to salted (0.15 M) versus unsalted formulas was evaluated monthly in infants 2 to 7 months of age. Again, a developmental change was observed: Based on some sucking measures, younger infants appeared to be indifferent to the salted formula relative to the unsalted formula whereas older infants tended to reject the salted formula, presumably because either it was less sweet than the unsalted formulas or because it was novel. These data are consistent with the hypothesis developed from animal model studies that during early human postnatal development, transductive elements sensitive to saltiness mature.
Dose-Response Relationship, Drug↗
Total and partial ossicular replacement prostheses in children.
Although ossicular reconstruction in children may carry a risk of failure because of recurrent middle ear disease, the procedure offers the potential for restoring binaural hearing during the school years when it is so critical. Of a series of 45 reconstructions with total and partial ossicular replacement prostheses, 6 were extruded for a surgical success rate of 87%. Of the successful cases, 74% had air-bone gaps of 30 dB or better, and 74% had speech reception thresholds of 30 dB or better on initial postoperative audiogram. Outcomes for these children were comparable with those reported for adults, supporting the value of early reconstruction.
Child↗
Effect of anesthetic gas on middle ear fluid.
Tympanometry was performed before (preoperative) and after (intraoperative) the administration of inhalation anesthesia including nitrous oxide and halothane on 109 children undergoing myringotomy with pressure equalization tube insertion. A total of 213 preoperative tympanograms were compared with their intraoperative counterparts and the presence or absence of middle ear effusion at myringotomy. When preoperative tympanograms were consistent with pneumatized middle ears, intraoperative findings demonstrated a mean middle ear pressure increase of +147 daPa. When preoperative tympanometry suggested middle ear effusion, less than 1% demonstrated intraoperative tympanometric changes and/or findings at surgery that would support anesthesia clearing middle ear effusion. Preoperative tympanometric data were poor predictors of the presence or absence of effusion at myringotomy. The relationship between inhalation anesthetics (i.e., nitrous oxide and halothane) and middle ear fluids, and the reliability of tympanometry to predict middle ear effusion are discussed.
Acoustic Impedance Tests↗
Childhood epiglottitis in recent years.
Fifty-five cases of acute epiglottitis were diagnosed and treated at the Children's Hospital of Philadelphia between 1985 and 1991. To evaluate the changing patterns of the disease over recent years, we compared the current results with those obtained from an earlier study reported at our institution in 1979. The overall annual incidence was higher in recent years than in the earlier study, with a sharp decline in new cases over the last two years. Thirty-six percent of the Hemophilus influenzae type B (HIB) infections were ampicillin-resistant in recent years, while no resistance had been found in the past. Twenty-seven percent of the cases were vaccine failures, all before 1990. Endotracheal intubation was the sole method for upper airway maintenance, while in the past 31% of the children underwent a tracheotomy. No mortality or long-term complications were found in either study.
Acute Disease↗
Concurrent right and left ear auditory brain stem response recording.
In auditory brain stem response testing, it is often advantageous to record the responses to right and left ear stimulation quickly. A method is described in which both ears are tested concurrently, each ear at a slightly different stimulus rate. With appropriate temporal parameters, the response of each ear can be recorded without contamination by the contralateral ear's response. When both ears were tested at the same intensity, either 40 or 70 dB nHL, there was little attenuation of wave V. When one ear was stimulated at 80 dB nHL, the response of the other ear at intensities down to 40 dB was not seriously affected; the response at 20 dB nHL was, however, so diminished by contralateral stimulation at 80 dB that binaural testing would save no time. This method has promise for intraoperative monitoring and infant screening, and could be used in threshold determination if the stimulus intensities for the two ears are not too dissimilar.
Acoustic Stimulation↗
Usefulness of computed tomographic scan in the evaluation of sensorineural hearing loss in children.
A retrospective chart study was conducted to determine the diagnostic yield of temporal bone imaging for children with sensorineural hearing loss of unknown cause. Seventy consecutive cases, spanning 4.5 years, were identified and individual computed tomography films reviewed. Cases were analyzed with respect to patients' age, duration of hearing loss, sudden onset vs progressive loss, unilateral vs bilateral, and other symptoms. Of the 70 computed tomographic scans, nine showed temporal bone or other intracranial abnormalities. The majority of these findings were localized to structures in the posterior and middle cranial fossae. No eight nerve tumors were identified. Congenital hearing loss and hearing loss secondary to viral infections are the most common cause of sensorineural hearing loss when discovered in early childhood and, often, have no radiographic abnormality. The decision to explore an ear for a presumed perilymph fistula is based almost exclusively on the history and physical examination, and not on the demonstration of any radiographic findings. For the children presenting with stable hearing impairment in the absence of other findings, computed tomographic scans were either negative or did not contribute to diagnosis. Since tumors of the eighth nerve are rare in children under 16 years of age (without neurofibromatosis), and radiologic studies have a low yield in identifying perilymph fistulas, the routine use of computed tomographic imaging in such children may be unjustified.
Adolescent↗
Signal to noise constraints on maximum length sequence auditory brain stem responses.
In conventional auditory brain stem response (ABR) testing, the stimulus rate must be low enough that the responses do not overlap. By using stimulus patterns derived from the pseudorandom binary series known as maximum length sequences (MLSs), it is possible to stimulate at mean rates of hundreds of clicks per second, and extract the responses. It has been suggested that this could reduce test time appreciably, but there is reason to believe that the MLS ABR is intrinsically noisier than conventional averaging. To test this premise, 10 ears were tested with conventional ABR procedures and with MLS ABRs having 2, 4, and 8 times as many stimuli per second as the conventional condition. Noise levels in control runs were in agreement with predictions. With a 40 dB nHL stimulus, wave V amplitude decreased in the MLS ABRs to the extent that none of the MLS conditions was as efficient as the conventional ABR. Any assessment of the value of MLS ABRs in reducing test time must take into consideration the higher noise levels inherent in this procedure.
Acoustic Stimulation↗
The auditory brain stem response recorded with 60 Hz notch filters.
Line-frequency (60 Hz in the USA) interference is a common source of contamination during recording of the auditory brain stem response (ABR). Notch filters are undeniably effective in eliminating this artifact, but concerns have been expressed as to their effect on the ABR itself. Theoretical considerations suggest that the degree of distortion should be minimal if the filter is sufficiently sharp and the stimulus rate has no multiples very close to 60 Hz. Responses simultaneously recorded through three notch filters of varying sharpness confirmed this: Latency was virtually unaffected with any filter or stimulus rate, and distortion was minimal when a sharply tuned filter was used in conjunction with a stimulus rate of 23.3 Hz, whose nearest harmonic to 60 is 69.9 Hz.
Acoustics↗
Developmental patterns of normal nutritive sucking in infants.
The purpose of this investigation was to quantify normal nutritive sucking, using a microcomputer-based instrument which replicated the infant's customary bottle-feeding routine. 86 feeding sessions were recorded from infants ranging between 1.5 and 11.5 months of age. Suck height, suck area and percentage of time spent sucking were unrelated to age. Volume per suck declined with age, as did intersuck interval, which corresponded to a more rapid sucking rate. This meant that volume per minute of sucking time was fairly constant. The apparatus provided an objective description of the patterns of normal nutritive sucking in infants to which abnormal sucking patterns may be compared.
Age Factors↗