Otolaryngology Head and Neck Surgery August 1996
Scientific Sessions - - M o n d a y
geal acid exposure c o m p a r e d with the other groups (nonrespiratory diseases, post-nissen, and random groups). Conclusions: The data suggest that extraesophageal reflux is underestimated by single probe intraesophageal monitoring alone. It also appears that 24-hour double-probe pH monitoring is the best diagnostic test available for the identification of pediatric reflux, especially when associated with airway and respiratory disorders. 10:44 AM
Discussion 10:52 AM
Pediatric Miniplates: To Remove or Not to Remove WAYNE BERRYHILL,MD (presenter), FRANK L. RIMELL, MD, and STEPHENJ. HAINES, MD, Minneapolis, Minn,
The use of miniplate rigid fixation systems in craniomaxillofacial surgery has become standard for the treatment of fractures. The use of these systems has been well documented in several fields of surgery. These systems are currently being used in the reconstruction of the pediatric calvarium. The advantages of the systems are well known; however, there is a paucity of knowledge on the complications and risks of their use. Thus far the miniplate systems have produced an excellent profile with low incidence of infection or plate exposure. Despite this record, there is currently no study to evaluate the fate of miniplates used in pediatric craniofacial surgery. Medical records of children requiring calvarium reconstruction between the years of 1986 and 1995 were included in the study. Medical records were reviewed to evaluate preoperative findings, hospital course, postoperative results, complications, and follow-up. Surgical procedure was evaluated for the type of fixation used (plate verus wire), location of fixation, number of miniplates, and number of screws.
Our study included a total of 83 procedures, including 39 fronto-orbital advancements, eight total skull reconstructions, seven bone grafts, two midface advancements, and 18 craniosynostosis corrections, performed on 67 patients. Two hundred thirty-four titanium plates and 1256 screws from three manufacturers were placed, and there were also 27 procedures involving wire and six procedures involving Acrylic. Patients ranged in age from 3 days to 16 years and averaged 3.4 years. Follow-up ranged from 1 month to 58 months and averaged 15.5 months. It has been our practice not to remove the plates unless the clinical situation dictates. Complications attributed to the titanium plates were delayed growth (5), plate migrations (2), hydrocephalus (1), palpable plates causing pain (4), fluid accumulation over plates (2), and instances of plate and screw removal as a result of the above complications (3). This study has shown that these plates have few complications overall and that they do not require removal unless clinical situations dictate otherwise.
Outcome of Gastroesophageal Reflux Therapy on Pediatric Rhinosinusitis MARCELLA R. BOTHWELL, MD (presenter), DAVID S. PARSONS, MD, ANDREW TALBOT, MD, and GUILIO BARBERO, MD, Columbia, Mo.
Objective: The objective of this study was to evaluate gastroesophageal reflux (GER) as an additional etiology for sinonasal edema and, thus, pediatric rhinosinusitis. The etiology of pediatric rhinosinusitis is multifactorial. The osteomeatal complex is blocked by sinonasal edema from recurrent URI, nasal or systemic allergy, and environmental irritants. Because chronic pediatric rhinosinusitis is so prevalent, the necessity of delineating all primary underlying etiologies must be addressed to prevent unwanted or unnecessary surgical procedures. Methods: In this study, 30 children whose initial medical evaluation was believed to be complete were determined to be surgical candidates. An extensive chart review noted the seven cardinal signs and symptoms of rhinosinusitis (nasal airway obstruction, purulent anterior rhinorrhea, post nasal drainage, cough, halitosis, headache or facial pain, and irritability). A GER evaluation was undertaken with use of one or more of the following: clinical history, DL/bronchoscopy with or without lipid laden macrophages, upper gastrointestinal series, and/or prolonged pH probe monitoring. The mean duration of GER therapy was 8.2 months. Parents were then questioned concerning the same seven signs and symptoms after treatment for GER. Results: To date, 93% of the children have avoided sinus surgery. Thirteen percent have thus far avoided sinus surgery but may progress to sinus surgery in the future because of poor response to medical management. Seventeen children showed a greater than 75% reduction in individual symptom scores. Overall, the response rate of symptom reduction to GER therapy using weighted analysis was 68%. Covariate analysis noted statistically significant values for positive pH probe (p = 0.032), day care attendance (p < 0.001), and history of Down Syndrome (p = 0.016). Allergy did not remain significant with multivariate analysis. Conclusion: The reduction in overall symptom scores clearly shows that GER contributes an etiology for pediatric rhinosinusitis. While this is a preliminary study, GER should be evaluated and treated before sinus surgical intervention. 11:08 AM The Role of Gastroesophageal Reflux in Pedlatrlc Upper Airway Disorders LUCINDA A. HALSTEAD, MD (presenter), Charleston, S.C.
Objective: Gastroesophageal reflux (GER) into the laryngopharynx causes or contributes significantly to a variety of upper respiratory problems in children. The results of pH probes, laryngeal examinations, and brochoalveolar lavage (BAL) for children with subglottic stenosis, recurrent croup, apnea, chronic cough, laryngomalacia, recurrent
Otolaryngology Head and Neck Surgery Volume 115 Number 2
choanal stenosis, vocal fold nodules, and chronic sinusitis/ otitis/bronchitis were reviewed in an effort to quantify the role of GER in each of these disorders. Methods: The pH probe and bronchoalveolar lavage resuits for 51 children, ages 2 days to 12 years, were reviewed. Children who were treated empirically for GER were excluded from this review. Two children had incomplete pH probes and were excluded from the study. Two children had two diagnoses. Results: Positive pH probes were obtained in 19 of 20 patients (95%) with subglottic stenosis, three of three patients (100%) with recurrent croup, three of four patients (75%) with laryngomalacia, one of one patients (100%) with TVC nodules, five of five patients (100%) with apnea, and five of five patients (100%) with chronic cough. BAL results were suggestive but not positive for the two patients with recurrent choanal stenosis. Five of 11 patients with chronic sinusitis/otitis/bronchitis had pH probe studies, and five of the five patients (100%) were positive. Of six patients who underwent BAL, three (50%) were positive for microaspiration of gastric contents. The majority of children treated for GER required high doses of antireflux medication to suppress acidity, as documented by repeat pH probe or empiric titration of medication. Fifty percent of children in the sinusitis/otitis/bronchitis group improved with T&A or aggressive medical management of sinusitis. GER tended to be a more important factor in the younger children in this group. Conclusions: This review suggests that GER plays a causative role in subglottic stenosis, recurrent croup, apnea, and chronic cough. It is an important inflammatory cofactor in laryngomalacia and possibly in TVC nodules and problematic recurrent choanal stenosis. GER is also an important inflammatory cofactor in chronic sinusitis/otitis/bronchitis, but may be the result of chronic illness in the older patients. Prospective pH probe studies will further elucidate the role of GER in pediatric upper airway disorders.
Scientific Sessions- - Monday
the relationship by comparing the prevalence of tympanosclerosis and tympanic membrane perforations among patients who had undergone (multiple) tube insertions and the prevalence of the TM findings in a control population with unrelenting otitis media who received neither antibiotics nor ear surgery. Methods: A multidisciplinary team of clinicians from four countries collaborated to investigate otologic and audiologic outcomes in children between 6 and 10 years of age who had a cleft palate. Investigators examined 50 children with cleft palates and 50 controls from each of the following countries: the United States, Sweden, Russia, and Ukraine. Tympanostomy tube insertion was typically performed several times in each of the children with a cleft palate in the United States, and less often but commonly in children from Sweden. In Russia and Ukraine, no children had tubes placed, otoscopes had not been available for clinical use, and children did not receive antibiotics for their otitis media. Results: Among the children with a cleft palate who were consistently afflicted with otitis media for at least 3 to 4 years, Russian and Ukrainian "ears" showed a 3% tympanosclerosis rate, Swedish ears a 33% rate, and U.S. ears a 44% rate. Chro~ic tympanic membrane perforations were seen in 1%, 3%, 8%, and 14%, respectively. Although the tympanic membranes from Russia and Sweden looked comparatively healthy, middle ear effusions that had persisted into the study years were present in approximately 36% of the Russian and Ukrainian children with a cleft palate and in only 8% of the U.S. children. Conclusions: This study suggests a strong causal relationship between tube insertion and tympanosclerosis and tympanic membrane perforation, with a relative risk associated with multiple tube insertions of approximately 10. On the other hand, the intubated children would be expected to have consistently better hearing, although the beneficial effect on hearing that persists into the study ages was modest. 11:32 AM
Discussion 11:24 AM Tympanosclerosis and Perforations Related to Tympanostomy Tubes MICHAEL D. POOLE, MD, PhD (presenter), W. N. WILLIAMS, PhD, B. SEAGLE, MD, and J. NACKASHI, MD, Houston, Tex., a n d Gainesville, Fla.
Objectives: Tympanosclerosis involving the tympanic membranes (myringosclerosis) has been anecdotally related to the prior placement of tympanostomy tubes. However, tympanosclerosis can be observed in patients who have never undergone myringotomy or tube placement, and a number of clinicians have suggested that the tympanosclerosis is related to the otitis media that led to tube insertion as opposed to the tube insertion itself. This study demonstrates
Airway Management in Pierre Robin Sequence CHARLES M. MYER III, MD (presenter), J. MARK REED, MD, ROBIN T. COTION, MD, a n d J. PAUL WILLGING, MD, Cincinnati, Ohio, a n d Jackson, Miss.
Objective: There is a great deal of controversy regarding the long-term management of airway obstruction in children with Pierre Robin sequence (PRS). This study surveys pediatric otolaryngology fellowship training programs to determine their current practice patterns. Methods: All 23 pediatric otolaryngology fellowship training programs were surveyed to determine their current practice patterns regarding airway management in children with PRS. There was a 100% response rate. Issues that were addressed included methods of evaluation of airway obstruction, choices for home care in children who fail observation and positioning, and complications of various treatment modalities. Result: The lack of unanimity among the respondents