Search

Introduction: Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation., Objective: Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy., Methods: Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method., Results: Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: CONCLUSION: This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Pediatric tracheostomy is performed in a variety of complex, comorbid patients. Tracheostomy involves a significant burden of care for families and a risk of life-threatening complications. There is little research regarding the ideal location and protocol for safe tracheostomy decannulation. This study aims to determine patient factors that may be predictive of trial of tracheostomy decannulation being able to take place safely outside of the intensive care setting., Methods: A 10-year retrospective review of all decannulation trials at our institution is used to assess for patient factors associated with a higher risk of decannulation failure. The timing of failure and the interventions required to secure the patient's airway are reviewed. This data is used to inform recommendations regarding location of tracheostomy decannulation trial and length of inpatient stay, aiming to rationalize the use of resources while maintaining safe tracheostomy decannulation practices., Results: One hundred and fifty-eight decannulation events occurred in 131 children over the study period, resulting in 132 successful decannulations (83.5%). Twenty-six failed episodes (16.5%) occurred in 16 patients (12.2%). Ten of these patients were successful on a second decannulation attempt and six had two or more failed decannulation attempts (4.6%). Failed decannulation was higher in patients with upper airway obstruction as the indication for tracheostomy (20.3% failure rate versus 0%). History of prematurity was significantly associated with failure of decannulation. Nine decannulation failures occurred immediately, with a further 9 failures occurring within the first 24 hours. A further 3 failures occurred in hospital and 5 following discharge. No mortality or significant morbidity occurred during any decannulation trial., Conclusions: Our study identified a higher rate of decannulation failure in patients with upper airway obstruction, suggesting that decannulation trials for this subgroup should occur in the intensive care unit. Patients with tracheostomy for other indications may be safe to decannulate in a ward setting. Early failures demonstrated more rapid deterioration. Further research is recommended on the utilization of capping trials or polysomnography prior to decannulation to help guide the ideal location and timing for trial decannulation., Competing Interests: Declaration of competing interest No conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: This retrospective study reviews the clinical presentation and management of children with airway FBs in our centre. It suggests a safe and reliable guideline to help differentiate which patients should proceed to investigation with rigid laryngobronchoscopy., Methods: A retrospective review of all case notes of laryngobronchoscopies performed for suspected FB aspiration from January 2003 to August 2013 at a tertiary paediatric institution was undertaken. Patient characteristics, history, clinical examination, radiological findings and outcomes were analysed., Results: 158 patients underwent rigid laryngobronchoscopy for suspected FB aspiration between January 2003 and August 2013. The baseline population demographics, the location and type of FBs retrieved were comparable to other similar studies; however, there is a statistically significant higher proportion of Pacific, Maori and Middle Eastern/Latin American/African children compared with the baseline population. Two or more positive findings in the presence of an acute history, any examination or radiology findings is a good indicator to proceed to laryngobronchoscopy with over 99% sensitivity., Conclusion: In a hospital presentation population, this retrospective study suggests that a guideline to proceed to laryngobronchoscopy in a case of suspected FB aspiration is two out of the three positive findings in the presence of an acute history, any examination or radiology findings. Patients who are stable and who do not have two of the three broad category findings can be considered for conservative management and observed on the ward, however, this is a guideline and must be combined with the clinical expertise of the paediatric airway specialist. Further studies are recommended to investigate contributing factors for the disproportionately higher incidence amongst Pacific, Maori and Middle Eastern/Latin American/African children., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Unlabelled: Optimal management of deep neck abscesses has been the subject of debate for more than a century: surgical drainage has been the mainstay of treatment, but recently many centres have reported successful non-operative management in selected cases., Objectives: Our objective was to review the management of deep neck abscesses in our institution and to identify characteristics that would predict successful non-operative management., Methods: A retrospective chart review from January 2001 to August 2010 was performed. Children up to age fifteen years with a CT-confirmed diagnosis of retropharyngeal or parapharyngeal abscess were included. A case-control study of small deep space neck abscesses (≤ 25 mm maximal diameter) was performed, comparing antibiotic treatment alone with antibiotics plus abscess drainage., Results: 54 children met the inclusion criteria, of whom half had abscesses ≤ 25 mm diameter. Younger children within the group with smaller abscesses were more likely to need surgical drainage (p<0.05). Of 13 children requiring operative management, ten underwent a period of antibiotic treatment and observation prior to surgery, eight (80%) had fever beyond 48 h compared with three (23%) in the non-surgical group (p<0.01). 27 children had an abscess > 25 mm diameter on CT scan, four (15%) of whom responded quickly to antibiotics and were managed non-operatively, while the rest underwent surgery. There were no significant differences between the surgical and non-surgical group characteristics with larger abscesses., Conclusion: High dose intravenous antibiotics are an effective treatment for deep space neck abscesses and may obviate the need for surgical drainage, particularly in smaller abscesses. Children who do not respond quickly to antibiotics are more likely to require surgery to achieve resolution. Children with larger abscesses may respond to antibiotic therapy alone but should be closely observed. A trial of high dose intravenous antibiotics in stable children with close observation is warranted as first line treatment, especially for small deep space neck abscesses., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: The congenital myasthenic syndromes (CMS) are a group of genetic disorders of neuromuscular transmission causing fatigable weakness. Symptoms may be present from birth, but diagnosis is often delayed for several years, notably in post-synaptic CMS due to mutations in the DOK7 gene. Recently, we noted a subgroup of children with CMS in whom congenital stridor and bilateral vocal cord palsy predated other symptoms. All had mutations in the DOK7 gene. The purpose of this study was to review our population of DOK7 CMS patients with congenital stridor and assess whether there were other phenotypic features which might raise suspicion of a diagnosis of CMS in the neonatal period, in the absence of limb weakness and ptosis and prompt earlier referral for neurophysiological investigation, genetic diagnosis and appropriate treatment., Methods: A retrospective case review of 11 DOK7 CMS patients at a tertiary referral centre., Results: Six patients were identified with DOK7 mutations and congenital stridor, four requiring intubation soon after birth. Four patients had a diagnosis of bilateral vocal cord palsy and three required tracheostomy, successfully decannulated in one after 3 years. All six patients had difficulty with feeding, with weak suck and swallow necessitating nasogastric feeding in five, two of whom required gastrostomy. Despite all six children having had neonatal symptoms, the mean age at CMS diagnosis was 5 years and 9 months., Conclusion: CMS, particularly caused by mutations in the DOK7 gene, is a rare but treatable cause of congenital stridor in the neonate. A combination of congenital stridor, especially with an apparently idiopathic bilateral vocal cord palsy and weak suck and swallow should alert the clinician to the possibility of CMS and prompt early referral for neurophysiology and genetic investigations. Confirmation of a CMS diagnosis enables treatment to be initiated, informed management of the VCP and anticipation of myasthenic symptoms, particularly life-threatening respiratory decompensation. Treatment may allow early decannulation or possible avoidance of tracheostomy. At least 12 genes are known to cause CMS; the presence of congenital stridor may help target genetic diagnosis., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Subglottic haemangioma is a rare but potentially life threatening condition which requires intervention. Many different treatments have been described with varying degrees of success and complications. Recently, successful treatment with propranolol has been reported in 11 cases of cutaneous haemangiomas and then in two cases of subglottic haemangiomas with extensive cutaneous lesions in conjunction with other treatment modalities. We describe the successful treatment with propranolol, of a stridulous four-month-old child with a 95% obstructing subglottic haemangioma. This was achieved without the need for tracheostomy or any other surgical intervention, and with no reported side effects. We now believe the new discovery of a dramatic response to propranolol allows treatment in the acute setting and following further study may render surgical treatment of subglottic haemangioma obsolete.

Objective: To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987-2003., Methods: A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies., Results: A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n=40, and subglottic stenosis, n=18) was the most common indication for surgery (n=86; 70%) with a lesser number (n=36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% (n=62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%) died from tracheotomy-related complications, with an overall mortality rate of 14%., Conclusions: Pediatric tracheotomies performed at Starship Children's Hospital between 1987 and 2003 were associated with a low incidence of procedure-related mortality and morbidity and successful decannulation in most cases. The majority of procedures were performed to treat upper airway obstruction, most commonly caused by craniofacial dysmorphism or subglottic stenosis.

Objective: There is a controversy about day stay pediatric tonsillectomy in the UK and Australia. New Zealand has a similar health structure and we wished to compare day stay tonsillectomy from our hospital with those reported from other centers., Methods: We performed a prospective audit of day stay tonsillectomy to determine conversion to hospital admission rate and the incidence of postoperative hemorrhage., Results: There were 4850 paediatric tonsillectomies performed with 80% of them as day stay procedures over a 9-year study period (1993-2002) in a university-affiliated tertiary children's hospital. The primary postoperative hemorrhage rate (within 24h of surgery) was 0.9% (CI 0.68-1.22%) and 83% occurred within the mandatory 4h postoperative observation period. Primary hemorrhage requiring re-operation to achieve hemostasis occurred in 18 children (0.37%, CI 0.2-0.54%). No child with a primary hemorrhage who presented after discharge following day stay surgery required re-operation or blood transfusion. Day stay surgery was planned in 4041 children and 4.7% (CI 4.1-5.4%) required conversion to hospital admission. Postoperative vomiting was the most common indication for conversion (2.65%, CI 2.2-3.1%), while hemorrhage contributed only 0.95% (CI 0.64-1.24%)., Conclusions: This study was performed in a health system similar to that of Australia and the UK. Complication and conversion rates are similar to those reported in North American centers. Pediatric day stay tonsillectomy is a safe procedure when performed with strict preoperative criteria, trained day stay unit (DSU) staff, and with in-patient facilities on site.