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BACKGROUND: Tracheostomy wounds are commonly encountered in children but rarely reported. Relatively few treatments are available or have been investigated to manage this problem. Healing times for pediatric tracheostomy wounds are often unpredictable and protracted. Recent use of maltodextrin gel (MD) and a silver alginate sponge (AG) at our institution has demonstrated expedited healing and interest in this novel treatment for tracheostomy wounds. METHODS: We conducted an 11-month retrospective review of children with wound complications following tracheostomy placement at a tertiary care facility. Wounds were evaluated and rated based upon the National Pressure Ulcer Advisory Panel staging system. Subjects identified with stage 2 or greater tracheostomy-related ulcers treated with MD and/or AG were included. Subject characteristics and wound healing rates were tabulated in a database that included age, wound site, initial and final wound stage, type of treatment, length of treatment, and complications. Tracheostomy wounds treated as an out-patient were excluded from the study. RESULTS: Eighteen subjects, which included both in-patients and out-patients, were treated with AG and/or MD during the study period for tracheostomy-related wounds. Of the 26 subjects with tracheostomies performed during the study period, 10 (38.5%) were treated for postoperative wounds. A total of 11 subjects completed their in-patient wound treatment and were thus included in the study. Average subject age was 5.3 y (range 0.25–15.6 y). Wound locations were as follows: infrastomal region (n = 8), stoma (n = 2), and lateral neck (n = 1). Six subjects had stage 2 wounds, 4 had stage 3 wounds, and 1 had a stage 4 ulcer. All wounds achieved complete epithelialization following treatment with MD and/or AG. The average length of treatment was 12.8 d (range 6–28 d). No adverse effects were identified. CONCLUSIONS: Postoperative tracheostomy wounds are common. The use of MD and AG provides an effective and safe treatment for tracheostomy-related ulcers. [ABSTRACT FROM AUTHOR]

Background: Arteriovenous malformations (AVMs) are a type of high-flow vascular malformations that most commonly occurs in the head and neck. They are present at birth but are usually clinically asymptomatic until later in life. The pathogenesis of AVMs remains unclear and therapeutic approaches to AVMs are unsatisfied. In order to provide a tool for studying the pathogenesis and therapies of this disease, we established and studied a xenograft animal model of human AVMs.Methods: Fresh human AVMs specimens harvested from 4 patients were sectioned (5 x 5 x 5 mm) and xenografted subcutaneously in 5 immunologically naïve nude mice (Athymic Nude-Foxn1(nu)). Each mouse had four pieces specimens in four quadrants along the back. The grafts were observed weekly for volume, color and texture. The grafts were harvested at every 30 days intervals for histologic examination. All grafts (n = 20) were sectioned and stained for hematoxylin and eosin (H&E). Comparative pathologic evaluation of the grafts and native AVMs were performed by two blinded pathologists. Immunohistochemical examination of human-specific nuclear antigen, vascular endothelial growth factor receptor-2 (VEGFR-2) and Ki-67 was performed.Results: Clinical characteristics and pathologic diagnosis of native human derived AVMs were confirmed. 85% (n = 17) of AVM xenografts survived although the sizes decreased after implantation. Histological examination demonstrated numerous small and medium-size vessels and revealed structural characteristics matching the native AVMs tissue.76.5% (n = 13) of the surviving xenografts were positive for Ki-67 and human-specific nuclear antigen suggesting survival of the human derived tissue, 52.9% (n = 9) were positive for VEGFR-2.Conclusions: This preliminary xenograft animal model suggests that AVMs can survive in the nude mouse. The presence of human-specific nuclear antigen, VEGFR-2, and Ki-67 demonstrates the stability of native tissue qualities within the xenografts. [ABSTRACT FROM AUTHOR]

Venous malformations (VMs) frequently occur in the head and neck with a predilection for the parotid gland, submandibular triangle, buccal space, muscles of mastication, lips, and upper aerodigestive tract. They are composed of congenitally disrupted ectatic veins with inappropriate connections and tubular channels. Because VMs have poorly defined boundaries and a tendency to infiltrate normal tissue, they require calculated treatment decisions in the effort to preserve surrounding architecture. Sclerotherapy, surgical excision, neodymium:yttrium aluminum garnet laser therapy, or a combination of these modalities is employed in the management of VMs. Although many small VMs can be cured, the objective is often to control the disease with periodic therapy. Location, size, and proximity to vital structures dictate the type of therapy chosen. Vigilance with long-term follow up is important. This review outlines current diagnostic and therapeutic approaches to simple and extensive cervicofacial VMs. [ABSTRACT FROM AUTHOR]

The article discuses a study on the relationship between food hypersensitivity and common upper aerodigestive disorders in children younger than two years. Patients were treated in both a tertiary pediatric gastroenterology and otolaryngology clinic and ninety-one percent of them showed improved symptoms. Cow's milk protein allergy (CMPA) is difficult to diagnose due to limited accurate diagnostic tools generally in children.

Objective: To examine the location and degree of endothelial nitric oxide synthase (eNOS) protein expression in hemangioma growth, involution, and during propranolol therapy. Design: Cross-sectional study. Setting: University hospital. Patients: Pediatric patients with hemangiomas. Interventions: Fresh human hemangioma specimens at various stages of development were harvested. Effective propranolol therapy had been implemented in some patients. Quantitative assessment and localization of eNOS protein expression was performed on each specimen by Western blot analysis and immunohistochemical analysis, respectively. Results: Hemangiomas in a proliferative phase (group 1: n=4; mean [SD] age, 4.25 [2.06] months), an early involuting phase (group 2: n=6; 12.00 [1.64] months), and a late involuting phase (group 3: n=6; 23.30 [1.97] months) were harvested. The mean (SD) eNOS protein expression was 0.88 (0.41) in group 1, 0.26 (0.26) in group 2, and 0.15 (0.08) in group 3, respectively. A statistically significant decrease in eNOS protein expression was observed between proliferating and involuting hemangiomas (group 1 vs group 2 and group 3; P⩽.01) but not between early and late phases of involution (P=.17). In a separate propranolol treatment group (n=7), the eNOS protein level was significantly lower than in age-matched controls (n=7; 0.08 [0.1] vs 0.45 [0.45]; P=.03). Immunohistochemical analysis demonstrated eNOS to be predominately in endothelial cells lining mature blood vessels. Conclusion: Expression of eNOS protein decreases during the hemangioma lifecycle. Propranolol may suppress hemangioma growth by inhibiting expression of eNOS protein and subsequent production of nitric oxide. [ABSTRACT FROM AUTHOR]

Objective: To develop an in vivo mouse model of human microcystic lymphatic malformations (LMs) and provide a tool for investigating the biological mechanisms and treatment of microcystic disease. Design: Animal model and histologic analysis. Setting: Tertiary referral center. Subjects: Fresh microcystic LM from human subjects were harvested and xenografted in the immunologically naïve nude mice (Athymic Nude-Foxn1nu). Main Outcome Measures: Specimens were divided (5×5×5 mm) and secured in 4 quadrants subcutaneously along the dorsum of 4 nude mice. Weekly observations for volume, color, and texture of the grafts were performed with sequential harvesting from each quadrant at 30-day intervals. All grafts (n=16) were sectioned and stained with hematoxylin-eosin. Comparative pathologic evaluation of the grafts and native LM was performed by 2 blinded pathologists. Immunohistochemical analysis for D2-40 (a known lymphatic endothelial cell marker), Ki-67, and human-specific nuclear antigen was performed. Results: Near complete microcystic LM xenograft survival (n=13 [81%]) was achieved in the mouse irrespective of the period of implantation. Xenografts underwent a brief growth phase to day 20 to 30 and were quiescent until approximately day 65 but ultimately had a gradual loss of volume following transplant. Histologic analysis revealed structural characteristics matching the native LM tissue. Immunohistochemical analysis found that 10 (77%) of the surviving xenografts (77%) were positive for D2-40, 9 (69%) were positive for human-specific nuclear antigen, and 8 (62%) were positive for Ki-67. Conclusions: This preliminary in vivo model suggests that microcystic LM can survive in the athymic nude mouse. The presence of markers for human antibodies, lymphatic endothelium, and cellular proliferation demonstrates the stability of native tissue qualities within the xenografts. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To demonstrate, in a case series, the relentless growth of arteriovenous malformations (AVMs) of the head and neck and the importance of their vigilant management within the context of a modified staging system. Study Design: Retrospective review. Setting: Tertiary care institution, Vascular Anomalies Center. Subjects and Methods: Subjects were patients with advanced AVMs presenting to our Vascular Anomalies Center. Medical records were examined for age at first diagnosis, disease course, prior treatments, age at presentation, management, therapeutic outcomes, stage of disease, and impact on quality of life. Early patient photographs were evaluated. Results: Ten patients (ages 13-46 yrs) with extensive cervicofacial AVMs were examined. Progressive growth, worsening symptoms, and graduated disease stage were universally experienced by each patient, as evident by serial photographs, over a course of many years. Each patient presented to our institution with massive lesions, bleeding, pain, and facial destruction. Prior embolization and/or surgery had been performed in all but one patient. Every patient had been previously told that their AVMs were incurable or that treatment options were exhausted. The patients were subsequently treated at our institution with surgical resection with or without preoperative embolization. Disease control, symptom improvement, and enhanced daily functioning were attained in each patient. Conclusion: The natural course of AVMs is progressive, invasive, and destructive. Vigilant observation, early treatment, and radical therapy are necessary for AVMs of the head and neck. [Copyright &y& Elsevier]

Objectives/Hypothesis: Venous malformations are rare congenital aberrations of vein development frequently presenting in the head and neck. Without treatment, venous malformations cause progressive disfigurement, dysfunction, and bleeding. In this study, we analyzed a cohort of pediatric patients with cervicofacial venous malformations (CFVM), with the goal of developing a treatment algorithm for these complex lesions. Study Design: Eleven-year retrospective chart review. The setting was a vascular anomalies center at a pediatric tertiary hospital. Nineteen patients (10 male, 9 female), aged 11 months to 17 years, presented with CFVM. Methods: Patient charts were reviewed for demographics, signs and symptoms, timing of first and subsequent interventions, total number and type of interventions performed, and procedural complications. A family questionnaire supplemented outcome measures by determining the perception of disease control. Results: Presenting symptoms for CFVM include growth (100%), disfigurement (63%), pain (58%), respiratory compromise (42%), and dysphagia (32%). A mean of 6.7 interventions were performed per patient (median, 6; range, 2-12), requiring a mean of 0.8 excisions, 4.6 laser treatments, and 1.3 sclerotherapy injections. Average age at first procedure was 8.5 years. Time between treatments averaged 8.9 months. Four complications occurred in 127 procedures (3.1%). Questionnaire responses indicated subjective improvement following therapy. A management algorithm could be developed from therapeutic outcomes. Conclusions: Treatment of CFVM can be safely and successfully performed with a combination of laser therapy, sclerotherapy, and surgical excision. A treatment algorithm involving multiple procedures during childhood can lead to successful management of CFVM. Laryngoscope, 2010 [ABSTRACT FROM AUTHOR]

Abstract: Objective: Arytenoid prolapse is a potential source of upper airway obstruction following laryngotracheoplasty, and may be difficult to identify. We explored the incidence, clinical features, etiology, and surgical approach to patients with arytenoid prolapse following laryngotracheoplasty. Study Design: Case series with chart review. Subjects and Methods: The charts of 93 patients diagnosed with arytenoid prolapse following laryngotracheoplasty from 1981 to 2007 were reviewed. Results: The incidence was 5.7 percent (93/1634). Forty-nine patients had unilateral prolapse; 44 had bilateral prolapse. Average time from laryngotracheoplasty to presentation was 36.8 months. Common symptoms were dyspnea on exertion, tracheostomy dependence, and sleep-disordered breathing. Fifty-four patients (58%) required surgical intervention, with arytenoid reduction performed in 45 patients. Nine underwent reduction during revision laryngotracheoplasty or cricotracheal resection. Fourteen patients required a second procedure for persistent prolapse. Thirty-nine (42%) required no intervention. Symptom resolution or decannulation was achieved in all patients in whom prolapse was the source of obstruction. Statistically significant differences were found when anterior vs posterior graft utilization was compared. Conclusions: Arytenoid prolapse is a cause of airway obstruction following laryngotracheoplasty. Subtle airway complaints and decannulation failures are common features. Both endoscopic and open procedures can successfully treat arytenoid prolapse. Potential etiologies are discussed. [Copyright &y& Elsevier]

Summary: Objectives: Previous reports suggest that patients with Turner syndrome have a predisposition for acute and chronic otitis media. However, the role of early or aggressive surgical management of otologic disease has not been explored in the pediatric population. With respect to otitis media in pediatric Turner syndrome patients, we examined (1) the impact of timing and (2) the type of surgical intervention in the treatment of disease. Methods: Retrospective 10-year review of patients with Turner syndrome and chronic otitis and its surgical management at a single pediatric tertiary institution. Results: One hundred and seventy-eight patients with Turner syndrome were evaluated at our institution from 1997 to 2007. Thirty-two (18.0%) were diagnosed with middle ear disease. Eighteen (10.1%) were referred to otolaryngology for evaluation. Average age at presentation was 4.7 years (range: 1 month to 12 years). The 18 patients referred to otolaryngology required a mean of 16 clinic visits each for otologic symptoms. A mean of 6.7 pressure equalization tubes (PET) were required per patient (range: 0–25). Middle ear effusions (n =14, 78%) along with tympanic membrane retractions and/or perforations (n =10, 55.6%) were the most common otoscopic findings. Patients with tympanic membrane retractions (8/18) required a higher average number of PET (9.1) and cumulatively underwent a total of five tympanoplasty-type procedures. Six ears had evidence of cholesteatoma. Two patients underwent myringoplasty, 6 patients underwent tympanoplasty (33.3%, mean age 11.6 years), and 3 patients (16.7%, mean age 9.4 years) underwent tympanomastoidectomy. Revision procedures were common. Older age at first PET placement was significantly correlated with the need for later tympanoplasty and/or tympanomastoidectomy operations (p <0.036). Tympanoplasty or tympanomastoidectomy patients had their first PET placed on average at 5.2 years as compared to 2.6 years in those not requiring tympanoplasty or tympanomastoidectomy operations. Conclusions: Recurrent and chronic otitis media is common in patients with Turner syndrome. Once established, disease is recalcitrant and leads to multiple surgical procedures. Early PET insertion is advocated to offset the future necessity of more extensive tympanic procedures. [Copyright &y& Elsevier]

Venous malformations are benign but symptomatic vascular lesions of the head and neck that undergo soft tissue infiltration and relentless growth. Here we present a 31-year-old female referred for an obstructing and painful right posterior nasal mass. Flexible nasopharyngoscopy and magnetic resonance imaging demonstrated a 3 cm × 4 cm enhancing mucosal and submucosal venous malformation of the nasopharynx and oropharynx. Three staged episodes of transnasal endoscopically guided Nd:YAG laser therapy were performed with dramatic and sustained reduction in size and symptoms. No bleeding or complications occurred. Nd:YAG laser treatment of nasopharyngeal venous malformations is a safe and effective alternative to open surgical excision and sclerotherapy. [ABSTRACT FROM AUTHOR]

Summary: Background: Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device''s thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature. Methods: FLIR Systems© Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries. Results: Temperatures exceeding 60°C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices. Conclusions: Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed. [Copyright &y& Elsevier]

Objectives: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials. Study Design: In vivo, rat model. Methods: Subcutaneous implantation of 1-mm thick, 1 cm × 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively. Results: AlloDerm showed significantly greater soft tissue ingrowth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks (P < 0.001). Conclusions: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model. [Copyright &y& Elsevier]