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BackgroundSuprastomal granulation tissue is a common complication of long-term tracheostomy. It may be associated with bleeding, aphonia, airway obstruction and delayed decannulation.MethodsThis study describes the experience of a tertiary paediatric medical centre with CoblationTM-assisted suprastomal granulation tissue excision.ResultsThirteen children (mean age, 5.7 years) who underwent the procedure from 2013 to 2019 because of delayed decannulation or aphonia were included. Lumen obstruction ranged from 50 to 90 per cent, with a mean of 68.8 per cent. After the procedure, decannulation was successfully performed in 7 patients, and voice quality improved in 10 patients. There were no peri- or post-operative complications.ConclusionThis is the largest series to date that describes Coblation used for the treatment of suprastomal granuloma. Coblation has advantages of high precision, relatively low temperature (thereby avoiding thermal injury to adjacent tissue), haemostatic resection and feasibility for use for even large granulomas. The promising results should prompt further studies in larger samples.

Objective The diagnosis of foreign body aspiration (FBA) is challenging. In a previous study, we developed a computerized scoring system (CSS) to support decision-making. In the present study, we aimed to validate it on a further cohort. Study design In this observational study, 100 children referred to the emergency department of a tertiary pediatric hospital for suspected FBA and treated according to standard protocol, were assigned a probability score using the CSS, between 0 and 1 (0, very low probability; 1, very high). The diagnosis of FBA was based on bronchoscopy, and if discharged without bronchoscopy, determined via telephone questionnaire, 4 to 6 months after discharge, supplemented by clinical re-evaluation and bronchoscopy, if respiratory symptoms persisted. Results Thirty-five out of 100 children (35%) underwent bronchoscopy with 12 of 35 (34%) positive for FBA. Sixty-five patients were discharged without bronchoscopy and completed a telephone questionnaire. Seven patients required clinical re-evaluation for persistent respiratory symptoms, in two out of them, additional bronchoscopies were performed and were negative. The CSS median probability score was 0.94 in patients with FBA, as compared to 0.73 in patients without FBA (P = .007). The CSS area under the receiver operating curve was 0.74. At a probability score threshold of 0.6, the sensitivity and specificity were 100% and 41%, respectively. Conclusion The present validation study suggests a high sensitivity of the CSS for the identification of FBA in children. We suggest that it might aid decision-making with regard to the need for bronchoscopy in children presenting to the emergency room.

Aerodigestive clinics are run by interdisciplinary medical and surgical teams, and provide complex care coordination and combined endoscopies.To describe the design and patient population of the first pediatric aerodigestive center in Israel.A retrospective single-center cohort study was conducted describing patients followed in the aerodigestive clinic of Schneider Children's Medical Center of Israel, a tertiary pediatric hospital, between its inception in January 2017 and June 2020.During the study period, 100 patients were seen at the combined respiratory and digestive (NoAM) clinic, with a total of 271 visits. Median age at first assessment was 29.5 months (range 3-216). Fifty-six patients (56%) had esophageal atresia and tracheoesophageal fistula. Thirty-nine patients had an identified genetic disorder, 28 had a primary airway abnormality, 28 were oxygen dependent, and 21 were born premature. Fifty-two patients underwent triple endoscopy, consisting of flexible bronchoscopy, rigid bronchoscopy, and gastroscopy. In 33 patients, esophageal dilatation was necessary. Six patients underwent posterior tracheopexy at a median of 6 months of age (range 5 days to 8 years) all with ensuing symptom improvement. The total mean parental satisfaction score on a Likert-type scale of 1-5 (5 = highest satisfaction) was 4.5.A coordinated approach is required to provide effective care to the growing population of children with aerodigestive disorders. The cross fertilization between multiple disciplines offers a unique opportunity to develop high quality and innovative care. Outcome measures must be defined to objectively measure clinical benefit.

All currently used web-repair techniques are safe and effective. Simple division of the web with application of mitomycin C yields poor results. Of the 4 techniques tested, keel placement offers the best long-term outcome. All children with congenital anterior glottic web should be evaluated for 22q11.2DS. Postoperative follow-up of at least one year is advised This article is protected by copyright. All rights reserved.

Objectives: Foreign body aspiration (FBA) is a life-threatening event in children. The gold standard for diagnosis is bronchoscopy, but there is no consensus regarding indications for the procedure. The aim of this study was to formulate a predictive model for assessing the probability of FBA in suspected cases as an aid in the decision to perform diagnostic bronchoscopy. Methods: The files of 150 patients who underwent bronchoscopy for suspected FBA at our center between 1996 and 2004 were reviewed for medical history, physical examination, and radiologic studies. The findings were analyzed by logistic regression. Results: Using the file data, we formulated a predictive model wherein each parameter received a numeric coefficient representing its significance in evaluating suspected FBA. The most significant parameters were age 10 to 24 months, foreign body in the child's mouth and severe respiratory complaints during the choking episode, hypoxemia, dyspnea or stridor following the acute event, unilateral signs on lung auscultation, abnormal tracheal radiogram, unilateral infiltrate or atelectasis, and local hyperinflation or obstructive emphysema on chest radiogram. Conclusions: In our predictive model, every case of suspected FBA can be assigned a score based on the specific parameters present, which is then entered into a probability formula to determine the likelihood of a positive diagnosis. This model may serve as a useful tool for deciding on the use of bronchoscopy in all children with suspected FBA.

Summary Objectives To present our experience with a new endoscopic technique for transnasal repair of choanal atresia. Methods Seventeen patients aged 2 months to 13 years with choanal atresia, bilateral in 6 and unilateral in 11, underwent endoscopic repair using a mucoperichondrial flap developed from the nasal septum. The bony stenosis was opened with a surgical curette or drill, and the raw surface was covered by the flap. All patients in these case series with bilateral atresia had been treated with dilatation at birth and had restenosis. Results A total of 23 choanae were operated. Follow-up ranged from 10 to 60 months. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. Conclusions Endoscopic repair of choanal atresia is a safe and rapid procedure even in very young children, with no complications and a high rate of success.

Background. Recent studies have demonstrated that cyclooxygenase-2 (COX-2) expression is associated with the carcinogenesis of numerous neoplasms. The aim of this study was to evaluate the role of COX-2 in medullary thyroid carcinoma (MTC). Methods. Tissue specimens of thyroid neoplasms were obtained from 22 patients with MTC and 15 control subjects with nonmalignant thyroid specimens. Results. This immunohistochemical study confirms the presence of COX-2 in a significant number of MTCs. A large area of staining was noted in only 2 patients in the control group (13%) compared with 18 (82%) in the medullary carcinoma group. On a scale of 0 to 3, the average area of positive staining measured 2.35 in the study group and 0.9 in the control group (p < .0001). The average intensity of staining on a scale of 0 to 5 (deep brown) was 2.15 and 0.8 mm, respectively (p < .001). Conclusion. COX-2 is expressed significantly in MTC including a larger area of staining and greater intensity than in nonmalignant thyroid tissue. These findings may have important treatment implications for the use of COX-2 inhibitors in patients with MTC. © 2007 Wiley Periodicals, Inc. Head Neck 2007

Background. The determination of malignancy in follicular patterned thyroid lesions is based on postoperative histologic findings. Therefore, affected patients are referred for surgery, although only 20% will have a final diagnosis of ma- lignancy. The aim of this study was to investigate the potential of galectin-3 as a marker of malignancy in these lesions. Methods. Fifty-four tissue specimens of follicular patterned thyroid lesions were immunohistochemically stained for galectin- 3. Area and intensity scores were recorded. Results. Significant differences were found between the be- nign and malignant lesions. The sensitivity, specificity, positive predictive values, and negative predictive values of galectin-3 staining were 82%, 68%, 75%, and 77%, respectively (p = .0002). Significant differences were also found between the subgroups of benign and malignant lesions (p V.05). Conclusions. Galectin-3 staining is highly sensitive for ma- lignancy in follicular patterned thyroid lesions. Diagnostic problems may arise in the presence of Hurthle cell proliferation

Squamous cell carcinoma (SCC) of the tongue is characterized by an unpredictable course, ranging from relatively benign to a high degree of locally aggressive growth and metastasis. Treatment guidelines have been developed according to TNM stage, but they do not always accurately predict clinical outcome. The aim of the present study was to evaluate the expression of the matrix metalloproteinases (MMPs) that degrade the extracellular matrices, their inhibitors (TIMPs), and angiogenic factors (factor-8 and CD-34) in tumor cells and to correlate these findings with the clinicopathological features and patient outcome. Tissue specimens from 23 patients with primary SCC of the tongue were immunohistochemically stained for these markers. High expressions of MMP-9 and TIMP-1 were detected in 60.9% and 65.2% of the specimens, respectively. Tumor invasion to adjacent muscle, lymph node metastasis, and disease status at the end of follow-up were positively correlated with the microvessel count using the CD-34 marker, but not with high expression of MMP-9 or TIMP-1. Expression of MMP-9 and TIMP-1 fails to predict aggressiveness in SCC of the tongue. However, the degree of vascularization in tumor tissue is indicative of disease aggressiveness and might be used as a basis for patient selection for more intensive therapy.

There is no standard for determining significant pharyngoesophageal reflux. This prospective blind comparison study compared dual pH probe studies, direct laryngoscopy, and mucosal biopsy in children without symptoms of gastroesophageal reflux who underwent airway evaluation. Significant reflux to the lower esophageal probe did not correlate with statistical significance with reflux to the upper probe. In this group of asymptomatic patients, a positive lower pH probe finding did not correlate with upper or lower esophageal mucosal inflammation. Eosinophilia in the esophageal mucosa is diagnostic of gastroesophageal reflux disease, and was seen in 5 of the laryngeal biopsies. A weak correlation was seen between positive findings at laryngoscopy and positive posterior cricoid biopsy in this group. There may be no consistent way to predict significant pharyngoesophageal reflux in asymptomatic patients. Single-probe pH testing will not predict significant pharyngoesophageal reflux with mucosal changes. Laryngoscopy and upper pH probe findings only weakly correlate with significant histologic findings. Laryngeal and posterior cricoid biopsy may be the only sensitive test for mucosal injury. Clinical trials of empiric antireflux therapy should be used to determine whether the laryngeal changes seen in these patients are reversible.

Laryngotracheal reconstruction (LTR) has been used for more than 20 years to treat infants and children with subglottic stenosis. Results after pediatric LTR have been satisfactory; however, approximately 10% of children have recurrent airway narrowing after LTR. The purpose of our study was to determine whether a correlation existed between specific growth factors and extracellular matrix in patients with adequate wound healing capability as compared with patients with poor wound healing capability. Histologic sections from 27 patients who underwent LTR were cut, and immunohistochemical staining was performed for transforming growth factor-β, platelet-derived growth factor, fibronectin, tenascin, transforming growth factor-α, and vascular endothelial growth factor. Results showed that patients with adequate wound healing capability had a positive correlation with vasculature fibronectin, vasculature tenascin, and stromal fibronectin. Patients with poor wound healing capability had a positive correlation with stromal vascular endothelial growth factor. (Otolaryngol Head Neck Surg 2000;122:363-6.)

Severe laryngotracheal stenosis (LTS) in the pediatric age group has been traditionally treated by laryngotracheoplasty procedures. This approach may be complex and multistaged. High success rates have been reported in adults with severe LTS who underwent partial resection of the cricoid and primary thyrotracheal anastomosis. However, this procedure has not been widely reported in infants and children. Since November 1993, 38 patients with grade III or IV subglottic stenosis were treated with partial cricotracheal resection (CTR) and primary anastomosis. In some patients a posterior cricoid split or partial arytenoidectomy was performed as well. The preoperative evaluation, surgical techniques, and postoperative care are described. There were no significant operative complications or deaths. Thirty-three patients were decannulated after a single open surgical procedure. Our results as well as those of previous series suggest that CTR with primary anastomosis is a relatively safe and effective procedure in infants and children with severe LTS.

Objective: To evaluate DNA ploidy in papillary thyroid carcinoma in children in correlation to the clinical course of the disease. Methods: Flow cytometric DNA ploidy measurements were performed on formalin-fixed, paraffin-embedded tumor specimens from 14 children and 14 adult patients with papillary carcinoma of the thyroid gland. Analysis of DNA content was performed blind to patient's age and clinical presentation. Results: Seven patients presented with cervical metastasis, one patient had distal metastasis and four patients had local invasion. All patients underwent total thyroidectomy. Seven children underwent bilateral modified neck dissection. Twenty-five tumors expressed diploid DNA content. No statistically significant difference in DNA content was observed between the tumors from child and adult patients. No correlation was found between DNA content and aggressive presentation in the pediatric group. Conclusion: Our primary results indicate that diploid DNA content is common in papillary thyroid carcinoma in children and aggressive clinical presentation is not associated with DNA aneuploidy. Larger prospective studies and long-term clinical follow-up is warranted to document the clinical significance of these observations.

Background. Thyroid carcinoma in young patients under the age of 20 years is uncommon. Because of the slow progression of this disease, there is still a great deal of debate as to which operation strategy is best. Methods. We undertook a retrospective study of 61 patients under 20 years of age with thyroid cancer treated at our institute between 1952 and 1995. They constitute 6.6% of the 921 thyroid cancer patients treated by us during the same period. Factors examined were: symptoms, metastases, treatment, complications, and survival. Results. Total or near-total thyroidectomy was performed in 51 patients. Regional lymph node dissection was performed in 17 patients and modified radical neck dissection in 13. Fifty-one patients underwent pretracheal and paratracheal lymph node dissection. During the 43 years of this study, two patients died of thyroid cancer. Conclusions. Although most children are initially seen with more extensive disease than adults, the overall prognosis is excellent. The excellent prognosis is the product of initial aggressive treatment: near-total or total thyroidectomy and at least pre-and paratracheal lymph node dissection, followed by radioactive iodine therapy.

Background Experimental evidence suggests that tumor growth beyond a certain size and tumor ability to metastasize depend on the degree to which the tumor can stimulate an angiogenic response. Methods Fifteen thyroid specimens of microinvasive follicular carcinoma were examined for vascularization by immunohistochemical stain with antifactor VIII antibodies and compared with an equal number of follicular adenomas. Results Pleomorphic areas in the histological specimens of follicular carcinomas had a higher rate of vascularization as did areas of tumor adjacent to or penetrating the capsule. These features were not noted in follicular adenomas. Conclusions Our findings indicate that vascularity may play a role in extracapsular extension and tumor aggression in follicular thyroid carcinomas. © 1996 Wiley-Liss, Inc.

Primary nonepithelial tumors of the thyroid gland are rare. We present the case of a neurilemoma of the right lobe of the thyroid gland in a 20-year-old female patient. The tumor was asymptomatic and measured 2.5 x 1.2 cm in size. Histologic examination was consistent with an Antoni A-type neurilemoma. The tumor was excised without difficulty. Only 12 other cases of neurilemomas of the thyroid gland have been reported in the literature. We discuss the clinical, radiologic, and pathologic findings of this rare tumor.

Objectives: We sought to investigate the immunologic status of children with recurrent respiratory papillomatosis and to evaluate possible correlations between the patients' immunocompetency and the clinical course of the disease. Methods: Twenty children with recurrent respiratory papillomatosis underwent immunologic evaluation every 6 months for determination of complete blood count, serum immunoglobulin levels, lymphocyte subpopulations, lymphocyte response to mitogen stimulation, and natural killer cell function. The patients were observed prospectively (42 to 56 months), and their clinical course was recorded. The findings were compared with those in healthy age-matched controls. Results: The CD4/CD8 ratio and the lymphocyte response to mitogen stimulation were significantly reduced in the study children compared to normal controls. A reduction in lymphocyte response to mitogen stimulation was significantly correlated to a high number of papilloma sites and more frequent recurrences. Abnormal natural killer cell function was significantly correlated to more frequent recurrences. Conclusions: A compromised cell-mediated immune response may be associated with repeated or persistent human pap-illomavirus infections, leading to the development of recurrent respiratory papillomatosis. Patients with an aggressive clinical course may have underlying cell-mediated immunodeficiency. Long-term prospective investigations are needed to establish the role of the host immune system in the pathogenesis of recurrent respiratory papillomatosis in children.

Summary Objective To determine the safety and effectiveness of endoscopic partial adenoidectomy for the treatment of nasal obstruction in children with submucosal cleft palate. Methods The medical files of children with symptoms of nasal obstruction and submucosal cleft palate who underwent partial transnasal endoscopic adenoidectomy from January 1993 to December 2003 were reviewed. Operative complications, relief of nasal obstruction, presence of postoperative velopharyngeal insufficiency were recorded. Results There were no operative complications. All the children had relief of nasal obstruction. Velopharyngeal insufficiency was not observed during the postoperative follow-up. Conclusions Endoscopic partial adenoidectomy is a safe and effective procedure for the treatment of nasal obstruction in children with submucosal cleft palate.

Purpose The clinical course of patients with squamous cell carcinoma (SCC) of the tongue is often unpredictable. Some patients have a fair course with good response to treatment, whereas others have aggressive locoregional disease despite diagnosis at an early stage. The purpose of the present study was to determine if histochemical staining for cytokeratins of the negative neck nodes obtained in prophylactic neck dissection could predict treatment failure in patients with SCC of the tongue. Materials and methods Between 1990 and 2000, 18 patients with early squamous cell carcinoma of the tongue (T1,T2N0M0) underwent partial glossectomy with neck dissection at the Rabin Medical Center in Israel. All had clear resection margins and no evidence of neck metastasis and were expected to do well. Nevertheless, 6 patients had an aggressive course and died of disease shortly after presentation because of local or regional failure. In an attempt to predict failure of treatment and patients’ outcome, paraffin-embedded blocks from the pathologically negative lymph nodes were subjected to immunohistochemical staining for cytokeratin using polyclonal antibodies. The antigen-antibody complex was identified by using the biotinylated secondary antibody and followed by the streptavidin-peroxidase detection method. Results None of the 142 sections from pathologically negative lymph nodes stained positive for keratin. On multivariate analysis, a statistically significant relationship was found between disease-free survival, early recurrence (P = .03), and metastasis to the neck (P = .008). Conclusions Keratin staining failed to yield evidence of micrometastasis. Further studies with more samples are needed to confirm these findings.

Objective: To assess the role of DNA ploidy as a predictor of radioresistance in T1, glottic carcinoma. Design: Case-control study. Flow cytometric DNA ploidy measurements were performed on formalin-fixed paraffin-embedded tumor specimens from 15 patients with T1 glottic laryngeal carcinomas in whom radiotherapy had failed and from a matched group of 15 patients in whom an identical radiotherapy regimen was curative. Analysis of DNA content was performed blind to outcome of treatment. Setting: Academic tertiary referral medical center. Participants: Thirty patients with clinically staged T1, N0, M0 glottic carcinoma. Intervention: All patients received radiation to the larynx through opposed lateral ports at a total dose of 64 to 70 Gy. Results: Ten diploid and five aneuploid histograms were found in the resistant group, and six diploid and nine aneuploid histograms were found in the radiosensitive group. This difference was not statistically significant. A trend toward a higher relapse rate after radiotherapy (62.5%) among patients with diploid tumor compared with those with aneuploid tumor (35.7%) was noted. Conclusions: DNA ploidy did not predict response to radiotherapy in patients with T1 glottic cancer, probably because of the small number of patients. A trend toward lower risk of local recurrence after radiotherapy in aneuploid tumors was noted. A larger prospective study is needed to assess the value of DNA ploidy in the treatment of early laryngeal cancer. (Arch Otolaryngol Head Neck Surg. 1995;121:1003-1005)

Cranial nerve palsies are uncommon complications of radiotherapy for head and neck cancer. A review of the literature reveals that cranial nerve damage after radiotherapy has been reported for the optic, oculomotor, trigeminal, abducens, cochlear, vagus, spinal accessory, and hypoglossal nerves. The hypoglossal nerve appears to be the most commonly affected, and the recurrent laryngeal nerve is seldom involved. The case histories of three patients who developed vocal cord palsy from 21 to 34 years after a course of curative or postoperative radiotherapy for carcinoma of the head and neck are presented. Two patients had bilateral palsy, and in the third patient, bilateral damage cannot be excluded. Physical examination and radiographic investigations on admission and on follow-up did not demonstrate any evidence of tumor recurrence, cervical or distant metastases, or second primary tumors. The distinction between irradiation-induced palsy and that due to malignancies is emphasized.

Squamous cell carcinoma (SCC) of the tongue is sometimes associated with local recurrence and regional metastases despite adequate surgical excision. The present study sought to determine if epidermal growth factor receptor (EGFR) and Cerb-B2 expression has prognostic or predictive value in SCC of the tongue, as with other epithelial malignancies. The study sample comprised of 27 patients with carcinoma of the tongue who underwent partial glossectomy and neck dissection between 1990 and 1999. Average follow-up was 54 months. Specimens from 23 patients were analyzed for growth factor expression using monoclonal antibodies specific for EGFR and Cerb-B2. Findings were correlated with the clinical course. EGFR and Cerb-B2 were expressed in 34% and 17% of the specimens, respectively. There was a statistically significant correlation between EGFR expression and tumor differentiation, and a borderline correlation between Cerb-B2 expression and T stage. No association was found between growth factor expression and tumor depth, lymph node status, extracapsular invasion, recurrence, or survival. Overexpression of EGFR and Cerb-B2 cannot serve as a prognostic factor or predictor of survival and treatment success in SCC of the tongue.

Bilateral vocal fold immobility in adduction usually creates severe dyspnoea. Many surgical procedures have been established to improve the airway insufficiency in affected patients.Over the last six years 22 patients with bilateral vocal fold immobility in our department have undergone CO2 laser posterior ventriculocordectomy with partial arytenoidectomy (PVCPA). None had dyspnoea or a disturbance in the immediate post-operative period or during follow up, which ranged from five months to six years. Only one patient required a second procedure.Laser PVCPA appears to be an effective and reliable method for the treatment of bilateral vocal fold immobility in selected patients.

Background Multiple procedures have been advocated for the surgical control of chronic sialorrhea in children. However, some of them are associated with significant complications or only short-term success. Objectives To evaluate the safety of bilateral submandibular gland excision (SGE) with parotid duct ligation (PDL) and to assess its long-term complications and efficacy in the treatment of chronic sialorrhea in children. Design Case series. Telephone interview of patients' families. Setting Tertiary care children's hospital. Patients Ninety-three patients with chronic sialorrhea who underwent bilateral SGE with PDL from 1988 to 1997. Main Outcome Measures Operative and postoperative complications, length of postoperative hospitalization, postoperative drooling, care requirements, xerostomia, dental caries, and overall satisfaction. Results The mean postoperative stay was 2.4 days. There were 3 postoperative complications. Seventy-two families were interviewed (follow-up time, 1-10 years): 62 (87%) reported no further drooling or significant improvement; 7 reported the occurrence of dry mouth; and 2 reported an increase in dental caries. Conclusion Bilateral SGE with PDL is a safe and consistently efficient procedure for the treatment of chronic sialorrhea in children.

The enhanced proliferation of epithelial cells is a typical feature of respiratory papilloma. The mechanism or mechanisms leading to abnormal epithelial proliferation remain unclear. Overexpression of growth factors and their receptors and inactivation of tumor-suppressor proteins are known to cause cell transformation and proliferation. The objectives of this study were to evaluate the expression of these factors in juvenile respiratory papillomas with correlation to cellular proliferation activity, and to determine whether such expression is associated with the clinical course of the disease. The expression of transforming growth factor-α, epidermal growth factor receptor, p53 protein, retinoblastoma proteins and Ki-67 was quantified by immunohistochemistry in paraffin-embedded biopsy specimens taken at the initial surgical excision from children in whom respiratory papillomatosis was diagnosed. Clinical information regarding the number of disease sites, tracheobronchial spread, malignant transformation, and frequency of recurrences was reviewed. Thirty-five specimens were suitable for immunohistochemical evaluation. Ki-67 expression was significantly higher in patients with multiple sites of disease and frequent recurrences. High p53 expression was significantly associated with malignant transformation. We concluded that Ki-67 and p53 expression may be predictive of the clinical course in children with respiratory papillomatosis. (Otolaryngol Head Neck Surg 2000;122:378-86.)

Several anesthetic techniques for microlaryngeal laser surgery in children have been advocated. The objective of this study was to evaluate the operative conditions and safety of the spontaneous respiration anesthesia technique for carbon dioxide laser surgery in children with recurrent respiratory papillomatosis (RRP). The anesthetic and operative records of 60 pediatric patients with RRP who underwent microlaryngeal laser surgeries between 1991 and 1997 were reviewed. Papilloma location, severity of involvement, oxygen saturation, airway stability, need for intubation, duration of procedure, and complications were recorded. The patients underwent 744 surgical procedures. Two hundred two procedures were randomly studied (statistical power ≥ 80%). The supraglottis and glottis were most commonly involved. Most of the papillomas were graded as moderate or severe disease. Complications occurred in 11 procedures. The surgical procedure was completed in all cases. No variable had predictive value regarding the outcome. Spontaneous respiration anesthesia is an efficient and relatively safe technique for microlaryngeal laser surgery in children with RRP.

Seventy-three patients with lip carcinoma were treated from 1970 to 1988 inthe Otolaryngology Department of the Beilinson Medical Center. The most common histological type was squamous cell carcinoma which occurred in 68 patients; four tumours were basal cell carcinoma and one acinic cell carcinoma. Carcinoma of the lip is more frequent in males. Nevertheless, the frequency of carcinoma in females in our series was substantially higher than the average reported in the literature. Forty-nine patients were treated surgically and 24 patients were treated by irradiation. Analysis of the results among thosetreated by surgery and those treated by irradiation shows a difference in tumour local control which was statistically significant (p = 0.025). Surgical treatment is recommended because of the advantage of tumour margin assessment, avoidance of radiotherapy complications and rapid rehabilitation. Two rare cases of carcinoma of the lip in young patients (age under 20 years) are presented.

The effect of 3-aminobenzamide, an inhibitor of poly (ADP-ribose) synthetase activity, was evaluated in a rat model of laryngeal injury induced by endotracheal intubation for 1 h. At 1 h after extubation, the laryngeal damage was characterized by areas of mucosal necrosis, submucosal edema, swelling of subglottic glands, and submucosal infiltration of inflammatory cells. Activity of myeloperoxidase, a marker of neutrophil infiltration, was also markedly increased into the damaged tissue. Immunohistochemistry for nitrotyrosine, an index of nitrosative stress, showed an intense staining in the inflamed larynx. Treatment with 3-aminobenzamide (10 mg/kg intraperitoneally) significantly reduced the appearance of mucosal damage and was associated with a significant reduction of tissue myeloperoxidase activity and nitrotyrosine immunoreactivity in the larynx. The results of this study suggest that poly (ADP-ribose) synthetase may play a role in the inflammatory process after laryngeal intubation and extubation, and administration of 3-aminobenzamide may be a beneficial therapeutic approach.

Different surgical methods have been advocated for closure of persistent tracheocutaneous fistula (TCF) in children. The objective of this study was to compare different methods of repair and postoperative care that were used for management of TCF in children. The charts of 98 children with persistent TCF who were surgically managed in our department between January 1990 and April 1997 were reviewed retrospectively. Excision of the fistulous tract and healing by secondary intention was employed in 18 patients. Eighty patients were managed by tract excision followed by primary closure. Sixty-three patients remained intubated for 18 to 24 hours postoperatively, while 17 patients were extubated in the recovery room. One patient had a large tracheal granuloma on follow-up endoscopy. Three patients needed a second procedure. No significant correlation was found between the method of surgical repair or the length of postoperative intubation and outcome. In our experience, TCF repair, either by primary closure or secondary intention, is a relatively safe and effective procedure in the pediatric age group. Preoperative evaluation and possible indications for selecting the method of repair are discussed.

Objective: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis. Study Design/]Methods: A retrospective review was performed of 38 children with severe subglottic stenosis who underwent partial cricotracheal resection. Information was obtained with regard to the specific anatomic location of the superior and inferior resection margins, the grade of subglottic stenosis preoperatively, the type of stenting material used postoperatively, and other surgical details specific to each procedure. Results: The superior resection margins were generally to the superior aspect of the cricoid cartilage but as high as the undersurface of the true vocal folds in a minority of patients. Inferior resection margins were generally to the second tracheal ring. Length of resection varied, but was as long as 3.0 cm in one patient. Overall surgical success based on decannulation was > 86%. Conclusion: Partial cricotracheal resection is a safe and successful procedure for the treatment of subglottic stenosis. The margins and length of resection should be tailored specifically for each patient; and special considerations must be taken when extensive resection to the level of the true vocal folds is required. Safe airway management in the postoperative period is essential. tracheal reconstruction.

Montgomery T-tubes are often used in adult patients; however, they are less commonly used in the pediatric age group. The purpose of this report is to describe our experience with this stent in pediatric laryngotracheal reconstruction. A retrospective chart review was performed to identify early and late complications. Nutritional assessments were made on the basis of weight percentile comparisons at the time of surgery and at the end of the stenting period. From 1990 to 1997, the Montgomery T-tube was utilized in 26 children undergoing 36 airway reconstruction procedures (21 laryngotracheoplasties and 15 cricotracheal resections). The upper limb of the tube extended above the level of the glottis in all patients. The patients ranged in age from 2.4 to 17.9 years. The duration of stenting ranged from 2 weeks to 23 months. Three patients (11.5%) had significant aspiration and did not improve following diet modifications and swallowing therapy, requiring tube feedings. One patient had postoperative subcutaneous emphysema that resolved spontaneously. Three patients required early removal of the stent due to an inability to tolerate plugging. Granulation tissue above the upper limb of the stent during the stenting period was noted after 6 laryngotracheal reconstruction procedures (16%). Only 1 patient fell off his growth curves during the period of stenting. There were no deaths in this series, and no emergent procedures were required. Postoperative and home care and management of complications are discussed. Our experience indicates that Montgomery T-tubes can be utilized relatively safely in children, providing that postoperative and home care are meticulous.

The clinical course of recurrent respiratory papillomatosis (RRP) in children is variable and unpredictable. At present there is no way to identify patients at risk for aggressive disease. The objective of this study was to evaluate whether DNA ploidy and cell proliferation analyses can predict the clinical course in children with RRP. Two different methods of estimating proliferation activity were compared. Nonembedded papilloma biopsy specimens from 18 pediatric patients were analyzed by flow cytometry providing DNA content with cell cycle analysis. The expression of the proliferative marker Ki-67 in papilloma tissue was quantified by immunohistochemistry. The patients were prospectively observed for 12 to 18 months. DNA content analysis and Ki-67 expression were compared to clinical information regarding number of disease sites, distal tracheobronchial spread, number of recurrences, need for tracheostomy, and disease remission. High S-phase fraction, proliferative index, and Ki-67 expression correlated with an aggressive clinical course. DNA ploidy analysis and immunodetection of proliferative markers may assist in predicting prognosis in children with RRP.

Objectives To determine the incidence of gastroesophageal reflux in patients with subglottic stenosis (SGS) and to determine if upper esophageal reflux occurs in addition to lower esophageal reflux in these patients. Design Esophageal pH probe studies were reviewed in patients diagnosed as having SGS. Setting A tertiary care pediatric medical center. Patients All patients diagnosed as having SGS between January 1990 and July 1996 who had undergone monitoring with an overnight esophageal pH probe. Seventy-four patients qualified for the study. All 74 patients underwent lower probe testing, and 55 of the 74 underwent dual (upper and lower) probe testing. Main Outcome Measures The percent of time a pH measurement of less than 4.0 was recorded in the upper and lower esophagus. A lower probe pH measurement of less than 4.0 more than 10% of the study time was considered high risk for developing reflux-associated pathologic symptoms. A lower probe pH measurement of less than 4.0 for 5% to 10% of the study time was considered a marginal risk for developing reflux-associated pathologic symptoms. Upper probe criteria for reflux-associated symptoms have not been established. Therefore, patients were grouped as having a pH of less than 4.0 in the upper esophagus for 0%, 0.1% to 0.9%, 1.0% to 1.9%, 2.0% to 3.0%, or more than 3% of the study time. Results Thirty-seven of the 74 patients who underwent lower probe testing had a pH of less than 4.0 more than 5% of the study time, and 24 had a pH of less than 4.0 more than 10% of the study time. Twelve of the 55 patients who underwent upper probe testing had no measurable reflux; 27 of the 55 had a pH of less than 4.0 more than 1% of the study time; 14 had a pH of less than 4.0 more than 2% of the study time, and 11 had a pH of less than 4.0 more than 3% of the study time. Conclusions Gastroesophageal reflux is frequently present in patients with SGS. Gastric contents frequently reach the upper and lower esophagus in these patients. In addition, the high incidence of gastroesophageal reflux in these patients suggests that it may play a role in the development of SGS. The possible effect of gastroesophageal reflux on the surgical repair of SGS requires further study.

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.

Extrathyroidal invasion of papillary carcinoma of the thyroid gland has a very bad prognosis. A retrospective study was performed on 40 specimens from patients with papillary carcinoma of the thyroid gland to find out whether DNA ploidy correlated with aggressive tumor behavior. The nuclear DNA content of 20 locally aggressive papillary thyroid carcinomas was studied by flow cytometry. The results were compared with those of a matched control group of 20 patients with noninvasive papillary tumors. Forty percent of the tumors with spread to extrathyroid tissue were aneuploid, whereas all the tumors without such extension were diploid. This difference was statistically significant (p < 0.003). The data suggest that the differentiation of locally noninvasive and invasive papillary thyroid carcinomas may be potentially possible by nuclear DNA determination.

Tall cell carcinoma of the thyroid gland is an aggressive variant of papillary carcinoma. A high nuclear DNA content has been associated with aggressive clinical behavior and an unfavorable prognosis in several malignant human tumors. It was also described in differentiated thyroid carcinoma. Therefore, analysis of the nuclear DNA content may yield information predictive of aggressive behavior. Accordingly, the DNA content of the tall cell variant was measured and compared with that of the usual form of papillary carcinoma by flow cytometry. Although all the aneuploid tumors were in the tall cell variant group, the difference in nuclear content was not statistically significant. We conclude that differences in the clinical behavior of these neoplasms are not related to alterations in DNA ploidy.

Objective: To evaluate the relationship between tumor angiogenesis and the subsequent development of cervical node metastases in patients with stage 1 carcinoma of the oral tongue. Methods: The study group consisted of 25 patients with T1 carcinoma with no evidence of neck disease at presentation. Paraffin blocks from 10 patients, in whom neck node metastases were found shortly after surgery, were stained for factor VIII and compared with those from 10 randomly chosen patients in whom no evidence of recurrent disease was observed during prolonged follow-up. Microvessels were counted in each group. Results: The microvessel counts correlated with metastatic disease. The mean±SD count was 103.41±40.72 per ×250 field in the patients with positive lymph node metastases and 50.03±13.74 per ×250 field in those with no lymph node metastases during follow-up ( P ≤.05). Conclusions: The number of microvessels per ×250 field in the area of most intensive neovascularization in early oral tongue carcinoma may be an independent predictor of nodal metastases. Assessment of tumor angiogenesis may therefore prove valuable in selecting patients with early oral tongue carcinoma for aggressive therapy. Arch Otolaryngol Head Neck Surg. 1996;122:865-868

Rhinocerebral mucormycosis is a fulminating, devastating fungal disease, usually associated with debilitating diseases such as diabetes mellitus, leukaemia and immunosuppressive conditions. Ten patients with this rare disease have been treated over the past 14 years at the Beilinson Medical Centre. Nine patients had an underlying debilitating disease and one patient had latent diabetes mellitus which was diagnosed only after presentation of mucormycosis. Only two of the 10 patients survived. Early aggressive surgical debridement, together with amphotericin B and correction of underlying metabolic acidosis were found to be important factors associated with survival.

The purpose of this study is to point out that contrary to traditional belief, there is a small but significant group of nondiabetic patients with malignant external otitis. Thirty patients with a diagnosis of malignant external otitis were treated and followed up at the Department of Otolaryngology—Head and Neck Surgery, Beilinson Medical Center, between 1987 and 1991. Nine of these patients did not have clinical or laboratory evidence of diabetes. This study analyzes this group and concludes that the diagnosis of malignant external otitis should be considered by the treating physician in nondiabetic patients presenting with a Pseudomonas aeruginosa infection of the external ear canal. Severe pain and edematous closure of the canal, together with typical granulation tissue and failure to respond to medical treatment, are specific characteristics of this group.

• Intravascular papillary endothelial hyperplasia is a vascular benign lesion bearing some similarities to malignant angiosarcoma. To the best of our knowledge, it has never been described within the paranasal sinuses. A case of such a lesion within the maxillary sinus appearing in a 17-year-old boy who presented with unilateral facial pains and proptosis is reported. The lesion, despite its benign nature, extended to the ethmoidal cells and nasal cavity and pressed the floor of the orbit. Clinically and histopathologically it may be mistaken for an angiosarcoma. An awareness of this similarity and the features in which it differs from angiosarcoma will prevent incorrect diagnosis and inappropriate treatment. ( Arch Otolaryngol Head Neck Surg . 1991;117:1182-1184)

Successful intubation can be accomplished in the majority of patients via direct laryngoscopy. However, situations frequently arise in which simple orotracheal intubation is contraindicated or impossible. In these situations retrograde tracheal intubation may be of particular use. This technique has been performed by novice physicians in cadavers, without difficulty or major complications. It has proved to be a quick, efficient and simple method to establish an endotracheal airway and should be a valuable adjunct for airway control.

Objective To determine if the presence of a tracheoesophageal fistula (TEF) alters outcome following laryngeal cleft repair. Design A retrospective review of patients diagnosed and treated for laryngeal clefts, with a minimum follow-up period of 1 year. Setting An academic tertiary care children's hospital. Patients Twenty-five pediatric patients diagnosed and surgically treated for laryngeal cleft. Main Outcome Measures Each chart was reviewed to determine if patients with a laryngeal cleft had been diagnosed with TEF and had undergone a surgical TEF repair procedure. The success of the surgery was evaluated based on the resolution of symptoms and the endoscopic evaluation of the repair site. Results Twenty-five patients were reviewed for study purposes. Fourteen had a history of TEF repair and 11, no history of TEF. All 25 patients underwent surgical repair of the laryngeal cleft. Twelve of the 14 patients with a history of TEF repair experienced a breakdown of the laryngeal cleft repair. Only 1 of the 11 patients with no history of TEF experienced such a breakdown. In 8 of 9 patients with a laryngotracheoesophageal type I cleft, surgical repair was not successful. Conclusions In our series, patients with laryngeal clefts who also had a history of TEF had a much higher incidence of breakdown of cleft repair compared with patients with no history of TEF. This finding is not conclusive and requires further investigation. The failure of cleft repair correlated with the severity of the cleft. The importance of these associations may lead to enhanced surgical planning and realistic preoperative family expectations.

Objective: To determine whether DNA ploidy and the S-phase fraction are predictive of the clinical course in children with recurrent respiratory papillomatosis. Design: Masked compression of DNA analysis findings to the clinical course of the disease. Setting: Tertiary referral center. Patients: All pediatric patients treated for recurrent respiratory papillomatosis at our institution between 1989 and 1995 who had adequate follow-up and whose primary biopsy specimen was available for examination. Fifty-five patients met these criteria. Methods: Information was collected from the case notes on the patient’s age at presentation, sex, sites of disease, duration of active disease, and frequency of operative interventions. Flow cytometric analysis was performed on the archival paraffin-embedded primary biopsy specimen obtained at the initial surgical excision, providing DNA content and percentages of S-phase cells. The investigators who performed the DNA analysis were masked to the clinical course. Results: The age of the patients at presentation ranged from 3 months to 16 years. Thirty patients had involvement in more than 1 anatomical site. The disease in 10 patients had spread to the distal tracheobronchial tree. The patients underwent a total of 1124 procedures, with a frequency range of 7 to 27 per year. All cell populations studied were diploid. The percentage of S-phase cells was significantly higher in the primary biopsy specimen from patients with disease characterized by more frequent recurrences, multiple sites, and distal extension (P,.05). In multiple regression analysis, the S-phase fraction was found to be an independent and powerful prognostic factor for aggressive disease. Conclusions: The S-phase fraction may be predictive of the clinical course in patients with juvenile respiratory papillomatosis. Prospective studies are needed to assess the diagnostic and clinical value of our primary results and to determine whether DNA analysis can assist in identifying patients at increased risk for an aggressive clinical course. Arch Otolaryngol Head Neck Surg. 1998;124:541-544