Publications by authors named "Peter J Koltai"

53 Publications

Sleep surgery in syndromic and neurologically impaired children.

Am J Otolaryngol 2020 Jul - Aug;41(4):102566. Epub 2020 May 27.

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, United States of America. Electronic address:

Purpose: To examine surgery performed for obstructive sleep apnea (OSA) in children with syndromic or neurologic comorbidities.

Material And Methods: Medical records of 375 children with OSA were retrospectively reviewed, including 142 patients with trisomy 21, 105 with cerebral palsy, 53 with muscular dystrophy, 32 with spinal muscular atrophy, 18 with mucopolysaccharidoses, 14 with achondroplasia, and 11 with Prader-Willi.

Outcome Measures: Apnea-hypopnea index (AHI), complications, length of postoperative stay, and endoscopic findings.

Results: 228 patients received 297 surgical interventions, with the remainder undergoing observation or positive pressure ventilation. Adenoidectomy was the most common procedure performed (92.1% of patients), followed by tonsillectomy (91.6%). Average AHI decreased following tonsillectomy, from 12.4 to 5.7 (p = 0.002). The most common DISE finding was the tongue base causing epiglottic retroflexion. Lingual tonsillectomy also resulted in an insignificant decrease in the AHI.

Conclusions: Adenotonsillectomy, when there is hypertrophy, remains the mainstay of management of syndromic and neurologically-impaired children with OSA. However, additional interventions are often required, due to incomplete resolution of the OSA. DISE is valuable in identifying remaining sites of obstruction and guiding future management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2020.102566DOI Listing
November 2020

Neonatal retropharyngeal abscess with complications: Apnea and cervical osteomyelitis.

Int J Pediatr Otorhinolaryngol 2019 Nov 31;126:109613. Epub 2019 Jul 31.

Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA. Electronic address:

Objective: To evaluate the clinical presentation and management strategies for neonatal retropharyngeal abscess (RPA).

Methods: Retrospective chart review was performed, and literature reviewed.

Results: We report two cases of neonatal RPA, with one complicated by cervical osteomyelitis, and the other presenting with apparent life-threatening events (ALTEs). A 6-week-old female underwent transoral drainage of an RPA, which grew methicillin sensitive Staphylococcus aureus. She had a prolonged recovery course and was found to have developed osteomyelitis of the dens and atlas. She was treated with 14 weeks of IV antibiotics and rigid collar fixation for spinal cord instability. A 2-month-old female was admitted after multiple ALTEs with episodes of apnea and pallor. Direct laryngoscopy revealed a bulging RPA, which was drained transorally. This grew multiple organisms including methicillin resistant Staphylococcus aureus, Streptococcal oralis and Prevotella species.

Conclusions: Uncommon in neonates, RPA can present in this age group without fever, and are is likely to have airway complications than in older children. In cases with prolonged recovery, additional diagnostic intervention is recommended to rule out rare complications such as osteomyelitis. Emphasis in such complex cases is placed on a multidisciplinary approach to patient care, coordinating neonatologists, infectious disease specialists, neurosurgeons, and otolaryngologists.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2019.109613DOI Listing
November 2019

Harare children's hospital airway symposium and pentafrica conference 2018.

Int J Pediatr Otorhinolaryngol 2018 10 20;113:v-vi. Epub 2018 Jul 20.

Department of Otolaryngology, Stanford University, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2018.07.001DOI Listing
October 2018

Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea: A Meta-analysis.

JAMA Otolaryngol Head Neck Surg 2017 06;143(6):561-568

Department of Otolaryngology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei5Sleep Center, National Taiwan University Hospital, Taipei.

Importance: Evidence indicates correlations between lingual tonsil hypertrophy and pediatric obstructive sleep apnea (OSA). However, to our knowledge, a meta-analysis of surgical outcomes for lingual tonsillectomy in children with OSA has not been conducted.

Objective: To evaluate the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric OSA.

Data Sources: The study protocol was registered on PROSPERO (CRD42015027053). PubMed, MEDLINE, EMBASE, and the Cochrane Reviews databases were searched independently by 2 authors for relevant articles published by September 2016.

Study Selection: The literature search identified English-language studies that used polysomnography to evaluate children with lingual tonsil hypertrophy and OSA after lingual tonsillectomy alone. The search keywords were lingual tonsil, lingual tonsillectomy, sleep endoscopy, sleep apnea, and child.

Data Extraction And Synthesis: Polysomnographic data from each study were extracted. A random-effects model pooled postoperative sleep variable changes and success rates for lingual tonsillectomy in treating pediatric OSA.

Main Outcomes And Measures: Four outcomes for lingual tonsillectomy were analyzed. These included net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum oxygen saturation, the overall success rate for a postoperative AHI less than 1, and the overall success rate for a postoperative AHI less than 5.

Results: This meta-analysis consisted of 4 studies (mean sample size, 18.25 patients), with a total of 73 unique patients (mean [SD] age, 8.3 [1.1] years). Fifty-nine percent (27 of 46) of the patients were male, and 1 of the 4 studies did not specify number of males. Lingual tonsillectomy was indicated for persistent OSA after adenotonsillectomy in all cases. Lingual tonsil hypertrophy was evaluated using computed tomography or magnetic resonance imaging in 1 study, sleep endoscopy in 2 studies, and cine magnetic resonance imaging in 1 study. The mean change in the AHI after lingual tonsillectomy was a reduction of 8.9 (95% CI, -12.6 to -5.2) events per hour. The mean change in the minimum oxygen saturation after lingual tonsillectomy was an increase of 6.0% (95% CI, 2.7%-9.2%). The overall success rate was 17% (95% CI, 7%-35%) for a postoperative AHI less than 1 and 51% (95% CI, 25%-76%) for a postoperative AHI less than 5. Postoperative complications that developed included airway obstruction, bleeding, and pneumonia.

Conclusions And Relevance: Lingual tonsillectomy is an effective surgical management for children with OSA caused by lingual tonsil hypertrophy, and it achieves significant improvement in the AHI and the minimum oxygen saturation. However, children frequently have residual OSA after lingual tonsillectomy, and postoperative complications must be carefully managed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoto.2016.4274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5824231PMC
June 2017

It Is Just Attention-Deficit Hyperactivity Disorder…or Is It?

J Dev Behav Pediatr 2017 Feb/Mar;38(2):169-172

*Division of Neonatal and Developmental Medicine, Stanford University School of Medicine Palo Alto, California; †Sleep Medicine Division, Stanford University Palo Alto, California; ‡Division of Otolaryngology, Stanford University School of Medicine Palo Alto, California; §Division of Orofacial Sciences, UCSF School of Dentistry San Francisco, CA; ‖Department of Psychiatry, Stanford University San Francisco, CA; ¶Division of Academic General Pediatrics and Developmental Behavioral Pediatics University of California San Diego, Rady Chilidren's Hospital San Diego, CA; **Division of Neonatal and Developmental Medicine, Stanford University School of Medicine Palo Alto, California.

Case: Carly is a 5-year-old girl who presents for an interdisciplinary evaluation due to behaviors at school and home suggestive of attention-deficit hyperactivity disorder (ADHD). Parent report of preschool teacher concerns was consistent with ADHD. Psychological testing showed verbal, visual-spatial, and fluid reasoning IQ scores in the average range; processing speed and working memory were below average. Carly's behavior improved when her mother left the room, and she was attentive during testing with a psychologist. Tests of executive function (EF) skills showed mixed results. Working memory was in the borderline range, although scores for response inhibition and verbal fluency were average. Parent ratings of ADHD symptoms and EF difficulties were elevated.Carly's parents recently separated; she now lives with her mother and sees her father on weekends. Multiple caregivers with inconsistent approaches to discipline assist with child care while her mother works at night as a medical assistant. Family history is positive for ADHD and learning problems in her father. Medical history is unremarkable. Review of systems is significant for nightly mouth breathing and snoring, but no night waking, bruxism, or daytime sleepiness. She has enlarged tonsils and a high-arched palate on physical examination.At a follow-up visit, parent rating scales are consistent with ADHD-combined type; teacher rating scales support ADHD hyperactive-impulsive type. Snoring has persisted. A sleep study indicated obstructive sleep apnea. After adenotonsillectomy, Carly had significant improvement in ADHD symptoms. She developed recurrence of behavior problems 1 year after the surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/DBP.0000000000000386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5401711PMC
December 2017

Comparison of treatment outcomes between intracapsular and total tonsillectomy for pediatric obstructive sleep apnea.

Int J Pediatr Otorhinolaryngol 2016 Dec 24;91:15-18. Epub 2016 Sep 24.

Stanford Department of Otolaryngology - Head and Neck Surgery, 801 Welch Road, Stanford, CA 94305, United States. Electronic address:

Background: Intracapsular tonsillectomy (IT) has been advocated as a treatment for pediatric obstructive sleep apnea (OSA). However, evidence in the literature utilizing polysomnography (PSG) is limited.

Objective: To examine the experience at a tertiary children's hospital to evaluate the effectiveness and risks of intracapsular tonsillectomy compared to total tonsillectomy (TT) for treating pediatric OSA.

Methods: A retrospective study was undertaken of pediatric tonsillectomy cases performed for OSA at a tertiary children's hospital from 2005 to 2010. Patients with recurrent tonsillitis, craniofacial abnormalities, chromosomal abnormalities, neuromuscular disease, and congenital malformations were excluded. Main outcome measures were apnea-hypopnea index (AHI), minimum oxygen saturation (minO), and surgical complications.

Results: Of the 1583 patients reviewed in this study, there were 75 IT and 93 TT patients with pre- and post-operative PSG results. The IT patients were younger, had lower BMI, larger tonsil size, lower pre-operative (AHI) and lower post-operative AHI (p < 0.05). There was a similar percentage of patients that showed improvement in AHI and minimum oxygen saturation between the IT and TT groups. There were statistically similar average change in AHI and minimum oxygen saturation between the IT and TT groups at 5.6 ± 8.6 and 8.6 ± 12.9, respectively (p = 0.8) as well as similar improvement in minimum oxygen saturation between the two groups at 3.3% ± 4.3% and 3.0% ± 5.2%, respectively (p = 0.66). Of TT patients, 2.9% experienced post-operative bleeding with 1.6% requiring OR for control of hemorrhage. Of IT patients, 2.2% were found to have tonsillar regrowth with 2.0% returning to the OR for secondary tonsillectomy.

Conclusions: Intracapsular tonsillectomy, like total tonsillectomy, is effective in improving polysomnogram results in appropriately selected children. Intracapsular tonsillectomy is a suitable option for the surgical treatment of pediatric OSA consequent to its demonstrated efficacy in relieving OSA and its favorable safety profile.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2016.09.029DOI Listing
December 2016

The current state of pediatric drug-induced sleep endoscopy.

Laryngoscope 2017 01 16;127(1):266-272. Epub 2016 Jun 16.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Otolaryngology, Head and Neck Surgery, University of California, San Francisco, California.

Objectives/hypothesis: The purpose of this investigation was to assess current drug-induced sleep endoscopy (DISE) practice patterns at centers that have published on the technique, to identify areas of agreement, and to identify areas of disagreement that may represent opportunities for improvement and standardization.

Study Design: Multi-institutional survey.

Methods: A survey was designed in two phases to evaluate preoperative assessment, intraoperative performance, and postoperative management of patients undergoing DISE. The survey was constructed iteratively in consultation with the all of the coauthors, each selected as an expert owing to their previous publication of one or more articles pertaining to pediatric DISE. In the first phase of survey creation, each expert was asked to provide narrative answers to questions pertaining to DISE. These responses served as the basis for a second survey. This second survey was then administered to all pediatric otolaryngologists at each respective institution.

Results: Overall, there was a low rate of agreement (33%) among the respondents; however, there was substantial agreement within institution, particularly for the use of anesthetic medications, the use of cine magnetic resonance imaging, and performance of bronchoscopy along with DISE. There was strong agreement among all respondents for performing DISE in a child with severe obstructive sleep apnea following adenotonsillectomy, regardless of comorbidities.

Conclusion: This multi-institutional survey demonstrated a lack of consensus between experts and multiple opportunities for improvement. In general, there was agreement regarding the workup prior to DISE performance and the endoscopic protocol but disagreement regarding anesthetic protocol and management decisions.

Level Of Evidence: 4. Laryngoscope, 127:266-272, 2017.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.26091DOI Listing
January 2017

Gizmo is a mean word!

Authors:
Peter J Koltai

Otolaryngol Head Neck Surg 2015 Apr;152(4):581-2

Stanford University, Stanford, California, USA

The editorial titled "Gizmos" in the April issue of Otolaryngology-Head and Neck Surgery was unfortunate. Intracapsular tonsillectomy is a rational surgical option for managing tonsillar hypertrophy causing obstructive sleep apnea in selected children. It is performed routinely by surgeons across the globe and has become the standard of care across northern Europe due to the high safety profile of the operation. The semirigid, dartlike design of the sinuplasty devices suggested the idea for an airway-specific set of high-pressure balloons. We began working on these in 2007 and had FDA approval in 2009. They are in wide use by many airway surgeons. Lingual tonsils are a frequent cause of obstructive sleep apnea, and there is no tool that manages this as effectively as endoscopic plasma ablation. We are all engaged in an honorable effort to improve care; surgical and creative skills are as important as analytical skills. Both are necessary for the continuous improvement of our work. Both are worthy of respect.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599814560131DOI Listing
April 2015

Pediatric teratoma and dermoid cysts.

Otolaryngol Clin North Am 2015 Feb;48(1):121-36

Division of Pediatric Otolaryngology, Lucile Packard Children's Hospital, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305-5739, USA. Electronic address:

Teratomas and dermoid cysts are germ cell neoplasms. This article focuses on cervical and craniofacial teratomas. Presentation of these neoplasms varies in degree of severity, from cosmetic deformities to airway distress requiring emergent intervention. Nasal lesions (particularly if suspicious for a nasal dermoid) require imaging before biopsy to assess for intracranial extension. Treatment consists of airway management if respiratory distress is present, and early surgical intervention. Postoperative follow-up is required to monitor for recurrence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.otc.2014.09.009DOI Listing
February 2015

The transpalatal approach to repair of congenital Basal skull base cephaloceles.

J Neurol Surg B Skull Base 2014 Apr 10;75(2):96-103. Epub 2014 Feb 10.

Division of Pediatric Otolaryngology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California, United States.

Basal skull base herniations, including meningoceles and encephaloceles, are rare and may present with characteristic facial and neurologic features. The traditional craniotomy approach has known morbidity, and nasal endoscopy may not allow for control of large posterior basal defects, especially in newborns. We present two cases of successful repair of basal transsphenoidal meningoceles using an oral-transpalatal approach. The first patient with an intact palate presented with respiratory distress, and a palatectomy was performed for access to the skull base. The second patient had a large basal herniation that was reduced through a congenital midline cleft palate, and a calvarial bone graft was used to repair the defect. A literature search revealed 10 previous successful cases using the transpalatal repair, which allows for excellent access, low morbidity, and a team-oriented method to skull base surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0033-1358374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083594PMC
April 2014

Pediatric button battery injuries: 2013 task force update.

Int J Pediatr Otorhinolaryngol 2013 Sep 27;77(9):1392-9. Epub 2013 Jul 27.

Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital and Wexner Medical Center at Ohio State University, Columbus, OH 43205, United States.

Over the last 10 years, there has been a dramatic rise in the incidence of severe injuries involving children who ingest button batteries. Injury can occur rapidly and children can be asymptomatic or demonstrate non-specific symptoms until catastrophic injuries develop over a period of hours or days. Smaller size ingested button batteries will often pass without clinical sequellae; however, batteries 20mm and larger can more easily lodge in the esophagus causing significant damage. In some cases, the battery can erode into the aorta resulting in massive hemorrhage and death. To mitigate against the continued rise in life-threatening injuries, a national Button Battery Task Force was assembled to pursue a multi-faceted approach to injury prevention. This task force includes representatives from medicine, public health, industry, poison control, and government. A recent expert panel discussion at the 2013 American Broncho-Esophagological Association (ABEA) Meeting provided an update on the activities of the task force and is highlighted in this paper.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2013.06.006DOI Listing
September 2013

Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: inter-observer correlation and comparison with awake endoscopy.

Int J Pediatr Otorhinolaryngol 2013 May 22;77(5):752-5. Epub 2013 Feb 22.

Pediatric Otolaryngology Unit, Department of Otolaryngology Head and Neck Surgery, Dana Children's Hospital, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: Evaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy.

Method:

Design: retrospective case series; blinded review.

Setting: tertiary care children's hospital.

Patients: Children with persistent obstructive sleep apnea.

Interventions: Both awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey.

Main Outcome Measures: reviewers scored the following parameters: each structure's contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good).

Results: When reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value<0.05). Level of confidence among the four observers was higher in older children and lower in children with severe OSA.

Conclusions: Sleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2013.02.002DOI Listing
May 2013

Effect of obesity and medical comorbidities on outcomes after adjunct surgery for obstructive sleep apnea in cases of adenotonsillectomy failure.

Arch Otolaryngol Head Neck Surg 2012 Oct;138(10):891-6

Department of Otolaryngology–Head and Neck Surgery, 801 Welch Rd, Second Floor, Stanford, CA 94305, USA.

Objective: To evaluate the effect of body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) and medical comorbidities on outcomes after lingual tonsillectomy and supraglottoplasty performed for obstructive sleep apnea syndrome (OSAS) caused by lingual tonsillar hypertrophy and occult laryngomalacia.

Design: Retrospective case review series

Setting: Academic tertiary referral center

Patients: Children with persistent OSAS after adenotonsillectomy who underwent surgery to correct obstruction at the level of the lingual tonsils and/or supraglottis identified on sleep endoscopy.

Interventions: All children underwent lingual tonsillectomy, supraglottoplasty, or both.

Main Outcome Measures: Change in polysomnographic parameters, including apnea-hypopnea index (AHI), number of nighttime apneas, and lowest oxygen saturation level.

Results: We analyzed the medical records of 84 children with persistent OSAS after adenotonsillectomy who underwent either lingual tonsillectomy (n = 68), supraglottoplasty (n = 24) or both (n = 8). Compared with children with lingual tonsillar hypertrophy, children with occult laryngomalacia were younger, had lower BMI, and were more likely to have a medical comorbidity. Overall, both operations significantly improved the AHI; however, children with comorbidities had significantly higher postoperative AHIs after supraglottoplasty than those without, and overweight children had significantly higher postoperative AHIs after lingual tonsillectomy than those of normal weight. The BMI z-score and age had direct, though weak, correlations with postoperative AHI among all children undergoing either technique of adjunct airway surgery.

Conclusions: Lingual tonsillar hypertrophy and occult laryngomalacia are 2 important causes of residual OSAS after adenotonsillectomy. However, they tend to affect distinct populations of children, and though appropriate surgical correction can improve AHI, cure rates are significantly worse for overweight children undergoing lingual tonsillectomy and for children with medical comorbidities undergoing supraglottoplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/2013.jamaoto.197DOI Listing
October 2012

The "postcricoid cushion": observations on the vascular anatomy of the posterior cricoid region.

Arch Otolaryngol Head Neck Surg 2012 Jun;138(6):562-71

Division of Pediatric Otolaryngology, Children’s Memorial Hospital, Chicago, IL 60614, USA.

Objective: To describe the cyclical vascular enlargement that occurs in the postcricoid region during the expiratory phase on an infant's cry, and to consider the anatomic, physiologic, and clinical implications of this phenomenon, which we term the "postcricoid cushion."

Design: A total of 125 consecutive office fiber-optic laryngoscopic examinations in children and infants were reviewed for engorgement and vascular discoloration of the postcricoid region. Presence of a postcricoid cushion in relation to patient age was reviewed. A comprehensive literature review was also performed.

Setting: Tertiary care pediatric hospital.

Patients: Patients from newborns to 17 years old undergoing laryngoscopy for any reason.

Results: Sixty-one percent of the videos showed a postcricoid cushion with cyclical enlargement during crying. Eighty-eight percent of children younger than 24 months had presence of a cushion compared with only 38% of children 24 months or older (P < .001). Twenty-five percent of the cushions had violaceous discoloration that resembled a vascular malformation.

Conclusions: Anatomic studies have demonstrated a rich venous plexus in the postcricoid region of the larynx. During the expiratory phase of an infant's cry, there is a cyclical engorgement, occasionally with vascular discoloration, in the postcricoid region at the same level of the venous plexus-the "postcricoid cushion." We propose that during crying, with acute elevation in intrathoracic pressure, there is a filling of the plexus, causing apposition of the postcricoid cushion against the posterior pharyngeal wall, which may serve as a protective barrier to emesis in infants. Our observations relate and differentiate this normal physiologic phenomenon from the rare cases of postcricoid vascular anomalies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archoto.2012.932DOI Listing
June 2012

Sleep endoscopy in the evaluation of pediatric obstructive sleep apnea.

Int J Pediatr 2012 15;2012:576719. Epub 2012 Feb 15.

Division of Pediatric Otolaryngology, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, CA 90027, USA.

Pediatric obstructive sleep apnea (OSA) is not always resolved or improved with adenotonsillectomy. Persistent or complex cases of pediatric OSA may be due to sites of obstruction in the airway other than the tonsils and adenoids. Identifying these areas in the past has been problematic, and therefore, therapy for OSA in children who have failed adenotonsillectomy has often been unsatisfactory. Sleep endoscopy is a technique that can enable the surgeon to determine the level of obstruction in a sleeping child with OSA. With this knowledge, site-specific surgical therapy for persistent and complex pediatric OSA may be possible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2012/576719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299368PMC
August 2012

Sleep endoscopy as a diagnostic tool in pediatric obstructive sleep apnea.

Int J Pediatr Otorhinolaryngol 2012 May 13;76(5):722-7. Epub 2012 Mar 13.

Division of Pediatric Otolaryngology, Lucile Packard Children's Hospital at Stanford, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Stanford, CA 94305, USA.

Objectives: Ten to twenty percent of children have persistent obstructive sleep apnea (OSA) after adenotonsillectomy (T&A). We hypothesize that sleep endoscopy, a flexible fiberoptic examination of the pharynx under anesthesia, is an effective tool for identifying sites of persistent obstruction.

Methods: In this retrospective cohort study, we reviewed records of children who had symptoms consistent with OSA and a positive polysomnogram (PSG) who underwent sleep endoscopy followed by sleep endoscopy directed surgery. Data collection included age, BMI and co-morbidities. Apnea-hypopnea index (AHI) was compared to pre and post surgery for each child using a paired t-test.

Results: Of the 80 children who underwent sleep endoscopy followed by directed surgery, 65% were male, mean age was 6 years (SD 3.75 years), average BMI was 19 (SD 0.43 years) and 28% had co-morbidities. For the 51% of patients who had persistent OSA after T&A, the mean AHI after sleep endoscopy directed surgery was significantly lower then before surgery (7.9 vs. 15.7, p<.01). For the 49% of patients who had never undergone surgery for OSA, or who were surgically naïve, and underwent sleep endoscopy directed surgery, the mean AHI was significantly lower then before surgery (8.0 vs. 13.8, p<.01).

Conclusions: Sleep endoscopy is a consistently reliable tool for identifying the sites of obstruction in both surgically naive children and those with persistent OSA after T&A.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2012.02.028DOI Listing
May 2012

Supraglottoplasty for occult laryngomalacia to improve obstructive sleep apnea syndrome.

Arch Otolaryngol Head Neck Surg 2012 Jan;138(1):50-4

Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, Stanford University School of Medicine, CA, USA.

Objective: To evaluate the polysomnographic outcomes after supraglottoplasty (SGP) performed for obstructive sleep apnea syndrome (OSAS) associated with occult laryngomalacia.

Design: Retrospective case series with medical chart review.

Setting: Tertiary pediatric medical center.

Patients: Twenty-two patients aged 2 to 17 years met the inclusion criteria of polysomnography-proven OSAS and occult laryngomalacia seen on flexible fiber-optic sleep endoscopy. Infants with congenital laryngomalacia were excluded.

Intervention: Carbon dioxide laser SGP was performed either alone or in conjunction with other operations for OSAS.

Main Outcome Measure: Preoperative and postoperative nocturnal polysomnographic data were paired and analyzed statistically.

Results: Supraglottoplasty for occult laryngomalacia resulted in statistically significant reduction in the apnea-hypopnea index (AHI) (from 15.4 to 5.4) (P <.001). Subgroup analysis of children who underwent either SGP alone or in combination with other interventions showed comparable reductions in AHI. Medical comorbidities were associated with worsened postoperative outcomes, although still significantly improved compared with baseline. Overall, 91% of children had an improvement in AHI, and 64% had only mild or no residual OSAS after SGP.

Conclusion: Supraglottoplasty is an effective technique for the treatment of OSAS associated with occult laryngomalacia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archoto.2011.233DOI Listing
January 2012

The use of botulinum toxin for pediatric cricopharyngeal achalasia.

Int J Pediatr Otorhinolaryngol 2011 Sep;75(9):1210-4

Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, United States.

Objectives: Cricopharyngeal achalasia is an uncommon cause of feeding difficulties in the pediatric population, and is especially rare in infants. Traditional management options include dilation or open cricopharyngeal myotomy. The use of botulinum toxin has been preliminarily reported for cricopharyngeal achalasia in children as a modality for diagnosis and management. This study describes the use of botulinum toxin as a definitive treatment for pediatric cricopharyngeal achalasia.

Methods: A retrospective analysis was performed of three patients who were diagnosed with cricopharyngeal achalasia and underwent botulinum toxin injections to the cricopharyngeus muscle. The charts were reviewed for etiology, botulinum toxin dosage delivered, length of follow-up, postoperative need for nasogastric tube placement, and swallow studies.

Results: A total of 7 botulinum toxin injections into the cricopharyngeus muscle were performed in three infants with primary cricopharyngeal achalasia between April 2006 and February 2011. Mean dosage was 23.4 units per session (range: 10-44 units), or 3.1 U/kg (range: 1.4-5.3 U/kg). Mean interval period between injections was 3.3 months (range: 2.7-4.0 months). Mean follow-up period was 22.1 months (range: 3.4-44.5 months). One patient required hospital readmission after injection for presumed aspiration but recovered without need for surgical intervention. No long-term complications were noted post-operatively. All patients improved clinically and ultimately had their nasogastric feeding tubes removed.

Conclusions: Botulinum toxin appears to be a safe and effective option in the management of primary cricopharyngeal achalasia in children, and may prevent the need for myotomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2011.07.022DOI Listing
September 2011

The use of botulinum toxin for pediatric cricopharyngeal achalasia.

Int J Pediatr Otorhinolaryngol 2011 Jun 17;75(6):830-4. Epub 2011 Apr 17.

Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA 94305, USA.

Objectives: Cricopharyngeal achalasia is an uncommon cause of feeding difficulties in the pediatric population, and is especially rare in infants. Traditional management options include dilation or open cricopharyngeal myotomy. The use of botulinum toxin has been preliminarily reported for cricopharyngeal achalasia in children as a modality for diagnosis and management. This study describes the use of botulinum toxin as a definitive treatment for pediatric cricopharyngeal achalasia.

Methods: A retrospective analysis was performed of three patients who were diagnosed with cricopharyngeal achalasia and underwent botulinum toxin injections to the cricopharyngeus muscle. The charts were reviewed for etiology, botulinum toxin dosage delivered, length of follow-up, post-operative need for nasogastric tube placement, and swallow studies.

Results: A total of 7 botulinum toxin injections into the cricopharyngeus muscle were performed in three infants with primary cricopharyngeal achalasia between April 2006 and February 2011. Mean dosage was 23.4 units per session (range: 10-44 units), or 3.1 U/kg (range: 1.4-5.3 U/kg). Mean interval period between injections was 3.3 months (range: 2.7-4.0 months). Mean follow-up period was 22.1 months (range: 3.4-44.5 months). One patient required hospital readmission after injection for presumed aspiration but recovered without need for surgical intervention. No long-term complications were noted post-operatively. All patients improved clinically and ultimately had their nasogastric feeding tubes removed.

Conclusions: Botulinum toxin appears to be a safe and effective option in the management of primary cricopharyngeal achalasia in children, and may prevent the need for myotomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2011.03.017DOI Listing
June 2011

Choanal atresia: current concepts and controversies.

Curr Opin Otolaryngol Head Neck Surg 2009 Dec;17(6):466-70

Division of Pediatric Otolaryngology, Stanford University, Stanford, California 94305, USA.

Purpose Of Review: Choanal atresia is a common and widely recognized craniofacial disorder characterized by obliteration of the posterior nasal aperture. Given the long time since its original description, controversy persists regarding pathogenesis and optimal surgical techniques. This review addresses current literature on choanal atresia and identifies areas of debate and future opportunities in research.

Recent Findings: Recent molecular mechanisms in retinoic acid receptor development have been described in the pathogenesis of choanal atresia. Whereas surgical treatment is generally believed to be effective in alleviating respiratory symptoms, consistent data confirming efficacy are scarce regarding best surgical approach with and without endoscopic sinus techniques, adjuvant use of stents, use of antiproliferative agents and laser-assisted surgery. Recent studies regarding each technique are discussed.

Summary: Despite vigorous research, the pathogenesis remains elusive and unproven. Many surgical techniques have been advocated; however, there is no dominant approach. Trends in treatment are directed towards the use of highly advanced endoscopic approaches with the use of microdebriders, small drill bits and telescopes to minimize traumatic injury that leads to postoperative scarring and restenosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MOO.0b013e328332a4ceDOI Listing
December 2009

Persistent pediatric obstructive sleep apnea and lingual tonsillectomy.

Otolaryngol Head Neck Surg 2009 Jul;141(1):81-5

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.

Objective: To describe a new method and the indications for lingual tonsillectomy with endoscopy and coblation, and to document its utility for treating children with persistent obstructive sleep apnea after previous tonsillectomy and adenoidectomy.

Study Design And Setting: Case series with chart review in a tertiary pediatric medical center.

Subjects And Methods: Twenty-six patients aged 3 to 20 met the inclusion criteria of polysomnography-proven persistent obstructive sleep apnea after tonsillectomy and adenoidectomy, as well as diagnosis of lingual tonsillar hypertrophy made by flexible fiberoptic sleep endoscopy. Endoscopic-assisted coblation lingual tonsillectomies were performed between June 2005 and January 2008. Preoperative and postoperative nocturnal polysomnogram data were paired and analyzed statistically.

Results: Statistically significant reductions in the respiratory distress index (RDI) were seen when preoperative and postoperative data were compared (mean, 14.7 vs 8.1). There were similar reductions in the number of obstructive apneas and hypopneas. The mean minimum O2 saturation did not change. Two patients in this series developed adhesions between the epiglottis and tongue base; there appeared to be no consequence for airway or feeding issues.

Conclusion: Endoscopic-assisted coblation lingual tonsillectomy is an effective technique for the treatment of lingual tonsillar hypertrophy causing persistent obstructive sleep apnea in some children.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.otohns.2009.03.011DOI Listing
July 2009

Airway management in Nager Syndrome.

Int J Pediatr Otorhinolaryngol 2008 Dec 22;72(12):1885-8. Epub 2008 Oct 22.

Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, United States.

Nager acrofacial dysostosis is a rare congenital syndrome characterized by malformed mandibulofacial structures and pre-axial upper limbs. Trismus and glossoptosis from mandibular abnormalities predisposes infants to life-threatening respiratory distress. A case of a Nager Syndrome mother delivering a similarly afflicted fetus is presented, with approaches to maintaining both tenuous airways described. Distinguishing this condition from similar syndromes is critical for care and prognosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2008.09.007DOI Listing
December 2008

Pediatric tracheal stenosis.

Otolaryngol Clin North Am 2008 Oct;41(5):999-1021, x

Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, CA 94305, USA.

Tracheal stenosis is a rare, potentially life-threatening condition described as innate narrowing of the tracheal lumen. The causes of tracheal stenosis vary widely. The most common forms result from prolonged intubation, although congenital causes usually involve complete tracheal rings or compression from cardiovascular malformations. The condition historically has harbored a poor prognosis, but significant advances in radiologic diagnosis, cardiac bypass, and endoscopic and surgical treatments have led to a range of options, better overall survival, and reduced morbidity. The complex, long-term manifestations of tracheal stenosis point to the need for individualized treatment as well as multidisciplinary care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.otc.2008.04.006DOI Listing
October 2008

The management of the obstructed pediatric airway. Preface.

Authors:
Peter J Koltai

Otolaryngol Clin North Am 2008 Oct;41(5):xiii

Division of Pediatric Otolaryngology, Sanford University, School of Medicine, Stanford, CA 94305, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.otc.2008.04.001DOI Listing
October 2008

Pathology quiz case 1. Foregut duplication cyst.

Arch Otolaryngol Head Neck Surg 2007 Sep;133(9):946, 948

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.133.9.946DOI Listing
September 2007

3.5-Year follow-up of intralesional cidofovir protocol for pediatric recurrent respiratory papillomatosis.

Int J Pediatr Otorhinolaryngol 2006 Nov 17;70(11):1911-7. Epub 2006 Aug 17.

Head & Neck Institute, Cleveland Clinic Foundation, Desk A71, 9500 Euclid Avenue, Cleveland, OH 44195, United States.

Objectives: Intralesional injection of cidofovir has been described as an adjunctive treatment for pediatric recurrent respiratory papillomatosis (RRP). However, questions remain regarding the optimal dosing schedule and side-effect profile. The objective of this study was to describe patient outcomes following a standardized cidofovir protocol.

Methods: Eleven pediatric patients originally treated with a standardized stepped-dose protocol of intralesional cidofovir for RRP were followed for an extended observational period. Additional interventions, disease severity, and adverse outcomes were recorded.

Results: Five of 11 patients have required no further treatments following the original cidofovir protocol. Two patients initially achieved remission but have subsequently required additional treatment for recurrent disease. Four patients never achieved remission and have undergone multiple additional interventions. Mean follow-up time for all patients from the conclusion of the original study was 30.2 months (10-45). No adverse outcomes were noted.

Conclusions: Intralesional injection of cidofovir may have some potential as an adjunct in the treatment of RRP. Response to cidofovir is unpredictable. Further study of cidofovir is necessary to more clearly define whether the favorable responses observed represent a true treatment effect or simply reflect the natural history of the disease. Perhaps as important is to refine treatment protocols and informed consents that reflect the concern about the carcinogenic potential of cidofovir and to better characterize the drug's side-effect profile.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2006.06.018DOI Listing
November 2006

Anterior and posterior cartilage graft dimensions in successful laryngotracheal reconstruction.

Arch Otolaryngol Head Neck Surg 2006 Jun;132(6):631-4

Division of Pediatric Otolaryngology, Stanford University, Stanford, Calif, USA.

Objective: To describe the dimensions of cartilage grafts used for successful laryngotracheal reconstruction, with the goal of establishing appropriate sizes for "off-the-shelf" tissue-engineered cartilage grafts.

Design: A retrospective review of prospectively maintained operative illustrations of a single surgeon's experience.

Setting: Two tertiary children's hospitals.

Patients: A consecutive sample of 54 patients (tracheotomized or intubated) with a diagnosis of subglottic stenosis.

Interventions: Each patient underwent anterior (n = 30), posterior (n = 3), or anterior and posterior (n = 22) laryngotracheal reconstruction. Rib cartilage was used in 51 patients and thyroid cartilage was used in 3 patients.

Main Outcome Measure: Successful or failed extubation.

Results: Of the 54 patients, 48 (89%) were successfully decannulated. The mean +/- SEM length of the anterior graft was 20.7 +/- 10.3 mm, and the mean width of the anterior graft was 7.7 +/- 2.5 mm. The mean length of the posterior graft was 13.9 +/- 2.9 mm, and the mean width of the posterior graft was 4.2 +/- 0.9 mm.

Conclusions: With the prospect of tissue-engineered cartilage implants becoming available for laryngotracheal reconstruction, the most appropriate templates for designing these implants should be based on the geometric dimensions of grafts carved from native tissues in cases that have been successfully decannulated. Based on our analysis, the use of 2-mm increments for the posterior grafts suggests a set of molds that are 2, 4, and 6 mm wide and 22 mm long. Using 2 x 2-mm increments for the anterior grafts indicates that 36 mold sizes will be sufficient for 90% of predicted cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.132.6.631DOI Listing
June 2006

Cost-effectiveness of tonsillectomy for recurrent acute tonsillitis.

Ann Otol Rhinol Laryngol 2006 May;115(5):365-9

Department of Otolaryngology-Head and Neck Surgery, Wakayama Medical University, Wakayama City, Japan.

Objectives: We used a retrospective case series to perform a preliminary study to determine the clinical effectiveness and cost-effectiveness of tonsillectomy for recurrent acute tonsillitis.

Methods: We studied 25 children and 16 adults who had tonsillectomy for recurrent acute tonsillitis. The adult patients and the children's caregivers were asked to respond to a questionnaire regarding the efficacy of their tonsillectomy. The cost of medical care and the work disability cost for tonsillitis and for tonsillectomy were calculated. We then applied the technique of break-even time analysis to assess when the total health care cost savings from surgery overtook the total cost of tonsillectomy.

Results: In children, the overall economic costs (medical costs and work-related costs) were recovered at 1.6 years after tonsillectomy (break-even point). In adults, the overall economic costs (medical costs and work-related costs) were recovered at 2.5 years after tonsillectomy (break-even point).

Conclusions: Tonsillectomy for recurrent acute tonsillitis is both clinically effective and cost-effective for children and adults in Japan.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/000348940611500509DOI Listing
May 2006

PHACE syndrome: report of a case with a glioma of the anterior skull base and ocular malformations.

Int J Pediatr Otorhinolaryngol 2006 Mar 6;70(3):561-4. Epub 2005 Sep 6.

The Head and Neck Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

PHACE syndrome consists of the constellation of manifestations including Posterior fossa anomalies of the brain (most commonly Dandy-Walker malformations), Hemangiomas of the face and scalp, Arterial abnormalities, Cardiac defects, and Eye anomalies. We present the case of a patient who presented with respiratory distress at birth secondary to a large nasal glioma. She was subsequently found to have a ventricular septal defect (VSD), a facial hemangioma, and a malformation of the eye and optic nerve head. The nasal glioma, which extended to the cribriform plate, has not been described in this syndrome. The tumor was resected through a coronal incision, midline nasal bone osteotomy, and a retrograde dissection from the nasal bones to the anterior skull base. Glioma of the skull base is a novel and serious manifestation of this uncommon condition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2005.07.014DOI Listing
March 2006

Surgical management of cervical ganglioneuromas in children.

Int J Pediatr Otorhinolaryngol 2006 Feb 15;70(2):287-94. Epub 2005 Aug 15.

The Head and Neck Institute, A71, The Cleveland Clinic Foundation, Cleveland, OH, USA.

Objective: To review the experience with ganglioneuromas in the head and neck of children including presentation, diagnostic testing, treatments, and outcomes.

Design: Case series. Retrospective chart review.

Setting: Tertiary care hospital.

Patients Or Other Participants: All patients with a history of ganglioneuroma of the neck in each authors practice were reviewed. All pathologically confirmed occurrences were eligible for inclusion, and five patients met these criteria.

Results: Five patients underwent surgical excision of head and neck ganglioneuromas between 1988 and 2004. There were no occurrences of secretory tumors, therefore all of the patients presented with enlarging masses. In all cases, the tumor arose from the cervical sympathetic chain, and thus, patients had subsequent ipsilateral Horner's Syndrome following resection. No synchronous tumors were noted, nor has a recurrent tumor been observed to this point. Complete excision was possible in all cases via a transcervical, or transoral approach, without mandibulotomy.

Conclusions: Ganglioneuroma of the neck is a rare tumor that most commonly presents as an enlarging neck mass. Complete surgical excision is the treatment of choice, and in this series of children was possible with transcervical approach, and once via transoral approach. This tumor may be suspected in children who are otherwise asymptomatic, and present with long history of enlarging neck masses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijporl.2005.06.020DOI Listing
February 2006