RESUMEN
PURPOSE: Despite the brevity of the procedure, bilateral myringotomy and tympanostomy tube placement (BMT) can result in significant postoperative pain and discomfort. As the procedure is frequently performed without intravenous access, non-parenteral routes of administration are frequently used for analgesia. The current study prospectively compares the efficacy of intranasal (IN) dexmedetomidine with IN fentanyl for children undergoing BMT. METHODS: This prospective, double-blinded, randomized clinical trial included pediatric patients undergoing BMT. The patients were randomized to receive either IN dexmedetomidine (1 µg/kg) or fentanyl (2 µg/kg) after the induction of general anesthesia with sevoflurane. All patients received rectal acetaminophen (40 mg/kg) and the first 50 patients also received premedication with oral midazolam. Postoperative pain and recovery were assessed using pediatric pain and recovery scales, and any adverse effects were monitored for. RESULTS: The study cohort included 100 patients who ranged in age from 1 to 7.7 years and in weight from 8.6 to 37.4 kg. They were divided into 4 groups with 25 patients in each group: (1) midazolam premedication+IN dexmedetomidine; (2) midazolam premedication+IN fentanyl; (3) no premedication+IN dexmedetomidine; and (4) no premedication+IN fentanyl. Pain scores were comparable when comparing groups 2, 3 and 4, but were higher in group 1 (midazolam premedication with IN dexmedetomidine). There was no difference in total time in the post-anesthesia care unit (PACU) or time from arrival in the PACU until hospital discharge between the 4 groups. The heart rate (HR) was significantly lower in group 3 when compared to the other groups at several different times after arrival to the PACU. No clinically significant difference was noted in blood pressure. CONCLUSION: Following BMT, when no premedication is administered, there was no clinical advantage when comparing IN dexmedetomidine (1 µg/kg) to IN fentanyl (2 µg/kg). The addition of oral midazolam as a premedication worsened the outcome measures particularly for children receiving IN dexmedetomidine.
Asunto(s)
Dexmedetomidina/uso terapéutico , Fentanilo/uso terapéutico , Ventilación del Oído Medio , Dolor Postoperatorio/prevención & control , Membrana Timpánica/cirugía , Administración Intranasal , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Niño , Preescolar , Método Doble Ciego , Femenino , Frecuencia Cardíaca , Humanos , Hipnóticos y Sedantes/uso terapéutico , Lactante , Masculino , Midazolam/uso terapéutico , Dimensión del Dolor , Premedicación , Estudios ProspectivosRESUMEN
OBJECTIVE: A major concern with the use of cuffed endotracheal tubes (cETT) in children is hyperinflation of the cuff which may compromise tracheal mucosal perfusion. To measure the intracuff pressure (CP), we devised a method using the transducer of an invasive pressure monitoring device. The objective of the study was to test the accuracy and validity of this device for instantaneous and continuous CP monitoring. METHODS: The study was conducted in 2 phases. In Phase 1 (200 pediatric patients), after inflation of the cuff, the CP was measured using the standard manometer and the transducer simultaneously. In Phase 2 (20 pediatric patients), the transducer was left connected to the pilot balloon of the ETT to obtain a continuous CP reading and the standard manometer was used to measure the CP at 5-min intervals. Statistical analysis included a Bland-Altman comparison and linear regression analysis. RESULTS: In Phase 1, linear regression analysis demonstrated an R2 value of 0.9956. The bias was 0.30 cmH2O, the precision was 0.75 cmH2O, and the 95% level of agreement (LOA) ranged from -1.16 to 1.77 cmH2O. In Phase 2, the linear regression analysis revealed an R2 value of 0.9846. The bias was 0.28 cmH2O, the precision was 0.7 cmH2O, and the 95% LOA ranged from -1.1 to 1.66 cmH2O. CONCLUSION: Our study demonstrates that when cETTs are used in the pediatric population, the transducer of the invasive pressure monitoring device can be used reliably to measure the CP at the time of inflation and continuously thereafter.
Asunto(s)
Intubación Intratraqueal/instrumentación , Monitoreo Fisiológico/instrumentación , Adolescente , Niño , Preescolar , Diseño de Equipo , Femenino , Humanos , Lactante , Masculino , Manometría , Presión , Estudios Prospectivos , Reproducibilidad de los Resultados , TransductoresRESUMEN
BACKGROUND: Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2 O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients. METHODS: Patients less than 18 years of age, undergoing surgery, requiring endotracheal intubation with a cuffed ETT were eligible for inclusion. No alteration in the technique of anesthetic induction or maintenance was required for the study. Following endotracheal intubation and inflation of the cuff with the head and neck in a neutral position, the intracuff pressure was measured. The intracuff pressure was then subsequently measured with the head turned to the right, head turned to the left, head and neck flexed, and head and neck extended. RESULTS: A total of 200 patients were included in the study resulting in a total of 1000 intracuff pressure readings. When compared to the neutral position, the intracuff pressure increased in 545 instances (68.1%) with changes in position of the head and neck. An increase in intracuff pressure was noted more frequently and to the greatest degree with head and neck flexion. The pressure decreased in 153 instances (19.1%), most frequently with neck extension. CONCLUSION: Significant changes in the intracuff pressure occur with changes in head and neck position. In several cases, this resulted in a significant increase in the intracuff pressure. For prolonged cases with the head and neck turned from the neutral position, the intracuff pressure should be measured following patient positioning to ensure that the intracuff pressure is within the clinically recommended range.
Asunto(s)
Intubación Intratraqueal/métodos , Posicionamiento del Paciente , Adolescente , Envejecimiento/fisiología , Presión del Aire , Niño , Preescolar , Estudios de Cohortes , Femenino , Cabeza , Humanos , Lactante , Masculino , Cuello , Estudios ProspectivosRESUMEN
We describe our experience with blowgun dart aspiration via an illustrative case series and review the resources available to teach children how to construct these objects. A 15-year-old boy presented with cough, wheeze, and eventually admitted to aspiration of a homemade blowgun dart. This instance heightened the awareness of our experience with blowgun dart aspiration as 3 cases presented within a 3-month period. Patients uniformly presented with cough and reported aspiration, and wheezing was noted in 2 of the 3. Although all ultimately admitted their behavior, 2 were initially reluctant to admit aspirating the blowgun dart. Radiographic findings of a needle-shaped metallic airway foreign body were consistent in all patients. Each admitted to finding instructions for blowgun dart construction on the Internet. Emergent rigid bronchoscopy with blowgun dart removal resulted in symptom resolution in all without complication. This represents the largest series of blowgun dart aspiration to date. During deep inhalation, when preparing to propel a blowgun dart, the vocal folds maximally abduct, leading to increased risk for aspiration. Twenty websites were identified providing instructions for the construction of homemade blowgun darts. With the accessibility of the Internet and number of instructional websites, this clinical entity may become more common in the future. Unfortunately, only a few of the websites provide any safety warnings. Certainly, prompt treatment can result in good outcomes; however, serious potential complications, including death, could occur especially given the hesitance our patients showed in divulging the truth of the inciting event.
Asunto(s)
Obstrucción de las Vías Aéreas/etiología , Bronquios , Broncoscopía , Cuerpos Extraños/etiología , Internet , Aspiración Respiratoria , Armas , Adolescente , Factores de Edad , Obstrucción de las Vías Aéreas/psicología , Obstrucción de las Vías Aéreas/terapia , Tos/etiología , Cuerpos Extraños/psicología , Cuerpos Extraños/terapia , Humanos , Masculino , Factores Sexuales , Estornudo , Revelación de la VerdadRESUMEN
BACKGROUND: Over the past 5 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in infants and children. As the trachea is sealed, one advantage is to eliminate the contamination of the oropharynx with oxygen which should be advantageous during adenotonsillectomy where there is a risk of airway fire. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during adenotonsillectomy in infants and children. METHODS: Following the induction of general anesthesia in patients scheduled for adenoidectomy, tonsillectomy or adenotonsillectomy, the trachea was intubated. The use of a cuffed or uncuffed ETT and the use of spontaneous (SV) or positive pressure ventilation (PPV) were at the discretion of the anesthesia team. The oxygen concentration was kept at 100% oxygen until the study was completed. Following placement of the mouth gag, the otolaryngolist placed into the oropharynx a small bore catheter, which was attached to a standard anesthesia gas monitoring device which sampled the gas at 150mL/min. The concentration of the oxygen and the concentration of the anesthetic agent in the oropharynx were measured for 5 breaths. RESULTS: The cohort for the study included 200 patients ranging in age from 1 to 18 years. With the use of a cuffed ETT and either SV or PPV, the oxygen concentration in the oropharynx was 20-21% and the volatile agent concentration was 0% in all 118 patients. With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The mean oxygen concentration was 71% during PPV with an uncuffed ETT and 65% during SV with an uncuffed ETT. In these patients, the oropharyngeal oxygenation concentration exceeded 30% in 73 of the 82 patients (89%). The oropharyngeal oxygen and agent concentration was greater when the leak around the uncuffed ETT was ≥10cmH(2)O versus less than 10cmH(2)O and when the leak around the uncuffed ETT was ≥15cmH(2)O versus less than 15cmH(2)O. CONCLUSIONS: With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The oropharyngeal concentration of oxygen is high enough to support combustion in the majority of patients. The use of a cuffed ETT eliminates oropharyngeal contamination with oxygen during the administration of anesthesia and may be useful in limiting the incidence of an airway fire.
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Anestésicos por Inhalación/efectos adversos , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/instrumentación , Orofaringe/efectos de los fármacos , Oxígeno/metabolismo , Adenoidectomía/métodos , Factores de Edad , Manejo de la Vía Aérea/métodos , Anestesia General/efectos adversos , Anestesia General/métodos , Anestésicos por Inhalación/metabolismo , Pruebas Respiratorias , Estudios de Cohortes , Diseño de Equipo , Seguridad de Equipos , Femenino , Humanos , Masculino , Orofaringe/metabolismo , Oxígeno/uso terapéutico , Seguridad del Paciente , Respiración con Presión Positiva , Estudios Prospectivos , Medición de Riesgo , Tonsilectomía/métodos , VolatilizaciónRESUMEN
Branchial anomalies are common cervical pathologic entities encountered in the field of otolaryngology and are typical in the pediatric and young adult populations. In most cases, these anomalies present as a cyst, sinus, or fistula in a rather stereotypical fashion. When a branchial anomaly deviates from the classic presentation, an improper diagnosis and inadequate management are more likely to occur, leading to an increased recurrence rate. We present a case of a 6-year-old girl with an incidental finding of a right posterior oropharyngeal wall mass, distinctly separate from the tonsillar fossa, which was found on pathologic analysis to be a branchial cleft anomaly. The theories regarding the pathogenesis of branchial anomalies are presented, along with other cases of atypical branchial anomalies.
Asunto(s)
Región Branquial/anomalías , Orofaringe , Enfermedades Faríngeas/etiología , Enfermedades Faríngeas/patología , Niño , Femenino , HumanosRESUMEN
OBJECTIVE: To examine whether histological changes in skin owing to intrinsic aging in a laboratory rodent model are modulated by caloric restriction (CR). METHODS: The abdominal skin from colony-raised ad libitum-fed Fischer 344 rats and age-matched rats subjected to CR was studied in the light microscope using histological morphometric methods. Animals 4, 12, and 24 months or older were used in this study. We studied the skin to obtain (1) quantitative data on the depth of the epidermis, dermis, and fat layer, the epidermal cellular density, the percentage fraction of dermal collagen, elastic fibers, pilosebaceous units, and capillaries, and the fibroblast density; and (2) qualitative assessment of histological staining for dermal glycosaminoglycans. We analyzed data by means of general linear model 2-way analysis of variance to obtain significance for the effects of age, diet, and age-diet interaction. RESULTS: The ad libitum-fed rats showed age-related increase in the depth of the epidermis, dermis, and fat layer. Calorie restriction prevented these changes, but epidermal nuclear density appeared to be stimulated. A trend toward increased values for collagen and elastic fibers, fibroblasts, and capillaries in skin samples from CR rats was observed. Pilosebaceous units were not modified. Moderately reduced staining for the dermal glycosaminoglycans in the skin of CR rats was noticed. CONCLUSIONS: Histomorphological changes resulting from intrinsic aging affected some of the studied variables in the rat skin, and these changes were delayed or prevented by CR. Some stimulatory effects, such as increased densities of fibroblasts and capillary profiles and higher values of connective tissue fibers resulting from CR, were also observed. Cutaneous morphological changes due to natural aging in this rat model seem to be modified by physiological or metabolic alterations imposed by CR.
Asunto(s)
Envejecimiento de la Piel , Análisis de Varianza , Animales , Restricción Calórica , Glicosaminoglicanos/metabolismo , Masculino , Ratas , Ratas Endogámicas F344 , Piel/anatomía & histología , Piel/metabolismo , Envejecimiento de la Piel/fisiologíaRESUMEN
OBJECTIVE/HYPOTHESIS: The objective of the study was to investigate predictive factors in the postoperative hearing outcomes in pediatric stapedectomy. STUDY DESIGN: Retrospective case series. The study was performed in a tertiary academic otological practice. METHODS: The outcome of 66 stapedectomies in children 17 years of age and younger were analyzed according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines. Factors evaluated included patient age, underlying diagnosis (tympanosclerosis, otosclerosis, congenital fixation), type of footplate graft and type of prosthesis used, associated ossicular abnormalities, and revision surgery. RESULTS: The mean postoperative air-bone gap following stapedectomy in children with tympanosclerotic footplate fixation (24.9 dB [+/-11 dB]) was significantly worse than in patients with an underlying diagnosis of congenital stapes fixation (15.7 dB [+/-9 dB]) or otosclerosis (13.1 dB [+/-3 dB]) (P =.024). Revision stapedectomy was also associated with a poorer outcome, but patient age and prosthesis and graft type did not contribute to the outcome in a statistically significant manner. CONCLUSIONS: Pediatric patients with stapes fixation resulting from tympanosclerosis showed poorer outcomes from stapedectomy than patients with congenital or otosclerotic fixation. Outcomes for congenital or otosclerosis fixation more nearly matched the outcomes in the literature for adult series.
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Pérdida Auditiva Conductiva/etiología , Otosclerosis/cirugía , Complicaciones Posoperatorias/etiología , Cirugía del Estribo , Adolescente , Niño , Preescolar , Femenino , Humanos , Modelos Logísticos , Masculino , Prótesis Osicular , Pronóstico , Reoperación , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: An intensified treatment regimen for previously untreated Stage III and IV resectable oral cavity, oropharyngeal, or hypopharyngeal squamous cell carcinoma was analyzed to assess disease control, patient compliance, and toxicity. METHODS: Forty three patients with previously untreated, advanced, resectable squamous cell carcinoma of the oral cavity, oropharynx, or hypopharynx were enrolled in a prospective Phase II institutional clinical trial at a tertiary care comprehensive cancer center. This regimen was a continuum of multimodal treatment in a contracted time interval. It included preoperative slightly accelerated hyperfractionated radiotherapy with concurrent cisplatin, followed immediately with surgery and intraoperative radiotherapy, and completed with early postoperative weekly paclitaxel (beginning on Day 6 after surgery), two additional cisplatin cycles, and concurrent once daily radiotherapy beginning on Day 28 after surgery. RESULTS: The current trial was designed to reduce the toxicity of the systemic therapy while maintaining or improving locoregional/distant disease control and patient compliance. There were 43 patients enrolled, and the range of time at risk was 2.6 to 24.7 months (median, 14.6 months). Of the 43 registered patients, 43 were evaluable. The locoregional (100%) and systemic (93%) disease control rates were excellent, with low rates of patient noncompliance (21%) and reduced levels of toxicity. CONCLUSIONS: An intensive treatment regimen that improves disease control and treatment compliance is clearly feasible for this patient population. Future plans include modifications to continue to reduce toxicity and expansion to a multi-center Phase II trial to determine if the single institutional results can be duplicated.
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Carcinoma de Células Escamosas/terapia , Neoplasias Hipofaríngeas/terapia , Neoplasias de la Boca/terapia , Neoplasias Orofaríngeas/terapia , Adulto , Anciano , Carcinoma de Células Escamosas/mortalidad , Terapia Combinada , Femenino , Humanos , Neoplasias Hipofaríngeas/mortalidad , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/mortalidad , Metástasis de la Neoplasia , Neoplasias Orofaríngeas/mortalidad , Cooperación del Paciente , Estudios Prospectivos , Accidente Cerebrovascular/etiologíaRESUMEN
As it becomes common for hyperparathyroidism to be detected earlier in the course of the disease, the bony manifestations of the disease are rarely seen. Presented here is a rare case of brown tumor of the maxilla as the presenting symptom of primary hyperparathyroidism.