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PURPOSE/METHODS: To improve intranasal visualization of nasolacrimal procedures we use a self-retaining nasal speculum with or without a sinuscope. RESULTS/CONCLUSIONS: Placement and retrieval of silicone stents can be accomplished with less trauma than with a blind sweep technique. Additionally, the valve of Hasner can be seen and the creation of false passages avoided.

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Retropharyngeal abscess is a rather rare, deep-neck infection of children and may seriously compromise the airway and mimic other diseases. A retrospective review of 17 cases of retropharyngeal abscess presenting to The Children's Hospital, Denver, from 1976 to 1986 was performed. Nine children (56%) had stridor or airway obstruction. Seven patients (41%) had perforations of their hypopharynx or esophagus, including two neonates (most likely associated with intubation attempts). Two patients presented in the emergency department with a tentative diagnosis of "epiglottitis," while another referred to as having "persistent fever" was found to have a needle embedded in the hypopharynx. Fourteen children (81%) were brought to the operating room for examination and/or drainage of the abscess under general anesthesia. One child received an elective tracheotomy, and two others remained intubated postoperatively, pending resolution of their airway compromise. X-rays of the lateral neck were confirmatory in all these cases, with an unusually high incidence of "air/fluid levels," probably reflecting the corresponding large number of perforations of the hypopharynx or esophagus with subsequent communication into the retropharyngeal space.

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Laryngotracheoplasty utilizing composite costal cartilage-perichondrium grafts placed both anteriorly and posteriorly within the cricoid ring has provided a significant advance in the management of acquired subglottic stenosis in children. Histopathologic data from a child who died after a laryngotracheoplasty is presented which indicates both the anterior and posterior grafts survive and grow.

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Placement of tympanostomy tubes is the most frequently performed otolaryngologic procedure. The common practice is to forbid swimming and to recommend limitation of liquids entering the external auditory canal based upon the premise that liquids entering the external auditory canal will pass freely into the middle ear space via the tube and thus contaminate the space. Indeed, otologic medications (drops) are presumed and are observed to enter the middle ear space by this same route. The physical characteristics of the middle ear and drumhead with a tube in place were examined and a model constructed to test by observation these characteristics. Measurements of the surface tension of water, 2N saline, Cortisporin suspension ear drops, and soapy bath water were performed to provide a clinical correlate. The study implies that limitation of swimming activities or liquid exposure of the ear with a tympanostomy tube in all children may be inappropriate.

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Anterior cricoidotomy or "cricoid split" was described in 1980 as an open incisional procedure for failed extubation in neonates. In the past year, we modified the technique to an endoscopic-percutaneous cricoidotomy in 22 patients. We broadened the eligible population to include children with a mature membranous stenosis or a congenital subglottic stenosis. Our overall success rate of 80% (73% in the premature group) demonstrates that a cricoidotomy can be used in children older than the neonatal group and suggests that a cricoidotomy does not need to be an open operative procedure, and should be considered before a tracheotomy in the child with a subglottic injury or narrowing.

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Acquired incomplete subglottic stenosis in children has historically been managed by serial bouginage of the strictured region sometimes accompanied by injection or systemic administration of corticosteroid medications. The forceful stretching of the scar whilst awaiting growth of the region to compensate for scar contracture, however, dooms that child to a prolonged period of waiting for an unpredictable result with a tracheotomy in place. Recently, laryngo-tracheoplasty has been undertaken in younger age groups and in a review of 30 children, with very similar types of stenosis, it was noted that the 19 children managed only by bouginage (with or without steroids) (1) had a much less predictable result, (2) were only able to be ultimately decannulated 52.6% of the time, and (3) had a mean time from the initiation of treatment to decannulation of 620.1 days. This contrasted very sharply with 11 children who underwent an elective laryngo-tracheoplasty of whom 81.8% were able to be decannulated with a mean time from the initiation of treatment of 82.33 days. It was noteworthy that of those managed by dilation alone 9 children (47.4%) were tracheotomy-dependent following treatment and 7 of these were aphonic (36.8% of the total group), whereas in the surgically managed group, 2 were tracheotomy-dependent (18.2% of the total), and all could talk around their tracheotomy tube. The methods and mechanics of such therapeutic approaches are examined and discussed.

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Sudden hearing loss from simultaneous rupture of both oval and round windows, occurring in the only hearing ear of a child, is described. The condition was surgically managed with recovery of hearing. Of particular note was the presence of air aspirated into the labyrinth at the time of membrane rupture, which has not previously been described. The possible mechanisms and some clinical correlates associated with anatomic predisposition to such rupture are discussed.

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Dermoid cysts of the floor of the mouth are very rare in children. True dermoid cysts occur in this site in less than 2% of all such cysts including those presenting in adults. Four massive (5-8 cm diameter) such cysts in children, which by virtue of their size threatened the airway, are reported. In the four cases reported, each demonstrated a distinct "stalk" inserting at the genial tubercle of the mandible and the cyst lay mostly superior to the mylohyoid muscle. This "stalk" provides a potential pitfall for the unwary surgeon who may leave a remnant if the "salk" is transected during removal and has not been previously reported. The embryologic origins of these large masses are uncertain and with the description of such a stalk would seem to be more complex than a simple developmental inclusion. The clinical presentations of these tumors and their possible pathogenesis are discussed.

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Children born prematurely are now enjoying improved survival with advances in neonatology and ventilatory support. A study of upper airway size in specimens from 39 prematurely born children reveals 7.7% having a cricoid ring diameter greater or equal to the diameter of the tracheal rings. The more commonly expected relationship of the cricoid ring being smaller than the tracheal rings existed in the rest. This may be of importance in instrumentation or intubation of the airway in premature neonates. The gestational age was a better indicator of cricoid ring diameter than birth weight. From these findings a formula for reliably predicting the cricoid diameter is proposed, aiding the clinician in endotracheal tube or airway instrument selection. The combined lung weights were directly related to airway diameter irrespective of measurements of tracheal or cricoid rings. This has not been previously reported and would imply the existence of laryngo-tracheo-broncho-pulmonary hypoplasia in the premature infant.

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The more common consequences of mesodermal migrational delay or failure in the fourth to seventh weeks of gestational life and of plate fusion failure in the seventh to twelfth weeks of gestational life are cleft lip and cleft palate, respectively. The team approach with a balanced emphasis allowing optimal development of deglutition, speech, hearing, facial growth, and dental development combined with acceptable esthetic results provides comprehensive treatment and an improved outlook for this long term problem.

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Thirty neonates with acquired airway stenosis were treated between 1975 and 1979 at the C. S. Mott Children's Hospital of the University of Michigan. Neonates surviving a period of ventilation are at risk of developing subglottic stenosis (8.3%). The stenosis is often severe. Children with respiratory distress syndrome and/or neurologic disorders were particularly prone to developing a stenosis (37%). Following treatment, 43% were successfully decannulated and decannulation occurred in a biphasic pattern. Thirty-seven percent were still tracheostomy-dependent but had a voice and were developing normal speech patterns. The mean decannulation time was 92.5 weeks, confirming that acquired subglottic stenosis in the neonate is a serious problem with long-term disability.

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Head and neck cancer patients who develop incurable recurrent tumors present the surgical team with unique problems dissimilar to patients with cancer of other areas. When the structures of the head and neck are violated by tumor, the dying process is slow, lingering, and painful; and the anatomic areas involved tend to be visible, difficult to shield from those in attendance, and of course, are very obvious to the patient. This review offers some practical guidelines for the management of head and neck cancer pain, nutrition, anorexia, odor control, mental confusion, and local control of visible tumor. Our approach includes the palliative use of surgery, radiotherapy, and chemotherapy, and the participation of members of a palliative team by which therapeutic decisions and timing can be individualized for each patient. This system of palliation offers significant advantages to the patient and to the surgeon, and is a new concept applicable to head and neck cancer patients for whom previously little could be offered.

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The non-healing granulomas of Wegener and Stewart (Wegener's granuloma and lethal midline granuloma) have been recognized since 1897. A mainstay of therapy has been the empirical application of treatments based upon theoretical or pathological assumption, and we are only slightly closer to classifying these diseases. Between 1967 and 1975 eight patients with non-healing granuloma of Wegener's type, and one patient with non-healing granuloma of Stewart's type, presented to the Otolaryngology Service of the conjoined McGill University Hospitals. All received corticosteriods and all those with the Wegener type of granuloma received azathioprine (Immuran). Four patients are alive and well today from five months to eight years and 10 months after starting therapy. Some aspects of the changing historical, clinical, pathologic, and therapeutic indices of these diseases are presented, with our experiences in these areas.

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Sudden hearing loss from spontaneous perilymphatic fistula in a child managed by prompt surgical intervention and with recovery of hearing has not previously been reported. The historical and contemporary theories of fistula formation are reviewed. A child with spontaneous oval window rupture associated with a congenital malformation of the stapes and cochlear aqueduct is described together with his complete recovery of hearing following surgical repair. Some rationales explaining the mechanism of oval window rupture in this patient are suggested.

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