Silver Nitrate Cautery Research Articles

Interventions for recurrent idiopathic epistaxis (nosebleeds) in children.

Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self-limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition. To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children. We searched the Cochrane ENT Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3, 2003), MEDLINE (January 1966 to August 2003), EMBASE (January 1980 to August 2003), CINAHL (January 1982 to August 2003), and reference lists of relevant articles. We identified all randomised controlled trials (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo, or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The full text articles of all the retrieved trials of possible relevance were reviewed by the two reviewers and the inclusion criteria applied independently. Trials were graded for methodological quality using the Cochrane approach. Data extraction was performed in a standardised manner by one reviewer and rechecked by the other, and where necessary investigators were contacted to obtain missing information. A meta-analysis was not undertaken because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented. Three studies - two randomised controlled trials (RCTs) and one controlled clinical trial (CCT) - involving 256 participants satisfied the inclusion criteria. One RCT compared Naseptin antiseptic cream with no treatment, the second RCT compared Vaseline(R) petroleum jelly with no treatment, and the CCT compared Naseptin antiseptic cream with silver nitrate cautery. Overall, results were inconclusive, with no statistically significant difference found between the compared treatments. No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The optimal management of children with recurrent idiopathic epistaxis is unknown. High quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow-up period of at least a year, are needed to assess the relative merits of the various treatments currently in use.

Complications of removing percutaneous endoscopic gastrostomy tubes in children.

Little information has been reported regarding the frequency and type of complications arising from removal of percutaneous endoscopic gastrostomy (PEG) tubes in children. The records of 397 patients who had PEG tubes placed from 1993 through 1998 were reviewed for complications after removal. Data collected included length of time the tube was in place, age of the patient at insertion, type of tube removed, and patient diagnosis. Fifty-four children had the PEG tube removed by traction or endoscopy. The only complication was persistent leaking through a gastrocutaneous fistula in 13 patients (24%). Leaking ceased in 6 children coincident with H2-antagonist therapy and silver nitrate cautery, and surgical closure of the fistula was required in 7 patients. Comparison of these 7 children with those who did not require surgery (n = 47) showed a longer duration of tube placement (mean +/- SE of 20.6+/-3.6 months, range 11-31 months vs. 11.1+/-1.3 months, range 1-35 months; P<0.05). Further analysis showed no child with a PEG tube removed before 11 months (n = 23) after insertion required surgery, whereas 7 (23%) of 31 children with a PEG tube removed after 11 or more months required surgery. Age at insertion, type of feeding device removed, and patient diagnoses were not different between the two groups. These data indicate that persistent leaking necessitating surgical closure of a gastrocutaneous fistula does not occur in children with a PEG tube removed within 11 months of insertion. In contrast, 23% of children with a PEG tube removed 11 or more months after insertion require surgery. In patients identified as candidates for tube removal, this time frame may be important in clinical decision making.

Fecal incontinence in children: treatment with percutaneous cecostomy tube placement--a prospective study.

To evaluate the technique used for and long-term results of percutaneous cecostomy tube placement for the treatment of fecal incontinence in children. After an initial pilot study in 15 patients, 42 additional patients with fecal incontinence aged 2-20 (mean, 11.5) years and weighing 9.9-109.0 (mean, 39.2) kg underwent percutaneous cecostomy tube placement. Twenty-nine patients had spina bifida, nine had imperforate anus, three had cloacal anomalies, and one had Hirschsprung disease. Mean follow-up was 265 days (range, 8-503 days). Tube placement was successful in all patients. One patient developed local inflammation after accidental early retention-suture removal, which was treated with suture replacement and intravenous antibiotics. Another developed postprocedural ileus, which resolved. Late complications included constipation in one patient (treated with diet alteration), granulation tissue in seven patients (treated with silver nitrate cautery), and accidentally dislodged tubes in three patients (two successfully replaced at home and one replaced at the radiology suite). Vomiting related to the phosphate enema occurred in two patients. Resolution of soiling was achieved in all patients. Percutaneous cecostomy and antegrade enemas are very successful in achieving fecal continence and patient independence and acceptability, with minimal early and late complications.

Management of secondary hemorrhage following pediatric adenotonsillectomy

A retrospective study was performed of all patients requiring admission to the Royal Children's Hospital, Melbourne over a 12 year period with secondary haemorrhage following adenotonsillectomy, to determine what percentage of these children received blood transfusions or were returned to the operating room to secure hemostasis, and to identify factors predictive of the need for major intervention. There were 163 children who presented from 2 to 15 days following surgery. Initial management in all cases was establishment of intravenous access, and 151 received intravenous or oral antibiotics. One hundred and forty one were managed without the need for major intervention (87%), including five who had silver nitrate cautery to the tonsillar fossae. Major intervention was required in 22 cases (13%): 5 patients were returned to the operating room for hemostasis; 15 received blood transfusions and 2 underwent both. All surgery was required within 12 h of admission and all blood transfusions within 24 h. The highest rates of major intervention were in those with fresh bleeding at the time of presentation (38%) and hemoglobin levels less than 100 g/l (36%). For those requiring admission with secondary haemorrhage, a period of observation of 24 h would probably be adequate in the majority of cases to identify those children who will require major intervention by surgery or transfusion.

Use of Oxymetazoline in the Management of Epistaxis

The purpose of this study was to determine if use of an intranasal vasoconstrictor (oxymetazoline) could be used to effectively treat epistaxis, avoiding nasal packing. The charts of 60 patients who presented to the emergency room with the diagnosis of epistaxis and who required medical management were reviewed. Sixty-five percent of these patients were successfully managed with oxymetazoline as their sole therapy. An additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline. In only 17% of patients was it necessary to use nasal packing as treatment for epistaxis after an initial attempt with oxymetazoline alone or in combination with silver nitrate failed. These data suggest that pharmacologic management may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications.

Emergency care for posttonsillectomy and postadenoidectomy hemorrhage

There are an estimated 4,300 cases of postoperative hemorrhage after tonsillectomy in the United States each year. Most patients seek care in the Emergency Department for this potentially fatal condition. This study was performed to characterize the clinical presentation of patients seeking Emergency Department (ED) care for posttonsillectomy and postadenoidectomy hemorrhage (PTAH). In addition, the investigators attempted to describe the ED treatment for PTAH. A retrospective review of ED and inpatient medical records was executed for patients presenting to the ED with PTAH from June 1, 1983 to May 31, 1993. All patients presenting to the ED who received a final ED diagnosis of PTAH were included in the study. The setting included two community-based teaching hospitals that share a single emergency medicine residency. The combined ED census averaged 72,000 annual visits over the study period. The ED population included both children and adults. Neither hospital had an otolaryngology residency, nor was there 24 hour in-hospital otolaryngology staffing. Factors that were reviewed included patient age, gender, final disposition, presenting vital signs, time from the initial surgery to the time of bleeding, ED treatment, and the interaction with the on-call otolaryngologist. Subpopulations were defined primarily by age (child versus adult) and disposition (home versus hospital). χ 2 Analysis was used for most comparisons. When χ 2 analysis showed an association, the phi (Ф) coefficient was calculated to determine the strength of the association. When appropriate, means were compared using the Student's two-tailed t test. There were 106 visits involving 93 patients. There were 51 hospital admissions (48%), and 55 (52%) visits resulted in discharge to home. Of the 93 patients involved, 57 (61%) were children (≤17 years), accounting for 61 total visits; 36 (39%) were adults (≥18 years), accounting for 45 visits. Children with PTAH were more likely to be admitted than adults ( χ 2, P = .008; Ф test = 0.25) Procedures to stop PTAH were frequently performed in the ED, often by emergency medicine physicians; silver nitrate cautery was the most frequent. Adults were more likely to receive a minor hemostatic procedure, yet children were more likely to receive a blood transfusion initiated while in the ED or require surgery to achieve control of the bleeding.

Management of epistaxis in children

A randomised clinical trial of antiseptic nasal carrier cream (Naseptin) and silver nitrate cautery in the treatment of epistaxis in children was carried out. Fifty-four percent responded to cautery with silver nitrate and 50% to treatment with Naseptin antiseptic carrier cream. There were 24 patients in each group. No statistically significant difference was observed between the groups when tested with the χ 2 test. We believe that the first line treatment of epistaxis in children should be the use of antiseptic nasal cream.

Voice restoration of the total laryngectomy patient: the Singer-Blom technique.

In 1979 Singer and Blom described an endoscopic technique of vocal rehabilitation of the total laryngectomy patient. We have used this technique in 26 patients. Fluent speech developed in 24 patients. Four patients inadvertently had the devices used in this technique fall out of the fistula with subsequent closure. They will need repuncture. Two patients who had excellent speech voluntarily removed their devices. One transient case of aspiration responded to silver nitrate cautery of the fistula and placement of a new device. We believe that at the present time this is the surgical procedure of choice to vocally rehabilitate the total laryngectomy patient.

Infrequency of metastasis to ovaries in Stage I carcinoma of the cervix

areas), two patients were found to have cytological changes suggestive of dysplasia (IIR) one week later. Histological examination of one of these, two weeks after cauterization, revealed superficial dysplasia. These preliminary observations suggest that silver nitrate cauterization may induce epithelial changes in the cervix similar to those of dysplasia, with the resultant possibility of cytological and clinical concern. The suggestion is offered that at least 6 to 8 weeks are allowed to elapse after silver nitrate cautery before cytological studies are repeated. Table I

Further Studies in Obstructive Pulmonary Atelectasis.

In some recent investigative work, two factors were found essential in the experimental production of massive atelectasis of the lung in dogs, viz., A straining type of respiration, and secondly, some form of obstruction to the bronchus of the lung lobe; either total or valvular. In this work an artificial means of obstruction was used, this obstruction being located in the primary bronchus of the lung lobe. Either total or valvular obstruction, in the presence of a staining type of respiration, was followed by a massive atelectatic condition of the obstructed lung. If a quiet, normal type of respiration was exhibited, no resultant atelectasis was observed. An example was given of complete obstruction of a secondary bronchus, of 6 weeks'duration, with quiet respiration in which no atelectasis occurred. In carrying out some experiments with thermal and silver nitrate cautery,, it was found that cauterization of a bronchus was followed by complete stenosis in from one to 2 weeks. If this stenosis was located in the primary bronchus of the lung lobe, that lobe was found to be completely atelectatic with the secondary bronchi and bronchioles filled with a mucogelatinous material. However, if the stenosis was located in one of the several divisions of the primary bronchus to the lobe, no resultant atelectasis occurred; only a filling of the secondary and tertiary bronchi and bronchioles distal to the stenosis with the mucogelatinous material. Group A. 4 dogs. Silver nitrate or thermal cauterization of a secondary bronchus of a lung lobe. Sacrificed at the end of 2 to 6 weeks. Results: Total stenosis of secondary bronchus with no atelectasis distal to the stenosis.