Treatment Of Upper Airway Obstruction Research Articles

Scientific rationale for the use of alpha-adrenergic agonists and glucocorticoids in the therapy of pediatric stridor.

Purpose. The most common pharmacological therapies used in the treatment of stridor in children are glucocorticosteroids (GC) and alpha-adrenergic (αAR) agonists. Despite the long-standing reported efficacy of these medications, there is a paucity of data relating to their actual mechanisms of action in the upper airway. Summary. There is compelling scientific evidence supporting the use of αAR-agonists and GCs in pediatric stridor. αAR signaling and GCs regulate the vasomotor tone in the upper airway mucosa. The latter translates into better airflow dynamics, as delineated by human and nonhuman upper airway physiological models. In turn, clinical trials have demonstrated that GCs and the nonselective αAR agonist, epinephrine, improve respiratory distress scores and reduce the need for further medical care in children with stridor. Future research is needed to investigate the role of selective αAR agonists and the potential synergism of GCs and αAR-signaling in the treatment of upper airway obstruction and stridor.

Early resection and reconstruction of head and neck masses in infants with upper airway obstruction

Objective Congenital airway obstruction can be caused by tumors or lesions arising from the neck, tongue and oral cavity. Neonates may require prolonged intubation or tracheostomy before curative resection and reconstruction. The aim of the study was to carry out surgical resection and reconstruction with locoregional flap and free bone graft in the neonatal and early infantile period for definitive management of head and neck masses and treatment of potential airway obstruction. Methods Newborns with obstructive head and neck masses in Queen Mary Hospital, University of Hong Kong Medical Centre between 2006 and 2009 were operated on in the neonatal period. Results There were one obstructive neck teratoma, two intraoral teratomas and one neuroglial heterotopia. All tumors were resected within the first 3 months of life without major complication. A local cervical cutaneous flap was first used to reconstruct the lateral pharyngeal wall defect in a neonate with a huge neck teratoma, followed by another infant with a neuroglial heterotopia. A piece of cranial bone was used for reconstruction of the skull base defect. None of them required tracheostomy or prolonged intubation. Oral feeding was resumed in the early postoperative period. Conclusion Surgical resection and reconstruction with locoregional flap and bone graft can be performed safely in neonatal and early infantile period as management of head and neck masses and treatment of upper airway obstruction.

Highlights of Archives of Facial Plastic Surgery

Archives of Facial Plastic SurgeryVol. 12, No. 1 Free AccessHighlights of Archives of Facial Plastic SurgeryPublished Online:1 Jan 2010AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Nimodipine and Acceleration of Functional Recovery of the Facial Nerve After Crush InjuryFacial nerve injury often results in devastating emotional and functional impairment. Commonly, a patient must endure a challenging and protracted recovery period in which further ocular, nutritional, and expressive complications may develop. Robin W. Lindsay, MD, and colleagues present their findings of accelerated facial nerve recovery in the rat animal model with nimodipine administration. Statistically significant improvements in whisking amplitude, velocity, and acceleration were observed in comparison with control animals. These findings demonstrate the first pharmacologic therapy to improve facial nerve recovery in an animal model that is safe for routine clinical use.See page 49Reconstruction of the Nasal Septum Using Polydioxanone PlateAs the central divide of the nasal cavity, the nasal septum is an integral component in air passage and structural support. Abnormalities in nasal airflow and external nasal appearance are often intimately related to architectural deviations or disruption of this important structure. Miriam Boenisch, MD, PhD, and Gilbert J. Nolst Trenité, MD, PhD, review their 10-year experience using the polydioxanone plate as a scaffold for septal reconstruction in 396 patients with severe nasal deformities. In their modification of the extracorporeal septoplasty, the authors remodeled and secured the quadrangular cartilage to the resorbable matrix prior to reimplantation. They present their notable functional and cosmetic outcomes as well as variations in their novel operative technique.See page 4Mandibular Distraction Osteogenesis Used to Treat Upper Airway ObstructionThe facial skeleton is an integral element in the establishment and maintenance of a patent airway. To this end, congenital and syndromic causes of mandibular deficiency often result in oropharyngeal narrowing and a variable degree of upper airway obstruction. Tracheostomy is required in nearly 25% of these patients but not without associated risks. Craig W. Senders, MD, and colleagues investigate mandibular distraction osteogenesis (MDO) as an alternative to tracheostomy tube placement in micrognathic patients with tongue-based obstruction. Multiplanar advancement was performed with the application of an external distractor in newborn patients and those with long-standing tracheostomies. The findings observed reveal the significant impact of MDO in the treatment of upper airway obstruction in select pediatric patients.See page 11Orbicularis Suspension Flap and Its Effect on Lower Eyelid Position: A Digital Image AnalysisAge-related changes of the lower eyelid tissues often produce redundancy in eyelid skin, pseudoherniation of orbital fat, and a ptotic laxity of the orbicularis oculi muscle. Some individuals also display a hollowing along the inferior orbital rim. It is this subset of patients that represent a complex challenge in periorbital rejuvenation. Christopher I. Zoumalan, MD, and colleagues discuss changes in lower eyelid position as related to performing an orbicularis suspension flap in combination with an inside-out blepharoplasty in this patient population. Digital analysis of 68 patients revealed a statistically significant decrease in postoperative margin reflex distance in addition to a more natural anatomic position of the lower eyelid.See page 24Hope by Sir Edward Coley Burne-Jones (1833-1898).See page 76This issue's Highlights were written by James Ridgway, MD.FiguresReferencesRelatedDetails Volume 12Issue 1Jan 2010 InformationCopyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Highlights of Archives of Facial Plastic Surgery.Archives of Facial Plastic Surgery.Jan 2010.3-3.http://doi.org/10.1001/archfaci.2009.112Published in Volume: 12 Issue 1: January 1, 2010PDF download

The Assessment of Midface Distraction Osteogenesis in Treatment of Upper Airway Obstruction

Le Fort III osteotomy with midface distraction osteogenesis (Le Fort III DO) can improve the midface form and change the upper airway space. Some surgeons believe that midface advancement can improve respiratory outcome dramatically, but others think it does not predictably result in the cure of obstructive sleep apnea (OSA). In this study, we evaluated the structural and functional changes of the upper airway before and after Le Fort III DO; we hope these studies can improve future protocols for midface advancement. A retrospective study of 11 patients with severe midface retrusion who underwent Le Fort III osteotomy with midface external distractor system was undertaken. These patients had an average of 5.4 months of follow-up. Three-dimensional volumetric assessment of the upper airway was used before and after surgery. We also evaluated the two-dimensional cross-sectional area of the upper airway to show the changes in different airway levels. Two patients with preoperative evidence of OSA were evaluated both preoperatively and postoperatively by overnight polysomnography. The midface was distracted for an average of 20.27 +/- 8.04 mm. Comparison between preoperative and postoperative three-dimensional computed tomographic data showed an average 64.30% increase in upper airway volume, an improvement of 9.13 +/- 6.94 mL (P < 0.05). The two-dimensional measurement also showed that the cross-sectional area at the posterior nasal spine and uvula airway level increased (P < 0.05), but the cross-sectional area at the epiglottis level and the separation of airway and esophagus level did not increase (P > 0.05). Two patients with preoperative evidence of OSA had both preoperative and postoperative sleeping studies that showed improvement. Le Fort III DO can significantly improve the upper airway space in the cases of syndromic craniosynostosis. The upper airway space above the uvula level was significantly enlarged after Le Fort III DO according to two-dimensional and three-dimensional image measurements, and according to the polysomnography, the OSA was alleviated. Le Fort III DO is a promising procedure in the treatment of severe midface retrusion with OSA in young patients.

Outcome of permanent tracheostomy for treatment of upper airway obstruction in cats: 21 cases (1990–2007)

To determine clinical outcome of permanent tracheostomy in cats with upper airway obstruction. Retrospective case series. 21 cats. Medical records were reviewed for information on history, signalment, clinical signs, results of preoperative clinicopathologic testing, cause of upper airway obstruction, surgical procedure, postoperative complications, and outcome. Causes of upper airway obstruction included neoplasia (squamous cell carcinoma [n = 6] or malignant lymphoma [2]), inflammatory laryngeal disease (5), laryngeal paralysis (4), trauma (3), and a laryngeal mass of unknown cause (1). Fourteen cats had dyspnea in the immediate postoperative period; dyspnea most often resulted from mucous plugs at the stoma or elsewhere in the respiratory tract. Eleven cats died, including 6 cats that died while hospitalized after surgery and 5 cats that died after discharge; 7 cats were euthanatized, most often because of progression of neoplasia; and 2 were still alive at the time of the study. The remaining cat was lost to follow-up after discharge from the hospital. Overall, median survival time for the 20 cats for which information was available was 20.5 days (range, 1 day to 5 years). Cats that underwent permanent tracheostomy because of inflammatory laryngeal disease were 6.61 times as likely to die as cats that underwent permanent tracheostomy for any other reason. Results indicated that permanent tracheostomy was an uncommon procedure in cats with upper airway obstruction that was associated with high complication and mortality rates.

Current perspectives on the obesity hypoventilation syndrome

Identifying and treating obesity hypoventilation syndrome is an important therapeutic goal, especially given the high morbidity and mortality associated with untreated disease. Significant weight loss or effective treatment of upper airway obstruction will reverse daytime hypoventilation, suggesting that these two mechanisms play key roles in the development and progression of this disorder. Only a subset of morbidly obese patients will develop awake hypercapnia, however, even in the presence of sleep disordered breathing. This implies that complex interplay between a number of known and unknown mechanisms is needed to produce daytime respiratory failure in this patient population. Work in the mouse model of obesity has been central in advancing our understanding of the role leptin plays in stimulating ventilation. Leptin deficiency or development of leptin resistance in obesity leads to alterations in central respiratory drive and reduced ventilatory responsiveness, permitting development of carbon dioxide retention. Changes in neuromodulators resulting from the effects of hypoxia may further exacerbate the problem by depressing arousal from sleep in the face of abnormal breathing. Understanding the various mechanisms contributing to development of obesity hypoventilation is important in order to identify new approaches to effective long-term management of this disorder.

Treatment of Upper Airway Obstruction in Infants with Micrognathia Using Mandibular Distraction Osteogenesis

Mandibular distraction osteogenesis has become an accepted alternative treatment for infants and children with upper airway obstruction associated with micrognathia. Several reports exist that purport the efficacy of mandibular distraction in these patients, such as preventing tracheostomy or facilitating tracheostomy removal. However, the majority of these studies are retrospective reviews with small cohorts and relatively short-term follow-up. Consequently, the ideal indications, pre- and postoperative evaluation, timing, and treatment are subject to controversy and not currently well established. Significantly less attention has been given to short- and long-term complications of mandibular distraction, such as effects on the developing tooth buds, impact on future mandibular development, and temporomandibular joint abnormalities. This article reviews the basic principles of distraction osteogenesis, summarizes the outcomes of recent literature involving pediatric mandibular distraction including this author's experience, and discusses the known and potential adverse sequelae of mandibular distraction. Before a clearly defined role of mandibular distraction in the treatment of infants with micrognathia-associated upper airway obstruction can be established, additional prospective studies are necessary to delineate its benefits and limitations.

Pediatric Feeding Disorder and Growth Decline following Mandibular Distraction Osteogenesis

Mandibular distraction osteogenesis has proven to be an effective treatment for upper airway obstruction related to micrognathia. Changes in the aerodigestive space can help facilitate tracheostomy removal in children and prevent tracheostomy in newborns. However, this may also precipitate changes in the ability to orally feed. There are few data on early postoperative feeding and growth rate following mandibular lengthening. The authors found evidence of growth rate decline and feeding difficulty in pediatric patients following mandibular distraction osteogenesis. Ten pediatric patients underwent mandibular distraction osteogenesis for treatment of upper airway obstruction. Outcomes in resolution of upper airway obstruction, oral feeding success, and growth rate were analyzed. Follow-up ranged from 12 to 28 months. All 10 patients had complete resolution of upper airway obstruction. The length of distraction ranged from 10 to 17 mm. Three patients demonstrated a feeding disorder after mandibular distraction osteogenesis, defined as requiring a long-term (>1 month) alternate feeding method (gastric tube in two patients and gastric gavage in one). Seven of 10 patients exhibited an early decline in growth rate following distraction. Data used to determine growth rate changes were weight measurements at the time of distraction, at the time of distractor removal (6 to 8 weeks after distraction), and at 6 and 12 months after the date of distraction initiation. These results suggest that infants and children undergoing mandibular lengthening by distraction osteogenesis should be carefully monitored for postdistraction feeding disorder and growth rate disturbance.

Radiofrequency ablation for the treatment of upper airway obstruction in pediatric patients

Radiofrequency ablation for volume reduction of tissue for treating upper airway obstruction is used for treating adult patients with snoring, nasal obstruction, and mild obstructive sleep apnea. Applications for using radiofrequency ablation in pediatric patients are expanding, and procedures can be performed safely when adhering to specific surgical principles. Appropriate care includes treatment of postoperative edema for tongue and palate procedures.

Rates and Risk Factors for Subsequent Tonsillectomy After Prior Adenoidectomy

To determine the role of adenoidectomy without concurrent tonsillectomy in the treatment of upper airway obstruction, by determining rates and risk factors for subsequent tonsillectomy. Retrospective cohort study with nested case-control study. Data were evaluated using Kaplan-Meyer curves with Cox proportional hazards regression analysis, as well as contingency table and logistic regression analysis. Tertiary care pediatric hospital with satellite clinics and surgical centers. A total of 2462 patients aged 5 months to 18 years undergoing adenoidectomy without concurrent tonsillectomy. A 5-year database was searched for birth dates, dates of initial surgery, and dates of subsequent tonsillectomy (if performed) or latest follow-up. Cases (tonsillectomies) were then matched 1:1 by age with controls (no subsequent tonsillectomy). Medical charts were reviewed to identify potential predisposing factors, including sex, tonsil size, and adenoidectomy or tonsillectomy indication. Within 5.4 years, 108 patients underwent subsequent tonsillectomy. The relative risk of subsequent tonsillectomy decreases by 0.83 (95% confidence interval, 0.78-0.88) for each increasing year of age at adenoidectomy. The odds of undergoing a future tonsillectomy significantly increase with increasing tonsil size at the time of adenoidectomy. There was a trend toward doubling the risk of subsequent tonsillectomy when the adenoids were removed for upper airway obstruction (including obstructive sleep apnea) compared with other indications (P = .06). Knowledge of the rates and risk factors for subsequent tonsillectomy will allow more informed counseling of parents regarding whether tonsillectomy should be performed or deferred at the time of an indicated adenoidectomy.

Dexamethasone for the Treatment of Infectious Mononucleosis

Emergency Medicine| July 01 2004 Dexamethasone for the Treatment of Infectious Mononucleosis AAP Grand Rounds (2004) 12 (1): 8–9. https://doi.org/10.1542/gr.12-1-8 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Dexamethasone for the Treatment of Infectious Mononucleosis. AAP Grand Rounds July 2004; 12 (1): 8–9. https://doi.org/10.1542/gr.12-1-8 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: dexamethasone, infectious mononucleosis Source: Roy M, Bailey B, Amre DK, et al. Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double blind, placebo–controlled, clinical trial. Arch Pediatr Adolesc Med. 2004;158:250–254. Pharyngeal pain from infectious mononucleosis (IM) can be severe and may persist for up to 14 days.1 Although corticosteroids have been used for treatment of upper airway obstruction caused by IM, 2–,3 their effectiveness in ameliorating throat pain is unknown. Researchers from the Hôpital Ste-Justine, Montréal, Quebec, conducted a randomized, double-blind, placebo-controlled trial in the emergency department to investigate whether routine corticosteroid treatment would relieve the sore throat associated with IM in patients between the ages of 8 to 18 years. Because a monotest was not available 24 hours a day to confirm the diagnosis, patients were enrolled if they had clinical symptoms suggestive of IM. Clinical diagnosis was based on the presence of sore throat, odynophagia, respiratory distress, fatigue, and fever. Epstein-Barr virus antibody levels, monotest, and bacterial throat cultures were performed on each patient to reach a final diagnosis of IM or another cause of pharyngitis. Patients were randomized to receive a single oral dose of dexamethasone (0.3 mg/kg, maximum 15 mg) or a placebo. To assess throat pain, visual analog pain scores (VAS) were recorded by patients at 0 hours, 12 hours, 24 hours, 48 hours, 72 hours, and on day 7. The primary outcome measure was an improvement of 20 mm from baseline on the VAS. A total of 40 patients were enrolled in the study, with 33 ultimately having confirmed IM, either by monotest or viral antibody testing (16 of 20 in the dexamethasone group and 17 of 20 in the placebo group). There was no difference between the treatment and placebo group in the frequency of use of other pain medications including acetaminophen. Hospitalization rates were also similar between the 2 groups (3 placebo patients and 1 dexamethasone patient), although the hospitalized dexamethasone-treated patient had a prolonged hospitalization, complicated by sepsis. A significantly greater proportion of patients given dexamethasone had a 20 mm improvement in VAS at 12 hours (12/20, 60%) when compared to the placebo treatment group (5/19, 26%). At 24 hours, 11 of 20 patients (55%) in the dexamethasone group showed improved pain relief compared to 6 of 20 patients (30%) in the placebo group, a difference that did not achieve statistical significance. At all other time measurements, the improvements in VAS were similar. The authors conclude that a single oral dose of dexamethasone may not provide lasting pain relief. Treatment of severe throat pain associated with IM is a clinical challenge because non-prescription analgesics like acetaminophen and non-steroidal anti-inflammatory medications often fail to provide sufficient analgesia. Dexamethasone is recommended for treatment of IM in the AAP’s 2003 Red Book, but only for significant complications including impending upper airway obstruction, massive splenomegaly, myocarditis, hemolytic anemia, or hemophagocytic syndrome.4 Corticosteroids have been studied in other pharyngeal infections and have... You do not currently have access to this content.

Noninvasive ventilation in the pediatric intensive care unit for children with acute respiratory failure.

Noninvasive ventilation, a novel treatment to increase alveolar ventilation, is accomplished with either subatmospheric or positive pressure administered via an external interface. In adults with acute respiratory failure, noninvasive positive pressure ventilation (NPPV) is superior to standard therapy in preventing intubation and reducing mortality. The role of NPPV in pediatric-age patients with acute respiratory distress is not as well established. Early case reports showed that NPPV treatment does acutely improve both the clinical manifestations of respiratory distress and respiratory gas exchange in children with respiratory distress. However, it is not clear whether NPPV in this setting can prevent vs. delay endotracheal intubation. Other uses of NPPV in the pediatric intensive care unit include the treatment of upper airway obstruction, atelectasis, and exacerbations of neuromuscular disorders, and to facilitate weaning from invasive mechanical ventilation. Successful use of NPPV in young infants with respiratory distress is impeded by the lack of suitable size interfaces, and the response characteristics of commercially available bilevel ventilators. Despite these challenges, NPPV is a promising alternate to standard therapies in the treatment of acute respiratory distress in the pediatric-age patient.

Crescimento pôndero-estatural de crianças após adenoamigdalectomia

A hiperplasia adenoamigdaliana é a principal causa de obstrução das vias aéreas superiores em crianças, sendo muitas vezes associada à apnéia do sono. Esta, por sua vez, resulta em uma série de comprometimentos: baixo rendimento escolar, cor pulmonale, distúrbios de comportamento não específicos, hiperatividade, sonolência diurna, distração e atrasos de desenvolvimento, sendo o déficit pôndero-estatural o mais grave. A adenoamigdalectomia é o tratamento de escolha. O objetivo deste trabalho é mensurar o crescimento e desenvolvimento das crianças antes e depois da adenoamigdalectomia através da comparação dos percentis pré e pós operatórios. FORMA DE ESTUDO: Clínico prospectivo randomizado. MATERIAL E MÉTODO: Cinquenta e cinco crianças de 2 a 12 anos, com história de obstrução das vias aéreas superiores por hiperplasia adenoamigdaliana foram submetidas a exame antropométrico (peso e altura), antes e 6 meses após a adenoamigdalectomia. Os dados foram transformados em percentil para peso e altura, de acordo com a idade e comparados através de análise estatística. RESULTADOS: No pré-operatório, encontramos a seguinte distribuição para o percentil altura: 78,2%, abaixo de p75 e para peso 70,9% abaixo de p50. No pós-operatório observou-se melhor distribuição das crianças: para altura 34,6% abaixo de p75, 32,8% entre p75-95 e 32,6% para p95 e acima e para peso: 35,5% abaixo de p50, 36,4% para p50-95 e 29,1% acima de p95. CONCLUSÃO: Observou-se uma melhora considerável do desenvolvimento pôndero-estatural das crianças após a adenoamigdalectomia.

Safety and efficacy of heliox as a treatment for upper airway obstruction due to radiation-induced laryngeal dysfunction

The mixture of helium and oxygen, called heliox, has been successfully used in the management of different respiratory diseases since 1935. Despite several reports on its usefulness, it is not widely available in acute care facilities and it remains somewhat controversial. In this article we present the case of a 69-year-old woman in whom bilateral vocal cord paralysis developed after radiation therapy and in whom heliox was successfully used to manage her upper airway obstruction. Although heliox offers an additional tool in the treatment of various airway and pulmonary problems, it can be used only as a temporizing agent to allow time for appropriate therapy of the underlying process. Given its beneficial physiologic and clinical effects, it seems that further studies are warranted to define a clear and concise protocol for its use in the emergency setting. (Heart Lung® 2001;30:146-7.)

Clinical management of upper airway obstruction: epiglottitis and laryngotracheobronchitis

OBJECTIVE: To present current concepts on diagnosis and treatment of upper airway obstruction, mainly related to differential diagnosis between acute viral laryngotracheobronchitis and epiglottitis.METHODS: Bibliographic review covering the last ten years, using both Medline system and direct research. The most relevant articles published about the subject were selected.RESULTS: Viral laryngotracheobronchitis is an acute self-limited disease of the upper airway in a child, clinically characterized by barking cough, stridor, hoarse voice, and upper respiratory symptoms. The disease is diagnosed by clinical signs and symptoms. Rarely, if no immediate airway management is needed, radiography of the neck may help to exclude other entities that cause laryngeal obstruction. In contrast to viral laryngotracheobronchitis, epiglottitis is characterized by inflammation of the supraglottic tissues and is caused mainly by Haemophilus influenzae type b. A previously healthy child suddenly develops a sore throat and fever. Within hours after the onset of symptoms the patient looks toxic, swallowing is painful and breathing is difficult. Drooling and cervical hyperextension are frequently present. Lateral neck radiograph is rarely required to the diagnosis and may delay appropriate management of the airway. Moderate viral laryngotracheobronchitis with stridor at rest and retractions should be treated with steroids (systemic or nebulized) and nebulized epinephrine. Severe viral laryngotracheobronchitis should be treated aggressively while arregements are made for endotracheal intubation. The diagnosis of epiglottitis requires immediate endotracheal intubation in the appropriate unit (emergency department, intensive care unit or surgical unit) and antimicrobial therapy. Alternatively at some medical centers children with severe upper airway obstruction have been treated with a mixture of helium and oxygen (70 to 80% concentration of helium) instead of room air or pure oxygen to avoid intubation.CONCLUSIONS: There are different levels of care for patients with upper airway obstruction, depending on their clinical presentation. The clinical manifestations of viral laryngotracheobronchitis may be confused with the presentation of epiglottitis. Despite this observation we believe that differential diagnosis between viral laryngotracheobronchitis and epiglottitis rests on clinical grounds.

Prevention and treatment of upper airway obstruction in infants and children.

This review examines some of the recent advances made in the prevention and treatment of upper airway obstruction in infancy and childhood. In some instances, the advances are the result of experimental studies that corroborate or refute therapeutic notions that had been adopted prematurely. Studies performed in the past few years, for instance, have demonstrated that both systemic and local corticosteroid treatments are indeed effective in the treatment of viral croup. In contrast, other studies carried out in the same period raise doubts about the usefulness of these medications in the prevention of postextubation laryngeal edema. In other instances, the advances are the result of pioneering efforts to correct anatomical defects, usually congenital, that cause severe airway obstruction. Tracheal and laryngeal stenoses and craniofacial deformities, which only 5 years ago would have been palliated by tracheotomy, undergo now routine primary correction. Despite all these advances, upper airway obstruction remains an important source of morbidity and mortality in early childhood.

Mandibular distraction osteogenesis in the treatment of upper airway obstruction in children with craniofacial deformities.

Over the past 3 years, 16 patients (12 males, 4 females) have undergone mandibular distraction osteogenesis in conjunction with soft-tissue procedures to treat medically refractory obstructive sleep apnea. Thirty distraction devices were placed for bilateral distraction in 14 children and unilateral distraction in 2. The mean age of treatment was 4 years and 8 months (range 14 weeks to 12 years and 8 months). Eight of the patients had failed conventional medical and surgical treatment of obstructive sleep apnea and were considered tracheostomy candidates, whereas the remaining eight had tracheostomies placed shortly after birth for upper airway obstruction. These eight children could not be decannulated by standard protocols. The average distraction distance was 25 mm (range 18 to 35 mm). To date, seven of the eight patients with tracheostomies have been decannulated, and one is still in progress. Clinical improvement in the signs and symptoms of sleep apnea and reduction or elimination of preoperative oxygen requirements occurred in seven of the eight children with medically refractory sleep apnea. Twelve-channel polysomnograms were obtained preoperatively and postoperatively in each of the eight patients without tracheostomies. Respiratory disturbance index decreased from a mean of 7.1 to 1.7 after surgery. Lowest oxygen saturation rose from a mean of 0.70 to 0.89 after surgery. Application of mandibular distraction osteogenesis is an important component in the treatment of obstructive sleep apnea and permits mandibular advancement in the younger child. As more experience is gained with distraction osteogenesis in the treatment of children with obstructive sleep apnea, the role of distraction will become better defined.

Surgical treatment of obstructive sleep apnea in neurologically compromised patients.

Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.

Synthesis of interleukin-1α, interleukin-6, and interleukin-8 by cultured human nasal epithelial cells

Nasal epithelium forms the initial barrier between the environment and the respiratory system and may be a potential source of proinflammatory interleukins, which contribute to the pathophysiology of allergic and nonallergic rhinitis. To explore this possibility, epithelium and cultured human nasal epithelial cells from nasal turbinates of patients undergoing surgery for treatment of upper airway obstruction were examined for the spontaneous expression of interleukin (IL)-1α, IL-1β, IL-6, and IL-8. Human nasal epithelial cell lysates and culture supernatants were assayed by two-site ELISAs specific for IL-1α, IL-1β, IL-6, or IL-8. Maximum concentrations of these cytokines in supernatants ranged from approximately 0.2 to 2 ng/ml for IL-1α, 1.5 to 7 ng/ml for IL-6, and 100 to 3000 ng/ml for IL-8. IL-1α was predominantly cell-associated, whereas most of the IL-8 and all of the IL-6 were detected in the supernatant. Little or no IL-1β was detected by ELISA in the supernatants or cell lysates. Whole tissue turbinates and isolated epithelium were also examined for IL-1β, IL-6, and IL-8 mRNA expression by Northern blot analysis. IL-6 and IL-8 mRNAs were detected, whereas IL-1β mRNA was not. Furthermore, IL-6 and IL-8 release from human nasal epithelial cell cultures was enhanced by addition to the cultures of lipopolysaccharide, and IL-6 release was inhibited by polymyxin B. Thus human nasal epithelium may be a major source of IL-1α, IL-6, and IL-8 in allergic and nonallergic rhinitis. Production of those proinflammatory cytokines by epithelial cells of the nasal and sinus mucosa may contribute to the pathologic and clinical events that occur in these diseases. (J A LLERGY C LIN I MMUNOL 1994;93:1060-7.)

幼小児におけるアデノイド切除術・口蓋扁桃摘出術施行患者の経過観察

During the seven years between July 1983 and June 1990,243 children underwent adeno-tonsillectomy. Questionnaires about symptoms of upper airway obstruction were sent to the families of these patients to investigate long term effects of adeno-tonsillectomy.Adeno-tonsillectomy was an effective long time treatment for upper airway obstruction. The following symptom were important in diagnosing the severity of upper airway obstruction; sleep apnea, snoring, restless sleep, nocturnal enuresis, night sweating, chest deformity, oral breathing, somnolence and susceptibility to colds.