nikki mills - Academia.edu (original) (raw)

Papers by nikki mills

Research paper thumbnail of A heuristic approach to foreign bodies in the paediatric airway

International Journal of Pediatric Otorhinolaryngology, 2014

This retrospective study reviews the clinical presentation and management of children with airway... more This retrospective study reviews the clinical presentation and management of children with airway FBs in our centre. It suggests a safe and reliable guideline to help differentiate which patients should proceed to investigation with rigid laryngobronchoscopy. A retrospective review of all case notes of laryngobronchoscopies performed for suspected FB aspiration from January 2003 to August 2013 at a tertiary paediatric institution was undertaken. Patient characteristics, history, clinical examination, radiological findings and outcomes were analysed. 158 patients underwent rigid laryngobronchoscopy for suspected FB aspiration between January 2003 and August 2013. The baseline population demographics, the location and type of FBs retrieved were comparable to other similar studies; however, there is a statistically significant higher proportion of Pacific, Maori and Middle Eastern/Latin American/African children compared with the baseline population. Two or more positive findings in the presence of an acute history, any examination or radiology findings is a good indicator to proceed to laryngobronchoscopy with over 99% sensitivity. In a hospital presentation population, this retrospective study suggests that a guideline to proceed to laryngobronchoscopy in a case of suspected FB aspiration is two out of the three positive findings in the presence of an acute history, any examination or radiology findings. Patients who are stable and who do not have two of the three broad category findings can be considered for conservative management and observed on the ward, however, this is a guideline and must be combined with the clinical expertise of the paediatric airway specialist. Further studies are recommended to investigate contributing factors for the disproportionately higher incidence amongst Pacific, Maori and Middle Eastern/Latin American/African children.

Research paper thumbnail of Flexible Endoscopic Evaluation of Swallowing in Breastfeeding Infants With Laryngomalacia: Observed Clinical and Endoscopic Changes With Alteration of Infant Positioning at the Breast

Annals of Otology, Rhinology & Laryngology

Objectives: This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of... more Objectives: This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of swallowing in infants with laryngomalacia, to ascertain the impact of infant positioning on airway compromise and fluid dynamics during breastfeeding. The study aims to identify whether modification of infant positioning at the breast may improve the possibility of safe, successful breastfeeding in infants with laryngomalacia and concurrent breastfeeding difficulty. Methods: Twenty-three infants referred for noisy breathing and difficulty feeding were assessed with flexible endoscopic evaluation of swallowing (FEES) during breastfeeding. All had endoscopically confirmed laryngomalacia. During FEES, observations were made of clinical signs of airway compromise as well as endoscopically observable anatomical features and swallowing dynamics during breastfeeding, including tongue base position, view of laryngeal inlet and vocal folds, dynamic supraglottic soft tissue collapse, timing of mi...

Research paper thumbnail of In vitro Inhibition of Clinical Isolates of Otitis Media Pathogens by the Probiotic Streptococcus salivarius BLIS K12

Probiotics and Antimicrobial Proteins

Research paper thumbnail of International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population

International Journal of Pediatric Otorhinolaryngology

Research paper thumbnail of Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery

International Journal of Otolaryngology

Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad ran... more Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad range of indications from birth through adulthood. This study utilizes histology to define the structure and tissue composition of the lingual frenulum and floor of mouth (FOM) fascia. En bloc specimens of anterior tongue, lingual frenulum, and FOM tissues were harvested from ten embalmed adult cadavers. An additional three fresh tissue cadaveric specimens were frozen with the tongue supported in an elevated position, to enable harvesting and paraffin embedding of the elevated lingual frenulum as a discrete specimen. All 13 specimens were prepared as ten-micron coronal sections using stains to determine the general morphology of the lingual frenulum, its relationship to neighbouring structures (Mason’s Trichrome), presence of elastin fibers (Verhoeff-van Gieson), and collagen typing (Picrosirius Red). Our results have shown a submucosal layer of fascia spanning horizontally across the FOM w...

Research paper thumbnail of Imaging the breastfeeding swallow: Pilot study utilizing real‐time MRI

Laryngoscope Investigative Otolaryngology

Research paper thumbnail of Pediatric tracheostomy decannulation: When can decannulation be performed safely outside of the intensive care setting? A 10 year review from a single tertiary otolaryngology service

International Journal of Pediatric Otorhinolaryngology

Research paper thumbnail of Complications following frenotomy for ankyloglossia: A 24‐month prospective New Zealand Paediatric Surveillance Unit study

Journal of Paediatrics and Child Health

Research paper thumbnail of Defining the anatomy of the neonatal lingual frenulum

Research paper thumbnail of PCV7- and PCV10-Vaccinated Otitis-Prone Children in New Zealand Have Similar Pneumococcal and Haemophilus influenzae Densities in Their Nasopharynx and Middle Ear

Vaccines

Otitis media (OM) is a major reason for antibiotic consumption and surgery in children. Nasophary... more Otitis media (OM) is a major reason for antibiotic consumption and surgery in children. Nasopharyngeal carriage of otopathogens, Streptococcus pneumoniae and nontypeable Haemophilus influenzae (NTHi), is a prerequisite for development of OM, and increased nasopharyngeal otopathogen density correlates with disease onset. Vaccines can reduce or eliminate otopathogen carriage, as demonstrated for pneumococcal serotypes included in pneumococcal conjugate vaccines (PCV). The 10-valent PCV (PCV10) includes an NTHi carrier protein, and in 2011 superseded 7-valent PCV on the New Zealand Immunisation Program. Data are conflicting on whether PCV10 provides protection against NTHi carriage or disease. Assessing this in otitis-prone cohorts is important for OM prevention. We compared otopathogen density in the nasopharynx and middle ear of New Zealand PCV7-vaccinated and PCV10-vaccinated otitis-prone and non-otitis-prone children to determine PCV10 impact on NTHi and S. pneumoniae carriage. We ...

Research paper thumbnail of What is a Tongue Tie? Defining the anatomy of the in-situ lingual frenulum

Clinical Anatomy

Surgical release of the lingual frenulum (frenotomy) has become an increasingly common procedure,... more Surgical release of the lingual frenulum (frenotomy) has become an increasingly common procedure, performed from birth through to adulthood. Surprisingly, detailed anatomy of the in-situ lingual frenulum has never been described, and no anatomical basis has been proposed for the individual variability in frenulum morphology. The lingual frenulum is frequently referred to as a "cord" or "submucosal band" of connective tissue, yet there is no evidence to support this anatomical construct. This paper aims to describe the anatomy of the in-situ lingual frenulum and its relationship to floor of mouth structures. Fresh tissue microdissection of the lingual frenulum and floor of mouth was performed on nine adult cadavers with photo-documentation and description of findings. The lingual frenulum is a dynamic structure, formed by a midline fold in a layer of fascia that inserts around the inner arc of the mandible, forming a diaphragmlike structure across the floor of mouth. This fascia is located immediately beneath the oral mucosa, fusing centrally with the connective tissue on the tongue's ventral surface. The sublingual glands and submandibular ducts are enveloped by the fascial layer and anterior genioglossus fibers are suspended beneath it. Lingual nerve branches are located superficially on the ventral surface of the tongue, immediately deep to the fascia. The lingual frenulum is not a discrete midline structure. It is formed by dynamic elevation of a midline fold in the floor of mouth fascia. With this study, the clinical concept of ankyloglossia and its surgical management warrant revision. Clin. Anat. 32:749-761, 2019.

Research paper thumbnail of Double button battery ingestion – The “macaroon” sign

Journal of Pediatric Surgery Case Reports

Research paper thumbnail of The bacterial species associated with aspirated foreign bodies in children

Research paper thumbnail of Long-standing inhaled foreign bodies in children: Characteristics and outcome

International journal of pediatric otorhinolaryngology, 2016

Aspirated foreign bodies in children present a potentially life-threatening condition and can be ... more Aspirated foreign bodies in children present a potentially life-threatening condition and can be challenging to diagnose. This study aims to elucidate the characteristics and outcome of children with long-standing aspirated foreign bodies. Retrospective case series of all cases of confirmed long-standing aspirated foreign bodies (LSAFB) between January 2003 to December 2015 in a single paediatric tertiary-level institution, defined as more than two weeks from choking episode or beginning of symptoms. Clinical files and operative records on 227 patients were screened and 35 children were confirmed to have been treated for LSAFB as per definition above. Median time to presentation was 4 weeks (mean 8.8 weeks). Eighty-six percent presented with cough and 51% with dyspnoea. Abnormal chest X-ray findings were found in 28 out 31 patients (90%). Organic foreign bodies (22) were more common than inorganic (14). Intraoperative granulation tissue was demonstrated in 89% of patients and in 46%...

Research paper thumbnail of Pneumococcal vaccine impact on otitis media microbiology: A New Zealand cohort study before and after the introduction of PHiD-CV10 vaccine

Vaccine, Jul 14, 2016

We compared the microbiology of middle ear fluid (MEF) in two cohorts of children having ventilat... more We compared the microbiology of middle ear fluid (MEF) in two cohorts of children having ventilation tube (VT) insertion; the first in the era of 7-valent Streptococcus pneumoniae conjugate vaccine (PCV7) and the second following introduction of the ten-valent pneumococcal vaccine (PHiD-CV10). During 2011 (Phase 1) and again in 2014 (Phase 2) MEF and NP samples from 325 children and 319 children were taken at the time of VT insertion. A matched comparison group had NP swabs collected with 137 children (Phase 1) and 154 (Phase 2). Culture was performed on all NP and MEF samples with further molecular identification of Haemophilus species, serotyping of S. pneumoniae, and polymerase chain reaction (PCR) testing on all MEF samples. In Phase 2 immunisation coverage with ⩾3 doses of PHiD-CV10 was 93%. The rate and ratios of culture and molecular detection of the 3 main otopathogens was unchanged between Phase 1 and Phase 2 in both MEF and NP. Haemophilus influenzae was cultured in one qu...

Research paper thumbnail of The starship children's hospital tonsillectomy: A further 10 years of experience

The Laryngoscope, Dec 27, 2016

Tonsillectomy as a day-stay procedure remains controversial, although it is an established proced... more Tonsillectomy as a day-stay procedure remains controversial, although it is an established procedure in New Zealand. We reviewed our last 10 years' experience. A prospective audit was used to determine unplanned conversion from day-stay to overnight hospital admission rates and the incidence of postoperative complications. There were 5,400 tonsillectomies performed over the 10-year study period (January 2004-January 2015); 71% as outpatients. The unplanned conversion rate to overnight stay was 0.4%. The median age of day-stay patients was 6.5 years (range 13 months-15 years) compared with those admitted for overnight stay (5 years; range 8 months-15 years). The primary postoperative bleed rate was 0.5% (confidence interval [CI] 0.3%-0.7%), and the combined primary and secondary posttonsillectomy bleed rate was 4.3% (CI 3.8%-5.0%). The rate of patients returning with postoperative complications within 1 month of surgery was 6.3% (CI 5.6%-7.0%). Day-stay tonsillectomy in the pedia...

Research paper thumbnail of Vaccination to prevent otitis media in New Zealand

The New Zealand medical journal, Jan 12, 2011

Otitis media (OM) is the most common illness requiring medical consultation in children less than... more Otitis media (OM) is the most common illness requiring medical consultation in children less than 3 years of age. 1 On 1 July 2011 the New Zealand Immunisation schedule changed to include a new generation pneumococcal conjugate vaccine with the potential to significantly reduce the burden of disease due to OM. We outline the recent changes and their implications for New Zealand children.

Research paper thumbnail of Pediatric tracheotomy: 17 year review

International Journal of Pediatric Otorhinolaryngology, 2007

Objective: To study the outcomes, complications, and indications for pediatric tracheotomies perf... more Objective: To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987-2003. Methods: A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies. Results: A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n = 40, and subglottic stenosis, n = 18) was the most common indication for surgery (n = 86; 70%) with a lesser number (n = 36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% (n = 62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%)

Research paper thumbnail of Congenital stridor with feeding difficulty as a presenting symptom of Dok7 congenital myasthenic syndrome

International Journal of Pediatric Otorhinolaryngology, 2010

The congenital myasthenic syndromes (CMS) are a heterogeneous group of genetic disorders of neuro... more The congenital myasthenic syndromes (CMS) are a heterogeneous group of genetic disorders of neuromuscular transmission. Mutations in at least 12 genes have been recognised to date, many associated with distinctive phenotypes and with variable response to treatment [1]. Most mutations cause fatigable weakness, which may be manifest from birth. Once the clinical diagnosis is considered, it may be rapidly supported by finding increased jitter on stimulation single fibre EMG (stimSFEMG), successfully carried out in most children with topical analgesia [2,3] and confirmed by genetic mutation analysis. However, diagnosis is frequently delayed [4], notably in the recently described postsynaptic CMS caused by mutations in DOK7, in which early motor milestones are often normal with later onset of weakness in a predominantly limb girdle pattern, which responds poorly to treatment with acetylcholinesterase inhibitors [5-9]. In a recent review of 46 childhood CMS cases [4] we noted stridor in 6 children, congenital in 5, with bilateral vocal cord palsy (VCP) in 3, with few other neonatal symptoms suggesting an

Research paper thumbnail of To drain or not to drain – Management of pediatric deep neck abscesses: A case–control study

International Journal of Pediatric Otorhinolaryngology, 2012

Optimal management of deep neck abscesses has been the subject of debate for more than a century:... more Optimal management of deep neck abscesses has been the subject of debate for more than a century: surgical drainage has been the mainstay of treatment, but recently many centres have reported successful non-operative management in selected cases. Our objective was to review the management of deep neck abscesses in our institution and to identify characteristics that would predict successful non-operative management. A retrospective chart review from January 2001 to August 2010 was performed. Children up to age fifteen years with a CT-confirmed diagnosis of retropharyngeal or parapharyngeal abscess were included. A case-control study of small deep space neck abscesses (≤ 25 mm maximal diameter) was performed, comparing antibiotic treatment alone with antibiotics plus abscess drainage. 54 children met the inclusion criteria, of whom half had abscesses ≤ 25 mm diameter. Younger children within the group with smaller abscesses were more likely to need surgical drainage (p<0.05). Of 13 children requiring operative management, ten underwent a period of antibiotic treatment and observation prior to surgery, eight (80%) had fever beyond 48 h compared with three (23%) in the non-surgical group (p<0.01). 27 children had an abscess > 25 mm diameter on CT scan, four (15%) of whom responded quickly to antibiotics and were managed non-operatively, while the rest underwent surgery. There were no significant differences between the surgical and non-surgical group characteristics with larger abscesses. High dose intravenous antibiotics are an effective treatment for deep space neck abscesses and may obviate the need for surgical drainage, particularly in smaller abscesses. Children who do not respond quickly to antibiotics are more likely to require surgery to achieve resolution. Children with larger abscesses may respond to antibiotic therapy alone but should be closely observed. A trial of high dose intravenous antibiotics in stable children with close observation is warranted as first line treatment, especially for small deep space neck abscesses.

Research paper thumbnail of A heuristic approach to foreign bodies in the paediatric airway

International Journal of Pediatric Otorhinolaryngology, 2014

This retrospective study reviews the clinical presentation and management of children with airway... more This retrospective study reviews the clinical presentation and management of children with airway FBs in our centre. It suggests a safe and reliable guideline to help differentiate which patients should proceed to investigation with rigid laryngobronchoscopy. A retrospective review of all case notes of laryngobronchoscopies performed for suspected FB aspiration from January 2003 to August 2013 at a tertiary paediatric institution was undertaken. Patient characteristics, history, clinical examination, radiological findings and outcomes were analysed. 158 patients underwent rigid laryngobronchoscopy for suspected FB aspiration between January 2003 and August 2013. The baseline population demographics, the location and type of FBs retrieved were comparable to other similar studies; however, there is a statistically significant higher proportion of Pacific, Maori and Middle Eastern/Latin American/African children compared with the baseline population. Two or more positive findings in the presence of an acute history, any examination or radiology findings is a good indicator to proceed to laryngobronchoscopy with over 99% sensitivity. In a hospital presentation population, this retrospective study suggests that a guideline to proceed to laryngobronchoscopy in a case of suspected FB aspiration is two out of the three positive findings in the presence of an acute history, any examination or radiology findings. Patients who are stable and who do not have two of the three broad category findings can be considered for conservative management and observed on the ward, however, this is a guideline and must be combined with the clinical expertise of the paediatric airway specialist. Further studies are recommended to investigate contributing factors for the disproportionately higher incidence amongst Pacific, Maori and Middle Eastern/Latin American/African children.

Research paper thumbnail of Flexible Endoscopic Evaluation of Swallowing in Breastfeeding Infants With Laryngomalacia: Observed Clinical and Endoscopic Changes With Alteration of Infant Positioning at the Breast

Annals of Otology, Rhinology & Laryngology

Objectives: This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of... more Objectives: This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of swallowing in infants with laryngomalacia, to ascertain the impact of infant positioning on airway compromise and fluid dynamics during breastfeeding. The study aims to identify whether modification of infant positioning at the breast may improve the possibility of safe, successful breastfeeding in infants with laryngomalacia and concurrent breastfeeding difficulty. Methods: Twenty-three infants referred for noisy breathing and difficulty feeding were assessed with flexible endoscopic evaluation of swallowing (FEES) during breastfeeding. All had endoscopically confirmed laryngomalacia. During FEES, observations were made of clinical signs of airway compromise as well as endoscopically observable anatomical features and swallowing dynamics during breastfeeding, including tongue base position, view of laryngeal inlet and vocal folds, dynamic supraglottic soft tissue collapse, timing of mi...

Research paper thumbnail of In vitro Inhibition of Clinical Isolates of Otitis Media Pathogens by the Probiotic Streptococcus salivarius BLIS K12

Probiotics and Antimicrobial Proteins

Research paper thumbnail of International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population

International Journal of Pediatric Otorhinolaryngology

Research paper thumbnail of Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery

International Journal of Otolaryngology

Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad ran... more Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad range of indications from birth through adulthood. This study utilizes histology to define the structure and tissue composition of the lingual frenulum and floor of mouth (FOM) fascia. En bloc specimens of anterior tongue, lingual frenulum, and FOM tissues were harvested from ten embalmed adult cadavers. An additional three fresh tissue cadaveric specimens were frozen with the tongue supported in an elevated position, to enable harvesting and paraffin embedding of the elevated lingual frenulum as a discrete specimen. All 13 specimens were prepared as ten-micron coronal sections using stains to determine the general morphology of the lingual frenulum, its relationship to neighbouring structures (Mason’s Trichrome), presence of elastin fibers (Verhoeff-van Gieson), and collagen typing (Picrosirius Red). Our results have shown a submucosal layer of fascia spanning horizontally across the FOM w...

Research paper thumbnail of Imaging the breastfeeding swallow: Pilot study utilizing real‐time MRI

Laryngoscope Investigative Otolaryngology

Research paper thumbnail of Pediatric tracheostomy decannulation: When can decannulation be performed safely outside of the intensive care setting? A 10 year review from a single tertiary otolaryngology service

International Journal of Pediatric Otorhinolaryngology

Research paper thumbnail of Complications following frenotomy for ankyloglossia: A 24‐month prospective New Zealand Paediatric Surveillance Unit study

Journal of Paediatrics and Child Health

Research paper thumbnail of Defining the anatomy of the neonatal lingual frenulum

Research paper thumbnail of PCV7- and PCV10-Vaccinated Otitis-Prone Children in New Zealand Have Similar Pneumococcal and Haemophilus influenzae Densities in Their Nasopharynx and Middle Ear

Vaccines

Otitis media (OM) is a major reason for antibiotic consumption and surgery in children. Nasophary... more Otitis media (OM) is a major reason for antibiotic consumption and surgery in children. Nasopharyngeal carriage of otopathogens, Streptococcus pneumoniae and nontypeable Haemophilus influenzae (NTHi), is a prerequisite for development of OM, and increased nasopharyngeal otopathogen density correlates with disease onset. Vaccines can reduce or eliminate otopathogen carriage, as demonstrated for pneumococcal serotypes included in pneumococcal conjugate vaccines (PCV). The 10-valent PCV (PCV10) includes an NTHi carrier protein, and in 2011 superseded 7-valent PCV on the New Zealand Immunisation Program. Data are conflicting on whether PCV10 provides protection against NTHi carriage or disease. Assessing this in otitis-prone cohorts is important for OM prevention. We compared otopathogen density in the nasopharynx and middle ear of New Zealand PCV7-vaccinated and PCV10-vaccinated otitis-prone and non-otitis-prone children to determine PCV10 impact on NTHi and S. pneumoniae carriage. We ...

Research paper thumbnail of What is a Tongue Tie? Defining the anatomy of the in-situ lingual frenulum

Clinical Anatomy

Surgical release of the lingual frenulum (frenotomy) has become an increasingly common procedure,... more Surgical release of the lingual frenulum (frenotomy) has become an increasingly common procedure, performed from birth through to adulthood. Surprisingly, detailed anatomy of the in-situ lingual frenulum has never been described, and no anatomical basis has been proposed for the individual variability in frenulum morphology. The lingual frenulum is frequently referred to as a "cord" or "submucosal band" of connective tissue, yet there is no evidence to support this anatomical construct. This paper aims to describe the anatomy of the in-situ lingual frenulum and its relationship to floor of mouth structures. Fresh tissue microdissection of the lingual frenulum and floor of mouth was performed on nine adult cadavers with photo-documentation and description of findings. The lingual frenulum is a dynamic structure, formed by a midline fold in a layer of fascia that inserts around the inner arc of the mandible, forming a diaphragmlike structure across the floor of mouth. This fascia is located immediately beneath the oral mucosa, fusing centrally with the connective tissue on the tongue's ventral surface. The sublingual glands and submandibular ducts are enveloped by the fascial layer and anterior genioglossus fibers are suspended beneath it. Lingual nerve branches are located superficially on the ventral surface of the tongue, immediately deep to the fascia. The lingual frenulum is not a discrete midline structure. It is formed by dynamic elevation of a midline fold in the floor of mouth fascia. With this study, the clinical concept of ankyloglossia and its surgical management warrant revision. Clin. Anat. 32:749-761, 2019.

Research paper thumbnail of Double button battery ingestion – The “macaroon” sign

Journal of Pediatric Surgery Case Reports

Research paper thumbnail of The bacterial species associated with aspirated foreign bodies in children

Research paper thumbnail of Long-standing inhaled foreign bodies in children: Characteristics and outcome

International journal of pediatric otorhinolaryngology, 2016

Aspirated foreign bodies in children present a potentially life-threatening condition and can be ... more Aspirated foreign bodies in children present a potentially life-threatening condition and can be challenging to diagnose. This study aims to elucidate the characteristics and outcome of children with long-standing aspirated foreign bodies. Retrospective case series of all cases of confirmed long-standing aspirated foreign bodies (LSAFB) between January 2003 to December 2015 in a single paediatric tertiary-level institution, defined as more than two weeks from choking episode or beginning of symptoms. Clinical files and operative records on 227 patients were screened and 35 children were confirmed to have been treated for LSAFB as per definition above. Median time to presentation was 4 weeks (mean 8.8 weeks). Eighty-six percent presented with cough and 51% with dyspnoea. Abnormal chest X-ray findings were found in 28 out 31 patients (90%). Organic foreign bodies (22) were more common than inorganic (14). Intraoperative granulation tissue was demonstrated in 89% of patients and in 46%...

Research paper thumbnail of Pneumococcal vaccine impact on otitis media microbiology: A New Zealand cohort study before and after the introduction of PHiD-CV10 vaccine

Vaccine, Jul 14, 2016

We compared the microbiology of middle ear fluid (MEF) in two cohorts of children having ventilat... more We compared the microbiology of middle ear fluid (MEF) in two cohorts of children having ventilation tube (VT) insertion; the first in the era of 7-valent Streptococcus pneumoniae conjugate vaccine (PCV7) and the second following introduction of the ten-valent pneumococcal vaccine (PHiD-CV10). During 2011 (Phase 1) and again in 2014 (Phase 2) MEF and NP samples from 325 children and 319 children were taken at the time of VT insertion. A matched comparison group had NP swabs collected with 137 children (Phase 1) and 154 (Phase 2). Culture was performed on all NP and MEF samples with further molecular identification of Haemophilus species, serotyping of S. pneumoniae, and polymerase chain reaction (PCR) testing on all MEF samples. In Phase 2 immunisation coverage with ⩾3 doses of PHiD-CV10 was 93%. The rate and ratios of culture and molecular detection of the 3 main otopathogens was unchanged between Phase 1 and Phase 2 in both MEF and NP. Haemophilus influenzae was cultured in one qu...

Research paper thumbnail of The starship children's hospital tonsillectomy: A further 10 years of experience

The Laryngoscope, Dec 27, 2016

Tonsillectomy as a day-stay procedure remains controversial, although it is an established proced... more Tonsillectomy as a day-stay procedure remains controversial, although it is an established procedure in New Zealand. We reviewed our last 10 years' experience. A prospective audit was used to determine unplanned conversion from day-stay to overnight hospital admission rates and the incidence of postoperative complications. There were 5,400 tonsillectomies performed over the 10-year study period (January 2004-January 2015); 71% as outpatients. The unplanned conversion rate to overnight stay was 0.4%. The median age of day-stay patients was 6.5 years (range 13 months-15 years) compared with those admitted for overnight stay (5 years; range 8 months-15 years). The primary postoperative bleed rate was 0.5% (confidence interval [CI] 0.3%-0.7%), and the combined primary and secondary posttonsillectomy bleed rate was 4.3% (CI 3.8%-5.0%). The rate of patients returning with postoperative complications within 1 month of surgery was 6.3% (CI 5.6%-7.0%). Day-stay tonsillectomy in the pedia...

Research paper thumbnail of Vaccination to prevent otitis media in New Zealand

The New Zealand medical journal, Jan 12, 2011

Otitis media (OM) is the most common illness requiring medical consultation in children less than... more Otitis media (OM) is the most common illness requiring medical consultation in children less than 3 years of age. 1 On 1 July 2011 the New Zealand Immunisation schedule changed to include a new generation pneumococcal conjugate vaccine with the potential to significantly reduce the burden of disease due to OM. We outline the recent changes and their implications for New Zealand children.

Research paper thumbnail of Pediatric tracheotomy: 17 year review

International Journal of Pediatric Otorhinolaryngology, 2007

Objective: To study the outcomes, complications, and indications for pediatric tracheotomies perf... more Objective: To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987-2003. Methods: A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies. Results: A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n = 40, and subglottic stenosis, n = 18) was the most common indication for surgery (n = 86; 70%) with a lesser number (n = 36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% (n = 62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%)

Research paper thumbnail of Congenital stridor with feeding difficulty as a presenting symptom of Dok7 congenital myasthenic syndrome

International Journal of Pediatric Otorhinolaryngology, 2010

The congenital myasthenic syndromes (CMS) are a heterogeneous group of genetic disorders of neuro... more The congenital myasthenic syndromes (CMS) are a heterogeneous group of genetic disorders of neuromuscular transmission. Mutations in at least 12 genes have been recognised to date, many associated with distinctive phenotypes and with variable response to treatment [1]. Most mutations cause fatigable weakness, which may be manifest from birth. Once the clinical diagnosis is considered, it may be rapidly supported by finding increased jitter on stimulation single fibre EMG (stimSFEMG), successfully carried out in most children with topical analgesia [2,3] and confirmed by genetic mutation analysis. However, diagnosis is frequently delayed [4], notably in the recently described postsynaptic CMS caused by mutations in DOK7, in which early motor milestones are often normal with later onset of weakness in a predominantly limb girdle pattern, which responds poorly to treatment with acetylcholinesterase inhibitors [5-9]. In a recent review of 46 childhood CMS cases [4] we noted stridor in 6 children, congenital in 5, with bilateral vocal cord palsy (VCP) in 3, with few other neonatal symptoms suggesting an

Research paper thumbnail of To drain or not to drain – Management of pediatric deep neck abscesses: A case–control study

International Journal of Pediatric Otorhinolaryngology, 2012

Optimal management of deep neck abscesses has been the subject of debate for more than a century:... more Optimal management of deep neck abscesses has been the subject of debate for more than a century: surgical drainage has been the mainstay of treatment, but recently many centres have reported successful non-operative management in selected cases. Our objective was to review the management of deep neck abscesses in our institution and to identify characteristics that would predict successful non-operative management. A retrospective chart review from January 2001 to August 2010 was performed. Children up to age fifteen years with a CT-confirmed diagnosis of retropharyngeal or parapharyngeal abscess were included. A case-control study of small deep space neck abscesses (≤ 25 mm maximal diameter) was performed, comparing antibiotic treatment alone with antibiotics plus abscess drainage. 54 children met the inclusion criteria, of whom half had abscesses ≤ 25 mm diameter. Younger children within the group with smaller abscesses were more likely to need surgical drainage (p<0.05). Of 13 children requiring operative management, ten underwent a period of antibiotic treatment and observation prior to surgery, eight (80%) had fever beyond 48 h compared with three (23%) in the non-surgical group (p<0.01). 27 children had an abscess > 25 mm diameter on CT scan, four (15%) of whom responded quickly to antibiotics and were managed non-operatively, while the rest underwent surgery. There were no significant differences between the surgical and non-surgical group characteristics with larger abscesses. High dose intravenous antibiotics are an effective treatment for deep space neck abscesses and may obviate the need for surgical drainage, particularly in smaller abscesses. Children who do not respond quickly to antibiotics are more likely to require surgery to achieve resolution. Children with larger abscesses may respond to antibiotic therapy alone but should be closely observed. A trial of high dose intravenous antibiotics in stable children with close observation is warranted as first line treatment, especially for small deep space neck abscesses.