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Posterior urethral valves (PUVs) are the most common cause of congenital urethral obstruction. However, the diagnosis of a PUV is sometimes difficult. A 13-year-old Japanese boy and his mother visited our hospital, and his mother complained that he frequently strained to void although he had no complaint. Uroflowmetry revealed a plateau-shaped curve and a voiding cystourethrography (VCUG) revealed a PUV. Thus, we performed a transurethral incision of the PUV, and his voiding status improved. Because some patients with mild PUV may not notice their dysuria, we believe that VCUG should be performed without hesitation when a urethral lesion is suspected.

Introduction Acquired skin-level strictures following posterior sagittal anorectoplasty (PSARP) and some rare cases of congenital anal stenosis can be managed using a Heineke–Mikulicz like anoplasty (HMA). We hypothesized that this procedure was an effective, safe, and durable outpatient procedure in select patients. Methods We retrospectively reviewed all patients who underwent HMA for skin level strictures following PSARP or for certain congenital anal stenoses from 2014 to 2017. Results Twenty-eight patients (19 males, 9 females) with a mean age of 5.8 years (range 0.5–24.4) underwent HMA. Twenty-six had a prior PSARP, of which 18 were redo, and 8 were primary procedures. Two patients had congenital skin level anal stenosis. The mean follow up was 1.0 years (range 0.4–2.9). The average preprocedure anal size was Hegar 8, which after HMA increased 8 Hegar sizes to 16 (95% CI 7–9, p Conclusion HMA is a safe procedure for skin-level anal strictures following PSARP (primary and redo) and can also be used in some rare cases of congenital anal stenosis. Long-term follow up to determine the restricture rate is ongoing. A plan to do an HMA if a stricture develops may offer an alternative to routine anal dilations, particularly after a redo PSARP in an older child. Type of study Case series. Level of evidence Level IV.

INTRODUCTION: This study aims to ascertain if there are any differences in supracondylar fractures between children under seven years of age and those above 7 years of age. MATERIALS AND METHODS: All cases of displaced humerus supracondylar fractures that required surgical stabilization were identified and retrospectively reviewed. Demographic data, mode of injury, associated neurovascular injuries and details of surgery performed were obtained from clinical records. The Gartland classification and the extent of comminution of fractures were also documented from review of radiographs. RESULTS: One hundred and twelve children were included in this study, of whom 61 (54.46%) were younger than seven years of age while 51 (45.5%) were aged seven years or older. Children aged seven or older had a greater incidence of associated neurological deficit at presentation (p=0.046). Of the six patients with nerve injury in the older age group, one patient (16.7%) had a radial nerve injury, two patients (33.3%) had ulnar nerve injuries while another two patients (33.3%) had median nerve injuries. There was one patient (16.7%) with both median and ulnar nerve injuries. Comminuted fractures were also more common in the older children (p=0.004). No significant differences were demonstrated between the groups with regard to age, gender and mechanism of injury, laterality, incidence of open fracture, vascular injuries and operative time. CONCLUSION: Children aged seven years or older who sustain supracondylar humeral fractures tend to get more comminuted fractures. There is also a higher incidence of associated neurological injury. These cases must be carefully examined for at presentation and parents need to be appropriately counselled about them.

Introduction Sunburns during childhood increase melanoma risk. Children of melanoma survivors are at higher risk, but little is known about their sunburn and sun protection. One study showed that almost half of melanoma survivors' children experienced sunburn in the past year. This study evaluated sunburn and sun protection in melanoma survivors' children, and relevant survivor characteristics from Social Cognitive Theory and the Health Belief Model. Methods Melanoma survivors (N=340) were recruited from a comprehensive cancer center. Survivors completed a baseline questionnaire administered by telephone to report on the behavior of their children (N=340) as part of an RCT of a sun protection intervention. Data were collected in 2008 and analyzed in 2015. Results In the prior 6 months, 28% of children experienced sunburn. "Always" or "frequent" sun protection varied by behavior: sunscreen, 69%; lip balm, 15%; wide-brimmed hats, 9%; sleeved shirts, 28%; pants, 48%; sunglasses, 10%; shade, 33%; and limiting time outdoors, 45%. Survivors' sunburn and sun protection were positively associated with these outcomes in children. Correlates of sunburn also included older child age and higher risk perceptions. Correlates of sun protection behaviors included younger child age; stronger intentions, higher self-efficacy, and more positive outcome expectations about sun protection; and greater number of melanomas in survivors. Conclusions Melanoma survivors may have a heightened awareness of the importance of their children's sun protection, but their children are not routinely protected. Correlates of children's sunburn and sun protection suggest subgroups of survivors to target with interventions to improve sun protection.

Posterior urethral valves (PUVs) present clinically across a varied spectrum, ranging from severe obstruction with massive distension of the bladder and upper urinary tracts in the fetus, to a much more indolent course with minor secondary changes in the young or older child. Type III (diaphragm) PUVs are relatively uncommon, and are associated with difficulty in passing a transurethral catheter into the bladder as well as smooth dilation of the bladder. The following case examines the unusual experiences of both diagnosing PUVs in a teenager, and capturing visual evidence of type III valves during cystourethroscopy.

An 11-year-old boy presented with fever and abdominal pain, and was diagnosed with retroperitoneal lymphadenitis. At the same time, a painless right scrotal mass was observed. On imaging the testis and the epididymal mass both had abundant blood flow, although tumor markers were negative. Although the right testis had shrunk after antibiotic treatment, swelling was persistent and incisional biopsy was therefore performed, resulting in diagnosis of granulomatous orchitis (GO). No recurrence was found. In cases of scrotal swelling in both the testis and the epididymis of an older child, it is necessary to consider the possibility of inflammatory GO, and orchiectomy should not be performed without careful consideration.

Introduction:We undertook a retrospective study to stratify the effect of patient’s age, delay in surgical drainage, and Staphylococcus aureus (SA) virulence on expected clinicoradiological outcomes following suppurative arthritis of hip joint in a walking child.Materials and methods:The study was conducted in 18 children over 2 years of age who suffered from joint fluid culture-positive SA arthritis of hip joint and treated with open arthrotomy. Outcomes were defined on the following criteria: age of child (≥5 years or Results:The mean patient age was 6.22 years at the time of index procedure. The average delay in surgery was 17.06 days. Follow-up averaged 15.28 months. Five patients had associated with osteomyelitis femur in preoperative radiographs. MRSA culture was grown in 8 hips (44.4%) of 18 hips. Unsatisfactory clinical results according to Moon’s criteria were obtained in 55.6% patients with 38.9% being MRSA infected. Unsatisfactory Choi’s radiological results were present in 33.3% patients, 27.8% under MRSA category. Our study did not find age to be a significant factor either in clinical or radiological outcome. The clinical results were unsatisfactory in 81.8% patients with surgical delays when compared to early surgery ( p < 0.05).Conclusions:The clinicoradiological outcome in suppurative hip arthritis of walking children was unsatisfactory when there was delay in treatment beyond 5 days, and the causative organism was virulent (MRSA). The presence of preoperative joint incongruency or osteomyelitis of proximal femur was another risk factor.

Purpose of review To review the literature on laryngomalacia that manifests in older children and contrast this with congenital laryngomalacia seen more prevalently in infants. In doing so, we hope to offer relevant diagnostic and management options to treat late-onset laryngomalacia based from our experience and the current literature. Recent findings Laryngomalacia in older children can present differently than congenital laryngomalacia, and the most common and best understood consequence of late-onset laryngomalacia is obstructive sleep apnea syndrome. Other manifestations include exercise-induced stridor and possibly even dysphagia. When the diagnosis is properly made and the etiology is isolated to the larynx, supraglottoplasty can be an effective treatment option. Summary Compared with congenital laryngomalacia, the diagnosis and management of late-onset laryngomalacia is not as well defined. Few articles have addressed this condition directly, and more research is needed to better delineate how it presents and how it should be diagnosed. Finally, its treatment options, including the role of supraglottoplasty, need to be better understood.

Purpose. To evaluate the effect of calamine lotion in reducing skin irritation in children with cast immobilisation and to identify factors correlating with skin irritation. Methods. 250 children aged 6 to 15 years who underwent cast immobilisation for limb fractures were assigned into calamine (n=122) and noncalamine (n=128) groups. Data were collected at the time the cast was applied and removed. Potential confounders (gender, age, race, medical history, drug allergy, cast type, duration of casting, and extent of itch prior to casting) were identified. Each patient graded his levels of itch, sweat, and heat using a 5-point scale (with 5 indicating most severe). The on-duty plaster technician recorded the presence and type of skin lesions (blisters, wounds, or others) during cast removal. Results. Children in the calamine group were less likely to develop skin lesions (1 vs. 9, odds ratio [OR]=0.115, p=0.009), had less itch during casting (mean difference=0.74, pConclusion. Calamine lotion may reduce skin irritation in children with full casts.

An investigation of the risk factors for haemorrhage after tonsillectomy with particular reference to the use of bipolar diathermy for tonsillar dissection and haemostasis, diathermy power settings and coblation tonsillectomy. The findings of the National Prospective Tonsillectomy Audit and subsequent related research are summarised and discussed with reference to the issue of use of hot versus cold tonsillectomy techniques. Additional unpublished data on coblation tonsillectomy is presented. Overall, increased haemorrhage rates were noted for diathermy dissection tonsillectomy (adjusted odds ratio 2.47, p < 0.0001) and coblation tonsillectomy (adjusted odds ratio 3.07, p < 0.0001) compared to the reference category of cold steel tonsillectomy. Use of bipolar diathermy for haemostasis only carried an intermediate risk of haemorrhage (adjusted odds ratio 1.57, p = 0.004). Further investigation of diathermy power settings demonstrated a quantitative relationship between increasing power usage and subsequent haemorrhage. Use of diathermy for haemostasis at the lowest effective setting may carry a comparable risk of haemorrhage to that of cold steel tonsillectomy. Recommendations are given on the optimum tonsillectomy technique for both the older child or adolescent and the particularly young or low weight child.

Background Magnet and button battery ingestions are increasingly common, and can result in significant morbidity. Timely identification of hazardous foreign body ingestions can be difficult in non-verbal and non-disclosing children. Objectives We aim to present a case that demonstrates some of the challenges around identifying and correctly locating magnets and batteries, and the importance of prompt identification and removal. Case Report We describe an older child with the covert ingestion of multiple magnets and batteries, with magnets that attracted across the stomach and a loop of jejunum. Mild symptoms and signs resulted in a delayed diagnosis and serious consequences. Radiographs suggested a gastric location of the foreign bodies. Conclusion Health care workers should consider the possibility of battery or magnet ingestions in children with vomiting and abdominal pain, even when well-appearing. Like esophageal batteries, multiple gastrointestinal magnets and combined magnet-battery ingestions can cause significant morbidity, and prompt identification is important. Providers should ask verbal children for ingestion histories, and consider radiographs when symptoms are atypical or persistent. Like esophageal batteries, gastrointestinal magnet-battery ingestions should be removed promptly to prevent complications. Caregivers should supervise or limit the use of toys that include magnets and batteries.

Background Treatment of neglected or relapsed clubfeet in older children is a challenging task. Particularly in developing countries, limited resources and difficulties in getting frequent follow-ups make selection of appropriate surgical procedures more difficult. These difficulties led to the evolution of a new single-stage surgicalprocedure consisting of percutaneous Achilles tenotomy, plantar fasciotomy, and closing wedge osteotomy. The aim of the study was to evaluate the outcome of this single-staged procedure. Methods Eighty-six children, with neglected or relapsed clubfeet, were operated on using the described procedure in this longitudinal follow-up study. Only children (n ¼62) who had a minimum postoperative follow-up of 3 years were included. Eight children (12.9%) were lost to follow-up. Fifty-four children (77 feet) were available for preoperative, intraoperative, and postoperative follow-up evaluations. Detailed morphological, functional and radiographic scoring was done as per the International Clubfoot Study Group. Results The age at surgery varied from 5--13 years (mean 8.35±2.64 years). Follow-up ranged from 36---62 months (mean 44.07± 8.22 months). Of 77 feet, results were excellent in 41 (53.25%) feet, good in 28 (36.36%), fair in six (7.8%) and poor in two (2.6%) feet. The proportion of excellent and good results was significantly higher in neglected feet as compared with relapsed feet (P ¼0.007). However, the procedure was found to be effective and useful in relapsed feet as well as neglected feet.

Purpose Persistent tibial torsion in the older child can be treated with a derotation osteotomy. Distal tibial osteotomy has been recommended due to concerns of peroneal nerve palsy, vascular injury, and compartment syndrome with a proximal tibial osteotomy. However, an osteotomy in the proximal tibia may achieve union more rapidly and skin issues, as described for distal tibial osteotomies, are less likely. This study investigates the safety and efficacy of proximal tibial derotation osteotomies. Methods We retrospectively reviewed 43 tibiae in 25 consecutive children with persistent tibial torsion treated with a proximal tibial derotation osteotomy between 1991 and 2006. Patients with concomitant varus or valgus osteotomies were excluded. Diaphyseal fibular osteotomies were performed in five patients, while all patients had a prophylactic anterior compartment fasciotomy. Results The mean age at surgery was 10.4 ± 4.0 years and the mean follow-up was 3.2 ± 3.5 years. Patients with internal tibial torsion had a mean preoperative thigh–foot angle (TFA) of −14° ± 6° and a mean postoperative TFA of 8° ± 4°. Patients with external tibial torsion had a mean preoperative TFA of 38° ± 9° and a mean postoperative TFA of 7° ± 5°. The overall mean correction was 26° ± 9°. Major postoperative complications occurred in 4 patients (9%), including one peroneal nerve palsy which resolved, one delayed union requiring revision surgery, and two patients with mild postoperative valgus deformities. Conclusions Proximal tibial derotation osteotomy with an anterior compartment fasciotomy is a reliable method for treating tibial torsion with an acceptable complication rate. Given the larger bony surface area and improved soft tissue envelope, proximal tibial derotation osteotomy can be considered as an alternative to a distal tibial derotation osteotomy.

Discharging lesions in the umbilical region are rare but well known in neonatal period. Omphalitis, umbilical granuloma, patent urachus and persistent vitelo-intestinal duct are some of the commonest causes. If such a lesion is found in an older child, a careful detailed history and examination of the lesion can give clue to the diagnosis. We present one such case of a rare case of umbilical granuloma.

Displacement of a portion of the torn anterior cruciate ligament (ACL) into the intercondylar notch can cause a focal fibrotic reaction similar to that seen following ACL reconstruction. This displacement, which can result in locking or limitation of knee extension, is termed stump entrapment and is described in adult MR imaging literature. We present a pictorial essay of the etiology and appearance of stump entrapment on MR imaging of the knee in an older child and adolescents and review the significance of this finding.

Background: Propranolol is a novel therapeutic agent in the treatment of cutaneous infantile haemangiomas. We assessed the effect of propranolol therapy in infantile haemangiomas of the orbit. Methods: A case series of four patients with orbital infantile haemangiomas were referred for management in our tertiary referral hospitals. Two of the patients had inadequate responses to prior corticosteroid therapy. One of the patients was commenced on propranolol at 2.5 years of age when the lesion was not in the proliferative phase. This represented the first case report of propranolol treatment for infantile haemangioma outside infancy. The other three children were in their infancy when propranolol was commenced. The patients were treated with oral propranolol. Results: All patients had significant improvement in their physical appearance, ocular examination findings and size of their lesions on radiological evaluation. No side-effects of propranolol treatment were observed. Conclusions: Propranolol is a promising treatment against infantile haemangiomas in the orbit, not only in infants but also in an older child with a stable lesion.

The intraocular distance and iris diameter of children and young adolescents were measured, with the aid of a measuring microscope, from photographs of their faces. True intraocular distance was measured with an intraocular caliper at the same time that the photographs were taken. These data were then compiled and horizontal visible iris diameters (HVIDs) were calculated. An equation was derived from the optics of the Gullstrand model eye to calculate horizontal corneal diameter (HCD) from HVID. Comparisons of HVIDs revealed no significant correlation with age in either a regression plot of cross-sectional data for subjects aged 1 month to 1 year, or all subjects whose ages ranged from 1 month to adolescence. Additional longitudinal data for 13 individuals, who had been photographed as both an infant (mean = 3.4 months) and as an older child or adolescent (mean = 8.6 years), were then compiled and HVIDs for these subjects at two different ages were compared. A Wilcoxon signed rank test revealed a small but significant amount of growth, 0.318 mm (p-value = 0.013), in the HVIDs over a mean age difference of 8.3 years for individuals measured twice during their lifetimes. The regression equation for this growth was: HVID = 10.52 (+/-0.095 S.E.) + 0.0305 (+/-0.014) x Age (years). From a comparison of data from earlier literature and our own measurements, we conclude that, after birth, the fastest growth of the cornea must occur during the first few months of life.

Two types of digital trauma are often met: in the young child, it is generally about a fingertip crushing by a door. In the event a of nail bed wound, the child will have to be addressed for a surgical treatment, the absence of a correct treatment being able to be responsible for after-effect. In the older child, the trauma is generally indirect during a sports activity or a game. Radiography often shows a fracture of phalanx epiphysal plate. The treatment is generally orthopaedic: simple immobilization if the fracture is not displaced, reduction and immobilization in the event of displaced fracture.

This manuscript describes the unusual presentation of infantile myofibromatosis (IM) in an older child with its diagnosis and management. An 8-year-old girl presented with a painless, rapidly expanding malar mass. CT demonstrated an erosive soft tissue lesion and needle biopsy was nondiagnostic. Complete excision returned the pathologic diagnosis of IM. The patient had no complications and no evidence of recurrence at 1 year. Almost 90% of IM cases present by age two and IM in older children is highly unusual. The solitary form of IM is most common and its treatment is complete excision with an excellent prognosis.

Summary Six children aged 9–14 years had primary TEN fixation of an isolated femoral diaphyseal fracture. Three of the six patients had major complications, including knee haemarthrosis, loss of position and refracture; two required revision to locked intra-medullary nails without early complication. Two of the six had significant stiffness of the knee requiring manipulation. In the age group 9–14 years, TEN fixation has a significant major complication rate. This needs to be recognised when TEN fixation with other treatment options.

Object The Chiari Type II malformation (CM II) is a unique hindbrain herniation found only in patients with myelomeningocele and is the leading cause of death in these individuals younger than 2 years of age. Several theories exist as to its embryological evolution and recently new theories are emerging as to its treatment and possible prevention. A thorough understanding of the embryology, anatomy, symptomatology, and surgical treatment is necessary to care optimally for children with myelomeningocele and prevent significant morbidity and mortality. Methods A review of the literature was used to summarize the clinically pertinent features of the CM II, with particular attention to pitfalls in diagnosis and surgical treatment. Conclusions Any child with CM II can present as a neurosurgical emergency. Expeditious and knowledgeable evaluation and prompt surgical decompression of the hindbrain can prevent serious morbidity and mortality in the patient with myelomeningocele, especially those younger than 2 years old. Symptomatic CM II in the older child often presents with more subtle findings but rarely in acute crisis. Understanding of CM II continues to change as innovative techniques are applied to this challenging patient population.

The effective management of constipation in childhood requires an understanding of the ways that the physical and psychological factors interact. The early difficulty with defecation that leads to pain, fear, and refusal to use the pot or lavatory often progresses to the formation of vicious cycles of increasing faecal retention as the rectum increases in capacity and the experience of passing large, hard stools is repeated. There is increasing distress as overflow faecal incontinence compounds the problem for the older child. The medical, psychological, and surgical management strategies are reviewed together with the rationale for their use.

Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients ( 11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.

Management of native aortic coarctation remains debatable, due to insufficient randomized trial. However, stent placement is considered a reasonable approach in the older child, adolescent, or adult presenting with a simple, native Coarctation. Contrast is necessary for endovascular interventions

Background: Long term results of tenotomy and Ponseti technique are established worldwide. However, functions of Tendoachilles following Ponseti’s tenotomy in these cases i.e. idiopathic/neglected/operated/relapsed clubfeet (after casting or surgical correction) are not established. Tendoachilles regeneration after tenotomy has been confirmed on USG and MRI but only a few studies have done functional evaluation of tendoachilles. This study was done to evaluate the functional outcome of tendoachilles after tenotomy in patients older than two years presenting with CTEV. This study also assessed the influence of age and any previous treatment on tenotomy.Methods: In this study, 42 children (68 clubfeet) were seen in the two year study period. Children between 2-13 years coming to the outpatient department for treatment using the Ponseti’s method were followed during and after completion of treatment for 2 years. Patients were divided into two groups-first according to age and second according to previous treatment. Clinical evaluation of tendoachilles regeneration was done by evaluating the child’s ability to stand on tip of toes on single leg and walking ability.Results: The ability to stand on tip of toes after removal of the final cast was delayed maximum in the previously operated patients (9.5 weeks), lesser in patients who were previously treated by casting (7.3 weeks) and least in neglected patients (7 weeks). It also increased as the age increased (2-5 years age group required 7.4 weeks whereas 11-13 years age group required 16 weeks). Neglected patients started walking earlier (4.6 weeks) as compared to patients treated conservatively (4.8 weeks) or operatively (7.2 weeks). Younger children started walking earlier (age 2-5 years required 4.7 weeks whereas 11-13 years age group required 12 weeks). Conclusions: Functional evaluation of tendoachilles showed that all children who had tenotomy could walk and stand on tip of toes irrespective of age and previous treatment. However, older child and children having history of previous treatment, required longer time for recovery.

Fifteen patients who were 2 years of age or older and had bilateral developmental dysplasia of the hip were reviewed. Thirty hips had required open reduction combined with osteotomy on the pelvic or femoral side or both as necessary. The results were assessed according to McKay and Severin classifications, and complications including asymmetric outcome were recorded. An asymmetric outcome existed if the clinical or radiologic result for the contralateral hip was more than one unit difference or a leg length discrepancy of more than 1 cm was observed. Before surgery, there was no significant difference clinically and radiologically between the right and left hips for all patients. Surgical procedures required for both hips also were symmetric in 14 (93%) patients. However, asymmetric outcome occurred in four (27%) patients, three of whom were older than 5 years. An asymmetric outcome as defined is a potential risk after surgical treatment of bilateral developmental dysplasia of the hip in children who are older than 5 years.

Hydronephrosis should be managed no differently in the newborn than in any other age group: UPJ obstruction should be surgically corrected as soon as the diagnosis is made. Unfortunately, the diagnosis of obstruction in the newborn with hydronephrosis is difficult and the traditional tests used in the older child or adult are not valid. Because newborn hydronephrosis is a relatively benign condition, surgical intervention should be delayed until the diagnosis of obstruction is proven. A protocol for evaluating the newborn with hydronephrosis is presented.

Background. Hirschsprung disease is usually diagnosed in patients who are younger than 1 year; but in some individuals it is found later in childhood. Objective. This retrospective study is focused on clinical signs and symptoms of Hirschsprung disease in older children. Materials and Methods. Patients with Hirschsprung disease were included in the study if they were older than 14 months at the time of diagnosis. Results. Ten patients older than 14 months were diagnosed with Hirschsprung disease; 7 were males and 3 females. In all, 60% had a positive history of recurrent gastrointestinal infection with vomiting and hospitalization. In 6 patients, the final diagnosis was delayed because of unspecific findings in contrast enema. Rectal biopsy confirmed the diagnosis in all patients. Conclusion. Contrast enema is not a specific method for diagnosing Hirschsprung disease. Rectal biopsy alone confirms the diagnosis and provides a clear indication for surgery.

Coarctation of the aorta in the older child and adult can be successfully treated by percutaneous stent implantation. Although afterload will be reduced by coarctation stenting, other factors including systemic blood pressure will influence left ventricular remodeling.

Objective To evaluate the results of endopyelotomy in children, an established method in adult practice as a treatment for pelvi-ureteric junction (PUJ) obstruction. Patients and methods Endopyelotomies undertaken between 1992 and 1999 by one surgeon in an established endourology unit were reviewed retrospectively. Children aged > 5 years presenting with pain and obstruction on isotope renography were selected for endopyelotomy. Patients with crossing vessels detectable on spiral computed tomography were treated by open pyeloplasty. Access to the renal pelvis was provided by a uroradiologist. Endopyelotomy was carried out through an Amplatz sheath of (median) 26 F. After applying traction to invaginate the PUJ an incision was made postero-laterally using electrocautery via an 11 F paediatric resectoscope. Stenting was maintained for 6 weeks. In all, 13 patients (median age 10 years, range 5–14) were treated; two had associated calculi. Results The symptoms resolved and the obstruction was relieved in only six patients, with a median (range) follow-up of 50 (26–68) months. The seven patients in whom endopyelotomy failed, as indicated by persistent pain, proceeded to open pyeloplasty at a median (range) of 4 (1.3–79) months. Of these, two had presented with associated multiple calculi and significant hydronephrosis (one with an associated duplex system) and three had crossing lower pole vessels at open operation. One developed a urinoma after the original endopyelotomy and one had a retained stent fragment removed at the time of pyeloplasty. Conclusions Endopyelotomy in the symptomatic child requires a careful preoperative evaluation. Crossing lower pole vessels warrant an open pyeloplasty.

Background: The failure rate following endoscopic third ventriculostomy (ETV) in infants younger than 2 years of age has been reported to be higher compared with that of older children, and it is unclear whether ETV might be superior to shunt placement in this age group. Methods: Between 2003 and 2009, 23 patients younger than 6 months and without a previous history of shunting underwent ETV in our institution. A review of the literature was performed on the basis of publications presenting detailed data on age and etiology in every single patient. Results: In our own patients, total success rate was 39.1%. In the successful cases, median age was 140 days, whereas in the unsuccessful cases it was 47 days. The difference between the two groups was statistically significant (p = 0.01). The median ages of both successful and unsuccessful groups corresponded to data gained from an analysis of the literature (p = 0.04). At a median follow-up of 47 months, 2 out of 14 patients shunted after a failed ETV were revised for ventriculoperitoneal shunt malfunction. Conclusion: The impact of age on ETV failure in infants is clear and becomes crucial during the first 2 months of life, even when excluding etiological factors. Nevertheless, age cannot be considered the only parameter of the decision-making process, especially in these very young patients. Probably, the definition of ‘unsuccessful ETV’ should be reevaluated in light of decreased risk of shunt malfunction observed after a failed ETV.

Objective To analyze the characteristics of post-tonsillectomy bleeding and its management comparing with adults. Methods A retrospective chart review of 1489 patients who underwent tonsillectomy in our institution (June 2003–June 2006). Results Post-tonsillectomy bleeding rate was 3.1%, 2.5% and 10.8% in younger children (age ≤ 11 years), older children (12 ≤ age ≤ 15 years) and adults (age > 15 years), respectively. Although adults showed an unimodal peak time for onset of post-tonsillectomy bleeding, children showed a bimodal peak time. In the younger child group, all of the 28 bleeders had spontaneous hemostasis. However, in the older child group, there was no spontaneous hemostasis. Bleeding was controlled under local anesthesia in 3 patients and 2 patients required general anesthesia for bleeding control. In the adult group, spontaneous cessation of bleeding occurred in 25 patients (60.9%) and hemostasis under local or general anesthesia was performed in 16 (39.1%) patients. Conclusions Post-tonsillectomy bleeding occurred more frequently in adults than in children. Spontaneous hemostasis was more prevalent in children than in adults. Post-tonsillectomy bleeding in the younger child group was controlled with close observation alone.

Most children with aortic valve disease present with isolated aortic regurgitation or stenosis, in which case valve repair is often possible, thus delaying or eliminating the need for valve replacement. In the child with mixed aortic stenosis and regurgitation, repair is often more complex and less successful, requiring replacement of the valve and/or root. Several elements require careful consideration in children including growth potential of the child, risk of future reoperations, and the need for anticoagulation. A formal decision tree in this context is difficult because of the high variability between patients and pathologies and the lack of prospective randomized data. Nevertheless, we here present our approach to the child with mixed aortic stenosis and regurgitation, exploring the various options and explaining our favored approach.

Since its initial description in the early 1980s, balloon dilation (with or without stenting) as a treatment for coarctation of the aorta has become increasingly common, particularly outside of the neonatal period. Catheter intervention is generally recognized as the preferred method of treating recurrent coarctation. For native coarcation most centers will consider treatment of the older child or adult with primary catheter therapy, whereas balloon dilation of native coarctation in infancy is rare. Obviously, there are many diverse situations in which arch obstruction can occur, ranging from isolated coarctation with an otherwise normal heart to complex postsurgical arch obstruction following single ventricle palliation. The approach to each patient will be individualized, but there are common elements to these cases which are outlined below.

The investigation of children with liver disease falls into two categories: the investigation of the cholestatic baby and the investigation of the older child (over 2 years) with hepatomegaly. The approach to investigation is directed by the clinical features and employs many different investigational methods including biochemistry, haematology, radiology, electrophysiology and histology. As the clinical presentation of many diseases is similar, it is appropriate to perform a variety of first-line tests, proceeding to more complex investigations only as indicated.

† Younger siblings of children with sensorineural hearing loss of possible hereditary cause underwent interval audiologic examination. Seven siblings (in unrelated families) were found to have progressive sensorineural hearing loss despite early audiograms documenting normal hearing levels for age. Continued testing of these children allowed for early identification and intervention. We advocate regular otolaryngologic and audiologic follow-up even after normal audiologic assessments are made for younger siblings of children with documented sensorineural hearing loss, unless a definite nongenetic origin of the hearing loss in the older child is known. Recessive sensorineural hearing loss with onset in infancy or childhood may present with no antecedent family history and with normal behavioral audiograms early in life. ( Arch Otolaryngol Head Neck Surg . 1991;117:332-335)

Selection of the most appropriate operations for a patient is as important as technical expertise in performing the procedures. Web deepening may be performed alone or in addition to tissue augmentation and should be planned in conjunction with bone lengthening. Skeletal augmentation is useful if fingers are missing or inadequate, and it is necessary to add bony tissue. In general, in order to grow, skeletal transfers must be performed on very young children or must include vascularized physes; complex cases may require microvascular composite toe-to-hand transfer. Distraction-lengthening for intercalary skeletal enhancement is indicated for patients with multiple hypoplastic, aplastic, and missing digits, but the cosmetic result is limited. The major procedures should be started by age 2 years and finished by age 4; unfortunately, it is most often not advisable to perform microvascular surgery at such an early age. Modification of functional patterns, even though they are abnormal or the result of incomplete anatomy, should be avoided in the older child or adult because tinkering does not lead to significant benefits. For a cooperative, and often difficult, staged venture to be maximally successful, physicians and parents must share realistic expectations of aesthetic and functional results.

Laryngomalacia is the most common cause of stridor in infancy. It is generally considered to be a fairly benign condition necessitating surgical intervention in relatively few cases. It resolves by the age of 4 years in the majority of children. We present three cases in which laryngomalacia persisted and actually worsened in later childhood and postulate a possible mechanism for this.

The one-stage surgical treatment for developmental dysplasia of the hip-consisting of open reduction, femoral shortening, and pelvic osteotomy-is a demanding procedure, one that is more challenging, technically, than a staged procedure. It can, however, be done safely and effectively, providing good conditions for proper development of the hip joint in the older child who has untreated developmental dysplasia of the hip.

Background Basidiobolomycosis is a rare chronic subcutaneous infection caused by Basidiobolus ranarum, which is usually treated with potassium iodide. Extensive deforming lesions in children can occur owing to lack of early diagnosis and/or inappropriate treatment. Case report An 8-year-old girl child presented to us with extensive deforming plaque-like lesions over the left thigh and leg with multiple ulcerations of 1 year's duration. Histopathology was suggestive of subcutaneous zygomycosis with Splendore Hoeppli phenomenon. Microscopic examination of the tissue showed branching, sparsely septate fungal hyphae on a 10%KOH mount, and culture yielded Basidiobolus ranarum. The patient was initially treated with potassium iodide for 6 weeks to which only a poor response was observed. Itraconazole therapy resulted in rapid regression of the lesions and complete resolution after 15 weeks of therapy. She continues to be disease-free at 1 year of follow up. Conclusions This case report highlights that in an older child even longstanding extensive basidiobolomycosis can be safely treated with itraconazole. Surgery is not usually necessary in these patients.

Neuroimaging and the neuropsychological evaluation are important components of the presurgical evaluation for epilepsy surgery. Advances in neuroimaging over the last decade, to a large part, underlie improvements in pediatric epilepsy surgery outcomes. The neuropsychological evaluation plays an important role in the evaluation of the older child and adolescent, particularly in the evaluation of mesial temporal sclerosis. However, its role in the young child being considered for surgery remains to be defined. This section reviews the definition of medical intractability, issues related to medication withdrawal during video-EEG monitoring, recent neuroimaging advances, and the neuropsychological evaluation.

(Nig J Surg Res 2000; 2: 164 - 167)

We compared the pediatric anterior capsulotomy preferences of members of the American Society of Cataract and Refractive Surgery (ASCRS) and the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) reported in 3 surveys (1993, 2001, and 2003). In 1993 and 2001, more than 50% of ASCRS respondents preferred manual anterior capsulotomy techniques; in 2001 and 2003, AAPOS respondents preferred manual and vitrector techniques. The ASCRS preferences remained unchanged when subdivided into domestic and international, as did AAPOS domestic preferences; however, more than 50% of AAPOS international preferences changed from manual alone in 2001 to a manual–vitrector combination in 2003. In 2003, more than 50% of AAPOS respondents worldwide preferred this combination: the vitrector for the very young patient and the manual anterior capsulotomy for the older child.

During a 2-year period, eight patients sustained burns caused by the tipping over of electric stoves. In seven of these cases, children aged 2 to 4 years stood up on the open oven door of a stove. The stove then tipped forward, and a pot of boiling liquid on the stove spilled onto the child, who fell forward across the oven door. The general area of involvement was back and buttocks, with spattered areas elsewhere on the body. In one other case, an older child, aged 8, sat on the open oven door and was burned when a pot fell on him. The weight of the children ranged from 12.7 to 20 kilograms, with a mean of 15.2 kilograms. The 8-year old weighed 14.9 kilos. Burn size ranged from 3% to 30%, with a mean of 16.75%. All burns were second-degree and were treated by debridement and coverage with either porcine grafts or Biobrane (Dow Hickman Pharmaceuticals, Inc.). Healing was satisfactory in all cases. Hospital stay ranged from 2 to 20 days. The increase in the use of electric stove has led to a situation in which children, usually toddlers, can overbalance the stove and bring down the pots sitting on the heating elements. This represents another mechanism by which young children can be injured in the kitchen; the awareness of this should be disseminated. Language: en

The synchondrosis between the dens and the body of axis normally fuses between 5 and 7 years of age. Until this age, synchondrosis fractures can occur in children. Most synchondrosis fractures are conventionally treated by external immobilization alone. We report a 10-year-old child with odontoid synchondrosis fracture who was treated by C1 lateral mass and C2 pars screw rod fixation with a successful outcome and discuss the possible reasons for occurrence of odontoid synchondrosis fracture in this older child as well as the indications for surgery in this condition.

Open surgical ligation has proven to be a safe and effective method to bring about closure of the patent ductus arteriosus (PDA). Recent studies have suggested that percutaneous transcatheter and video-assisted thorascopic closure may be better and more cost-effective techniques for PDA closure. The authors reviewed their experience with open thoracotomy for the elective ligation of PDA in 42 children over a 3-year period. The male:female ratio was 1.6:1; the age of the patients (mean +/- SD) was 2.8 +/- 2.3 years and their weight was 14 +/- 7 kg. In all cases the diagnosis was confirmed preoperatively by echocardiography. Open ligation of the PDA was performed through a limited left posterolateral thoracotomy with exposure, by an extrapleural approach. Closure was established with two silk ligatures or a silk ligature and clip, and drainage of the extrapleural space was not used. The operating time was 85 +/- 12 minutes. The total duration of hospitalization was 3.1 +/- 0.8 days. There were no deaths. Successful closure was confirmed by auscultation in 39 children and by subsequent echocardiography in three patients. No surgical complications occurred, and no transfusions were required. Minor respiratory symptoms occurred in two patients postoperatively. Transient systemic hypertension was seen in two patients, and one wound infection occurred.