In Reply:

We thank Dr. Ueda for his interest in our study of nasal fentanyl in children undergoing myringotomy with placement of ventilating tubes. 1We chose the nasal route of administration because it avoids the need for vascular access in an operation that takes less than 5 min to perform, and this route has been used for administering drugs in children, including opioids and midazolam. 2–4We chose fentanyl over other opioids, such as sufentanil, because of its lower cost. Dr. Ueda has raised concerns about increased rhinorrhea when this technique of nasal fentanyl was used in adults. There are data to indicate midazolam is more irritating to nasal mucosa of children than sufentanil is. 2,4Other investigators have not reported increased nasal secretions after using sufentanil by the nasal transmucosal route in children, but it is unclear whether these investigations were specifically designed to examine this question.

The parents of all 265 patients enrolled in our study received phone calls from experienced nurse practitioners on the day after the procedure, and no parent reported an increase in rhinorrhea during the follow-up period. However, children undergoing bilateral myringotomy and pressure equalization tube placement commonly have nasal congestion from associated allergic rhinitis or during recovery from frequent viral upper respiratory infections. This may skew the parents’ perspective, and their concerns about nasal congestion may not reach the threshold for reporting it during the follow-up phone call.

In conclusion, we have not noted findings similar to those reported by Dr. Ueda, but we agree that additional follow-up should focus on determining whether fentanyl increases nasal secretions to the point to which it interferes with the child’s sleep on the first night after surgery.

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Henderson JM, Brodsky DA, Fisher DM, Brett CM, Hertzka RE: Pre-induction of anesthesia in pediatric patients with nasally administered sufentanil. A nesthesiology 1988; 68: 671–5
Karl HW, Keifer AT, Rosenberger JL, Larach MG, Ruffle JM: Comparison of the safety and efficacy of intranasal midazolam or sufentanil for preinduction of anesthesia in pediatric patients. A nesthesiology 1992; 76: 209–15