International Journal of Pediatric Otorhinolaryngology

Editorial Board

2010-04-01

Adenomatoid odontogenic tumour: Tumour or a cyst, a histopathological support for the controversy

Dilip R. Gadewar, N. Srikant — 2010-04-01

Abstract: Adenomatoid odontogenic tumour (AOT) is a well-established odontogenic tumour with various clinicopathological variants. AOT quite frequently mimics an odontogenic cyst commonly a dentigerous cyst. Histologically a cystic component of AOT has been described in the literature. In the present paper we review the literature for the AOTs arising in an odontogenic cyst and add to the literature a case of cystic AOT. The present review is aimed to provide an insight to the varied demographic profile, clinical behavior and prognosis of cystic variant of AOT.

Propranolol therapy for infantile haemangiomas: Review of the literature

A.P. Zimmermann, S. Wiegand, J.A. Werner, B. Eivazi — 2010-04-01

Abstract: Objectives: Haemangiomas are the most common tumors of infancy affecting approximately 1 in 10 children. Unlike other tumors, haemangiomas enter an involution phase, during which they usually regress over the next several months to years. Sometimes intervention is required due to proliferative growth which is complicated by ulceration, bleeding, persistent aesthetic deformity or infection.Methods: Review of the literature.Results: Propranolol, a nonselective beta-blocker, has recently been introduced as a novel modality for the treatment of proliferating haemangiomas. The exact mechanism of action of propranolol in the treatment of haemangiomas remains unclear, but vasoconstriction, down-regulation of angiogenic factors such as VEGF and bFGF and up-regulation of apoptosis of capillary endothelial cells may be responsible for the reduction of haemangiomas. Besides, an inhibition of MMP-9 and HBMEC expression by propanolol is discussed as possible mechanism influencing the growth of haemangiomas. However, there are different case reports of successfully treated infants in the current literature.Conclusion: There is the obtain that propranolol will detach steroids in the therapy for infantile haemangiomas.

Treatment patterns of pediatric nontuberculous mycobacterial (NTM) cervical lymphadenitis as reported by nationwide surveys of pediatric otolaryngology and infectious disease societies

E.F. Pilkington, C.J. MacArthur, S.E. Beekmann, P.M. Polgreen, K.L. Winthrop — 2010-04-01

Abstract: Objective: To describe physician diagnostic and therapeutic strategies for pediatric nontuberculous mycobacterial (NTM) lymphadenitis, a disease for which surgical excision is recommended.Methods: We surveyed members of the Infectious Diseases Society of America Emerging Infections Network (EIN) and the American Society of Pediatric Otolaryngology (ASPO). We asked them to report clinical and microbiologic details of recent cases of NTM lymphadenitis seen in their practices.Results: 200 physicians reported a total of 277 NTM lymphadenitis cases. Cervical lymph nodes (84%) were most frequently involved, and a majority of patients were non-Hispanic white (62%) males (54%) with median age 3.0 years. Tissue culture (61%) or polymerase chain reaction (12%) was utilized most frequently to confirm NTM etiology. In most (59%) cases, an etiologic organism was not identified. In cases, where an NTM organism isolate was identified, Mycobacterium avium complex (n=82, 72%) was the most common. Surgical excision followed by adjunctive antibiotic therapy was favored in the majority (59%) of cases where a treatment method was reported. The use of surgical excision alone or antibiotic therapy alone was reported respectively in 24% and 17% of cases. Antibiotics were prescribed without diagnostic confirmation of infectious organisms in 28% of cases.Conclusion: Pediatric otolaryngologists and infectious disease specialists frequently treat cervical lymphadenitis empirically as NTM disease without bacteriologic confirmation. Antibiotic therapy is frequently employed with or without surgical excision.

Sialendoscopy in children

Noel Jabbour, Robert Tibesar, Timothy Lander, James Sidman — 2010-04-01

Abstract: Background: The definitive cause of most cases of recurrent salivary gland inflammation in children remains unknown. Relatively little has been written about the use of sialendoscopy as a diagnostic and therapeutic tool in children.Objective: To evaluate the safety and efficacy of sialendoscopy as a diagnostic and therapeutic tool for recurrent salivary gland inflammation in children.Study Design: Retrospective case series.Methods: Medical records of all patients who underwent sialendoscopy for recurrent salivary gland inflammation from a single tertiary-care pediatric otolaryngology practice were reviewed. Comparison of pre-procedure vs. post-procedure frequency and severity of disease was reviewed. Operative reports, images, and video were analyzed for causes of inflammation.Results: Six patients (aged 3–16 years old) underwent sialendoscopy (3/6 bilateral parotid, 2/6 unilateral parotid, 1/6 unilateral submandibular). There were no complications. No post-operative recurrence was noted in 3/6 patients; decreased frequency of recurrence was noted in 2/6 patients; repeat sialendoscopy was required in 1/6. Operative findings from sialendoscopy from 10 parotid glands showed fibrinous debris (7/10), mucoid debris (1/10), purulent debris (1/10), or duct stenosis (1/10). No stones were noted.Conclusions: Sialendoscopy is a safe, minimally invasive procedure that may decrease the frequency of recurrences for salivary gland inflammation in children. In contrast to previously published work, the most common cause of salivary gland obstruction in this series was debris, rather than stones. Increased use of sialendoscopy as a diagnostic and therapeutic tool will allow for improved understanding of the causes of and management for recurrent salivary gland inflammation in children.

Prevalence of the c.35delG and p.W24X mutations in the GJB2 gene in patients with nonsyndromic hearing loss from North-West Romania

2010-04-01

Abstract: Objective: In Central and South-Eastern European countries, the most frequent mutation types responsible for congenital nonsyndromic sensorineural hearing loss (NSHL) are c.35delG and p.W24X (15–55.8% and 2.5–4.3%, respectively). The aim of the study was to determine for the first time in Romania the prevalence of c.35delG and p.W24X mutations in patients with NSHL.Material: 75 unrelated children with NSHL from Transylvania (North-West Romania).Methods: a. Audiological examination (otoscopy, tympanogram, acoustic otoemission and tonal audiogram or auditory evoked potentials); b. detection of the c.35delG (semi-nested-PCR, RFLP and ARMS-PCR analysis) and p.W24X (ARMS-PCR analysis) mutations.Results: Audiological examination allowed the diagnosis of hearing loss of various degrees: moderate in 8 patients (10.7%), severe in 14 cases (18.7%), profound in 53 patients (70.6%). The number of reported mutation cases as against the number of alleles indicates a 33.3% frequency rate for c.35delG mutation and respectively 5.3% for p.W24X mutation. All 22 patients with 35delG/c.35delG genotype (19 patients), c.35delG/p.W24X genotype (2 patients) or p.W24X/p.W24X genotype (1 patient) presented profound/severe hearing loss.Conclusion: Our study confirms that the frequency rate of the two mutations analyzed in patients with NSHL from North-West Romania is comparable to that seen in other Central and South-Eastern European countries. The homozygote or compound heterozygote states represent a major risk factor for profound or severe deafness. Audiological screening in newborns and genetic testing in confirmed congenital hypoacusis cases are compulsory for early therapeutic intervention (hearing prosthesis or cochlear implant) and genetic counselling.

Correlation between NRT measurement level and behavioral levels in pediatrics cochlear implant patients

Hamad Al Muhaimeed, Fatma Al Anazy, Osama Hamed, Eba’a Shubair — 2010-04-01

Abstract: Objective: To determine the relationship between the electrically evoked nerve action potential (Neural Response Telemetry [NRT]) and behavioral levels (T- and C-level) for pediatric patients using the Nucleus 24 cochlear implant system.Method: A hospital based study of pediatric cochlear implant patients in the period between June 2000 and December 2008. At King Abdul-Aziz University Hospital (KAUH) Saudi Arabia the Neural Response Telemetry was administered to 47 children (mean age at implantation: 4 years) with the Nucleus 24 cochlear implants. Four intra cochlear electrodes (numbers 5, 10, 15, and 20) were tested one-month post-implantation, the neural response threshold compared with the behavioral threshold and the maximum comfort level estimated at the same time.Results: At all the electrode numbers, the mean for NRT level measurements was significantly higher than that for the T-level measurements and the mean for the C-level measurements was significantly higher than that for NRT level measurements The correlation analyses showed positive correlation between C-level and NRT level measurements and T-level and NRT level measurements.Conclusion: There was a positive correlation between NRT value measurements and both T and C value measurements. Therefore, it is useful to use the NRT values to predict the behavioral T and C values in prelingual children.

Ototoxicity caused by once- and twice-daily administration of amikacin in rabbits

2010-04-01

Abstract: Objective: The cochleotoxic effects of aminoglycosides, such as amikacin, are well-established. The aim of the present study was to investigate the possible differences in cochleotoxic effects between once-daily administration (ODA) and twice-daily administration (TDA) of amikacin simulating pediatric dosing.Methods: Twenty-one rabbits were used. Seven animals received intramuscularly amikacin once daily (ODA-group) and seven received the drug twice daily (TDA-group), for a total time period of 2 weeks. All the animals were subjected to Distortion Product Otoacoustic Emissions (DPOAEs) every 3 days since beginning of the experiment. The rest 7 animals did not receive any medication and served as controls (Control group). Two measurements (7 and 14 days) were obtained following the cease of drug administration.Results: Reduced cochlear activity (as depicted in the respective reduced DPOAE-amplitudes) compared to the pre-treatment state was found in both ODA- and TDA-groups. Cochlear activity was reduced at a wider range of frequencies (from 593 to 4031Hz in TDA-group and from 593 to 1093Hz in ODA-group) and to a higher degree in group B than in group A. Cochlear activity was reduced earlier in ODA-group than in TDA-group. No differences to the pre-treatment state were observed in the control group.Conclusions: The above findings suggest that less frequent administration in higher dose of amikacin is associated with minimal cochleotoxicity.

Does adenoid hypertrophy really have effect on tympanometry?

2010-04-01

Abstract: Objective: The goal of this study is to determine the correlation between the radiographic measurements of adenoid size and tympanometric findings.Study design: Prospective study.Setting: Haydarpasa Numune Research and Education Hospital, Istanbul, Turkey.Subjects and methods: Nine five consecutive children complaining of one or more of the symptoms of upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were included in the study. Symptom severity was assessed by a standardized questionnaire. All patients underwent digital lateral soft tissue radiographs. Assessment of nasopharyngeal obstruction in radiographs was done according to four different methods. Tympanometry was used to evaluate the middle ear.Results: Of 190 ears, 79 were type A, 49 were type B and 62 were type C tympanograms. The symptom severity of 14 patients was graded as mild, 56 patients as moderate and 25 patients as severe. There was no statistically significant difference between UAO symptom severity groups and tympanogram types (p>0,05). Each one of the four methods of radiologic measurements of the adenoid enlargement showed no statistically significant difference between the tympanogram types (p>0,05).Conclusion: The adenoid hypertrophy in both means of radiologic measurements and symptom severity does not correlate with the changes in tympanograms. These findings do not support the hypothesis that adenoidal size plays a major role in the etiopathogenesis of middle ear effusion (MEE).

Bupivacaine versus normal saline for relief of post-adenotonsillectomy pain in children: A meta-analysis

Jiehao Sun, Xiuying Wu, Yinan Meng, Lielie Jin — 2010-04-01

Abstract: Objective: A meta-analysis was performed to explore the role of peri-operative bupivacaine infiltration in the relief of pain in adenotonsillectomy.Methods: Data from Medline, EMBase, Springer and the Cochrane Collaboration database were searched. Reference lists from identified publications were scanned. RevMan 5.0 software was used for statistical analysis.Results: 7 random controlled tests (a total of 286 cases) were included. Pain intensity was evaluated by VAS score or Cheops score. The pain of group bupivacaine (Group B) was less severe than group placebo (Group P). Analgesic requirement of Group B was less than Group P. Nevertheless the difference of complication between bupivacaine and placebo had no statistical difference.Conclusion: Bupivacaine infiltration is a safe and effective method for relief of pediatric post-adenotonsillectomy pain.

The Effects of topical viscous lignocaine 2% versus per-rectal diclofenac in early post-tonsillectomy pain in children

2010-04-01

Abstract: Introduction: Tonsillectomy is frequently associated with postoperative pain of considerable duration, which is usually accompanied by the substantial consumption of both opioid and non-opioid analgesic such as NSAIDs and local anaesthetics.Objective: The aim of this study was to evaluate the efficacy between 2% viscous lignocaine and sodium diclofenac based upon the visual analogue scores (VASs), consumption of pethidine 0.5mgkg−1 as the rescue drug postoperatively and time taken to resume feeding.Methods: 130 patients aged between 5 and 12 years old were randomly allocated into 2 groups to be given either 2% viscous lignocaine 4mgkg−1 body weight topically post-tonsillectomy or sodium diclofenac 1mgkg−1 per-rectal post-induction of anaesthesia. Postoperatively visual analogues score was done for 24h, the amount of pethidine given and time when the patient start taking oral feeding of clear fluid, soft diet and normal diet were documented.Results: There was no significant difference in the visual analogue scores in both groups, however the requirement of pethidine as the rescue drug postoperatively was significant 2h post-tonsillectomy (p=0.023) in viscous lignocaine group compared to sodium diclofenac. The time taken to resume oral feeding and soft diet was also significant in viscous lignocaine group (p=0.016 and p=0.007) whereas there was no significant in taking normal diet.Conclusion: We concluded that 2% viscous lignocaine applied topically post-tonsillectomy is comparable to sodium diclofenac per-rectal in providing analgesia and faster oral feeding.

Quantification of vocal tract configuration of older children with Down syndrome: A pilot study

Steve An Xue, Laura Kaine, Manwa L. Ng — 2010-04-01

Abstract: Objective: To quantify the vocal tract (VT) lumen of older children with Down syndrome using acoustic reflection (AR) technology.Design: Comparative study.Setting: Vocal tract lab with sound-proof booth.Participants: Ten children (4 males and 6 females), aged 9–17 years old diagnosed with Down syndrome. Ten typically developing children (4 males and 6 females) matched for age, gender, and race.Intervention: Each participant's vocal tract measurements were obtained by using an Eccovision Acoustic Pharyngometer.Main outcome measures: Six vocal tract dimensional parameters (oral length, oral volume, pharyngeal length, pharyngeal volume, total vocal tract length, and total vocal tract volume) from children with Down syndrome and the typically developing children were measured and compared.Results: Children with Down syndrome exhibited small oral cavities when compared to control group (F(1,18)=6.55, p=0.02). They also demonstrated a smaller vocal tract volumes (F(1,18)=2.58, p=0.13), although the results were not statistically significant at the 0.05 level. Pharyngeal length, pharyngeal volume, and vocal tract length were not significantly different between the two groups.Conclusion: Children with Down syndrome had smaller oral cavities, and smaller vocal tract volumes. No significant differences were found for pharyngeal length, pharyngeal volume, and vocal tract length between these two groups.

Glucocorticoids reduce nitric oxide concentration in middle ear effusion from lipopolysaccharide induced otitis media

2010-04-01

Abstract: Objective: Otitis media with effusion (OME) is a common childhood disease that is characterized by an accumulation of fluid in the middle ear. Chronic OME can also lead to sensorineural hearing loss (SNHL). Nitric oxide (NO), an inflammatory mediator (IM) of OME, is a free radical known to regulate cell proliferation, cell death, and angiogenesis. Previous studies have shown that nitric oxide may cause SNHL through outer hair cell (OHC) cytotoxicity. This experiment was designed to determine whether glucocorticoids, dexamethasone, fluticasone propionate, or rimexolone, can reduce the concentration of NO in middle ear effusion (MEE).Methods: Fifty-three chinchillas were divided into 7 groups, vehicle vs. each glucocorticoid at 0.1% and 1.0% concentrations. Due to anesthesia complications, N ranged from 6 to 9 per group. Two hundred microlitres of each test article was injected into the bullae of each animal. Two hours later, lipopolysaccharide (LPS) (0.3mg in solution) was added. Test articles were re-administered at 24 and 48h post-LPS induction. After 96h, animals were euthanized and the MEE was collected.Results: All three glucocorticoids numerically reduced NO concentration in the middle ear when administered at 0.1%, but only FP showed a significant reduction. At 1.0% concentrations, all 3 steroids significantly reduced NO concentration.Conclusion: This study suggests that glucocorticoid treatment reduces NO concentration in the MEE and may protect the ear from the SNHL caused by NO.

Exploration of the relationships among medical health history variables and aspiration

Barbara K. Giambra, Jareen Meinzen-Derr — 2010-04-01

Abstract: Objectives: (1) Determine the relationships among a family's specific answers to health history questions and their child's risk for aspiration as determined by a swallow study. (2) Identify key factors which may predict a child's risk for aspiration.Methods: Answers to questions and results of Functional Endoscopic Evaluation of Swallow (FEES) and/or Video Swallow Study (VSS) for a sample of 198 children were collected. Subjects were categorized into groups: “aspiration”, “penetration” or “no aspiration or penetration”. Logistic regression modeling was used to determine the contribution of certain characteristics to the odds of aspiration. A model for predicting aspiration or penetration based on those characteristics was assessed. The sensitivity and specificity of the model in predicting aspiration and penetration was determined.Results: One hundred ninety eight subjects had a FEES or VSS. Of these, 18% (n=36) aspirated and 21% (n=42) were found to have penetration. Many of the factors identified in the health history were found to be significantly associated with aspiration or penetration. The variables “demonstrated aspiration” (this included parent or caregiver seeing food in the tracheotomy tube or aspiration noted on a previous FEES or VSS) (p=0.02), “hypotonia” (p=0.02) and “tracheotomy” (p=0.001) were most predictive of aspiration. History of tracheotomy was found to have an inverse relationship with aspiration. “gastroesophageal reflux” (GER) (p=0.0007) was most significantly associated with penetration, followed by “prematurity” (p=0.03) and “developmental delays” (p=0.04). Based on the prediction model, the probabilities for a child with a history of combinations of the above variables to have aspiration or penetration were calculated.Conclusions: Significant relationships exist between aspiration or penetration and the family's answers about their child's medical history. Practitioners should consider a swallow assessment whenever a child has a history which includes variables with a strong association with aspiration or penetration.

Iatrogenic perinatal pharyngoesophageal injury: A disease of prematurity

Theodore A. Schuman, Britni Jacobs, William Walsh, Steven L. Goudy — 2010-04-01

Abstract: Objective: Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage. Our objective was to estimate the incidence of iatrogenic perinatal pharyngoesophageal injury (IPPI) in preterm versus term infants in a children's hospital neonatal intensive care unit (NICU). A secondary goal was to explore the clinical characteristics and outcomes associated with these complications.Methods: All NICU discharge summaries from 2004 to 2008 were searched for IPPI-related keywords. Highlighted records were reviewed and the incidence of complications calculated by gestational age and weight.Results: Of 5910 total NICU discharges, 6 cases of IPPI were identified, for an overall incidence of 0.10%. All injuries occurred in infants less than 33 weeks gestational age and 1500g, with a trend towards higher incidence with increasing prematurity. The incidence of IPPI rose to 4/1321 (0.30%) at 27–32 weeks and 2/521 (0.38%) at less than 27 weeks gestation. Similarly, IPPI occurred in 3/675 (0.44%) babies born at 1000–1500g and 3/642 (0.47%) babies below 1000g. All affected infants survived with conservative management.Conclusions: IPPI is a rare but serious complication of perinatal airway instrumentation and is primarily a disease of prematurity. In this sizeable cohort, no complications occurred in term infants, and the incidence of injury increased with decreasing gestational age and weight. This increased propensity towards injury should prompt special care when performing even routine airway procedures on premature neonates.

Lymphatic malformations: A proposed management algorithm

J.C. Oosthuizen, P. Burns, J.D. Russell — 2010-04-01

Abstract: Objective: The aim of this study was to develop a management algorithm for cervicofacial lymphatic malformations, based on the authors’ experience in managing these lesions as well as current literature on the subject.Study design and methods: A retrospective medical record review of all the patients treated for lymphatic malformations at our institution during a 10-year period (1998–2008) was performed. Data collected: age at diagnosis, location and type of lesion, radiologic investigation performed, presenting symptoms, treatment modality used, complications and results achieved.Results: 14 patients were identified. Eight (57%) male and six (43%) female. There was an equal distribution between the left and right sides. The majority (71%) of cases were diagnosed within the first year of life. The majority of lesions were located in the suprahyoid region. The predominant reason for referral was an asymptomatic mass in 7 cases (50%) followed by airway compromise (36%) and dysphagia (14%). Management options employed included: observation, OK-432 injection, surgical excision and laser therapy. In 5 cases (36%) a combination of these were used.Conclusion: Historically surgical excision has been the management option of choice for lymphatic malformations. However due to the morbidity and high complication rate associated this is increasingly being questioned. Recent advances in sclerotherapy e.g. OK-432 injection have also shown significant promise. Based on experience in managing these lesions as well as current literature the authors of this paper have developed an algorithm for the management of cervicofacial lymphatic malformations.

Role of endoscopic nasal examination in reduction of nasopharyngeal adenoid recurrence rates

Waleed F. Ezzat — 2010-04-01

Abstract: Objectives: To evaluate the benefit of endoscopic examination after adenoidectomy in detecting residual adenoid tissue that would need completion surgery, in ultimate aim to reduce rates of adenoid recurrence.Methods: A total of 312 children were included in the study conducted at Ain-Shams University Hospital from January till December 2007, following routine adenoidectomy, 118 had a nasal and nasopharyngeal rigid fiberoptic examination and 194 did not, randomly according to the surgical subunit that performed the surgery. Patients were followed up for a minimum of 2 years for recurrence of symptoms of adenoid enlargement.Results: Endoscopic examination revealed that 14.5% of patients undergoing adenoidectomy had residual adenoid tissue that needed further removal, of these the most common site was at the lateral walls of the nasopharynx (47%). The recurrence rate of adenoid hypertrophy needing re-surgery with endoscopic examination (0.85%) approaches that of the lowest recorded (0.5%) with more expensive and costly methods, and statistically significant lower than rates when endoscopy is not performed (5.6%). Additional time needed for such examination was negligible in terms of cost–benefit relationship.Conclusion: Rigid fiberoptic endoscopy of the posterior choana and nasopharynx at the end of adenoidectomy provides the benefit of detecting unremoved adenoid tissue without significantly extra cost, time, nor expertise, and helps reduce significantly the rates of recurrence of adenoid enlargement, which might be attributed to residual “missed” adenoid tissue.

Do diet and activity restrictions influence recovery after adenoidectomy and partial tonsillectomy?

Olaf Zagólski — 2010-04-01

Abstract: Objective: To determine if restrictions of postoperative diet concerning hard food and hot drinks as well as excessive physical exertion influence recovery during 14 days after T&A surgery.Methods: 800 patients aged 3–13 years (median 6) underwent curette adenoidectomy with or without scissors tonsillotomy. 413 adenoidectomies and 387 adenotonsillotomies were performed. Caregivers of the children completed a questionnaire reporting their child's postoperative activity, diet, pain level, peak and duration, episodes of nausea and fever, medication and caregivers’ satisfaction scores. The children were enrolled to food and effort restricted (FER), food non-restricted (FnR), effort non-restricted (EnR), and food and effort non-restricted (FEnR) groups at the end of follow-up.Results: Two hemorrhages requiring repeat surgery under general anesthesia in FER group and 42 mild episodes of spontaneously subsiding bleeding from nose or mouth occurred. More than one episodes of hemorrhage were observed in other 8 individuals (total incidence of hemorrhages 9.7%). No hemorrhages were noted in the FEnR and FnR groups. There were 23 (4.4%) participants with episodes of bleeding, among them 21 mild hemorrhages, in the FER group and 21 (12.0%) in the EnR group (p<0.001). Peak pain level was lowest in FEnR group (p<0.001) and indications for antibiotics most frequent in FnR group (p<0.001). Parental satisfaction level was highest in FnR and FEnR groups (p<0.001).Conclusions: The majority of caregivers reported care of children after T&A surgery according to the instructions. Most frequently disobeyed instructions were those concerning physical exertion. Diet and activity restrictions seem to influence postoperative recovery. Parental satisfaction scores were highest in non-restricted groups.

How is the Children's Implant Profile used in the Cochlear Implant Candidacy Process?

Evelyn Lazaridis, MaryKay Therres, Roger R. Marsh — 2010-04-01

Abstract: Objective: The complex process of cochlear implant candidacy assessment at The Children's Hospital of Philadelphia (CHOP) is guided by a modified version of the Children's Implant Profile (ChIP) that has been used world wide over the past 18 years. The aim of this study is to analyze the use of the modified ChIP (mChIP) in the candidacy process by the CHOP Cochlear Implant Program. Of special interest were those cases in which the recommendation regarding implantation appeared inconsistent with the mChIP score. These were further analyzed to understand the real-life decision processes.Methods: This retrospective study involved 121 children assessed for cochlear implant candidacy at CHOP over a 2-year period. The mChIP ratings of No Concern, Some Concern and Great Concern were assigned values of 1, 2 and 3, respectively. Values of 1.5 and 2.5 were used when the check mark was on the boundary between two categories. An average score was calculated and the relationships between mChIP scores and the recommendation regarding implantation were examined.Results: Eighty-seven children were considered suitable for cochlear implantation; implantation was not recommended for 20. Another 14 cases in which one or more areas of the mChIP had not been completed were excluded. Using a criterion based solely on the mean score would correctly predict 75% of the team's recommendations to implant and 75% of recommendations not to implant. Examination of the cases where implantation was not recommended illuminated the decision-making process.Conclusions: A statistical analysis of the mChIP fails to capture the complexity of the decision-making process. Most important, it appears that the team's practice is generally to recommend implantation when there is at least a modest prospect of benefit, unless there are absolute contraindications or many areas of Great Concern.

A comparison of the consonant production between Dutch children using cochlear implants and children using hearing aids

Nele Baudonck, Ingeborg Dhooge, Evelien D’haeseleer, Kristiane Van Lierde — 2010-04-01

Abstract: Objectives: The main purpose of the present study was to compare the consonant error patterns of Dutch prelingually deaf CI children with prelingually hearing-impaired hearing aid (HA) children. The authors hypothesized that subjects using conventional hearing aids would have poorer consonant production skills. Additionally, the impact of the age at implantation (CI) and the degree of hearing loss (HA) was determined.Methodology: This is a comparative study of 29 prelingually deaf CI children (m.a. 9;0 y) and 32 prelingually hearing-impaired HA children (m.a. 9;11 y) who received their first hearing aid before the age of 2 years. Nineteen CI children were implanted before the age of 5 years. Nine HA children had thresholds above 90dB (range: 91–105dB), 15 between 70 and 90dB (range: 72–90dB) and 8 below 70dB (range: 58–68dB). Speech samples of all the children were elicited by means of a picture naming test and were video-recorded for further phonetic and phonological analysis.Results: Considerably more phonetic and phonologic errors were observed in the HA children with thresholds above 70dB (range: 72–105dB). No notable differences could be found between deaf CI children and HA children with thresholds below 70dB. Even children implanted after the age of 5 years showed significantly fewer phonetic and phonological errors than HA children.Conclusion: The consonant production of implanted children is more adequate than the consonant production of HA children with a hearing loss of 70dB or more. In addition, the results also indicate that even after the age of 5 years, implantation can still have an advantageous effect on a child's consonant production.

Percutaneous sclerotherapy of juvenile nasopharyngeal angiofibroma using fibrin glue combined with OK-432 and bleomycin

Wei-liang Chen, Zhi-quan Huang, Jin-song Li, Qiang Chai, Da-ming Zhang — 2010-04-01

Abstract: The purpose of this study was to determine the appropriate conditions for percutaneous sclerotherapy of juvenile nasopharyngeal angiofibroma using fibrin glue combined with OK-432 and bleomycin. Three patients with juvenile nasopharyngeal angiofibroma were treated with an injection of fibrin glue combined with OK-432 and bleomycin. No major complications occurred in any of the patients. The follow-up period ranged from 12 to 14 months. The following outcomes were obtained: one lesion was completely involuted and two lesions were mostly involuted. All of the patients had normal liver and kidney function. Additionally, none of the patients presented with hematologic toxic effects or signs of pulmonary involvement. Percutaneous sclerotherapy using fibrin glue combined with OK-432 and bleomycin provided a simple, safe, and reliable alternative treatment for juvenile nasopharyngeal angiofibroma.

Single-stage total endoscopic resection of a plexiform neurofibroma of the maxillary sinus in a child with type 1 neurofibromatosis

Ralph N. Abi Hachem, Anthony Bared, Joseph Zeitouni, Ramzi T. Younis — 2010-04-01

Abstract: Plexiform neurofibromas are peripheral nerve sheath tumors associated with neurofibromatosis type 1. The maxillary sinus is an extremely rare location of the plexiform neurofibroma and only two adult cases have been previously reported. We report the first case of plexiform neurofibroma of the maxillary sinus occurring in a child with neurofibromatosis type 1. This unusual location presents a management challenge considering the infiltrative nature and the potential malignant degeneration of this type of tumor. MRI is highly valuable to diagnose and plan the surgical approach of the plexiform neurofibroma of the maxillary sinus. Due to the location of the tumor and the patient's age, conservative surgery is highly recommended. We performed an endoscopic total en-bloc resection of the tumor with no recurrence after nine months of follow-up.

Diaphragmatic paralysis after pediatric heart surgery: Usefulness of non-invasive ventilation

2010-04-01

Abstract: Diaphragmatic paralysis after cardiac surgery is an important complication especially in infants. We report a child who developed diaphragmatic paralysis, atelectasis, bronchomalasia and respiratory failure following cardiac surgery. Ventilatory support alleviated respiratory distress in this child. This report illustrates the usefulness of invasive and non-invasive ventilatory support for a pediatric patient with diaphragmatic paralysis.

Re: Migratory foreign body of neck in a battered baby: A case report

Ankur Gadodia, Ashu SeithBhalla — 2010-04-01

We read with great interest “Migratory foreign body of neck in a battered baby: A case report” by Bakshi et al. . They have described an unusual case of foreign body in neck of battered child. We would like to share a similar experience of child abuse caused by percutaneous insertion of sewing needles in neck and abdomen.

Lateral sinus thrombosis as a complication of acute mastoiditis in children

Jerzy Kuczkowski, Waldemar Narożny, Łukasz Plichta — 2010-04-01

We have read with great interest the recent article by Christensen et al. , which presents important clinical observations for otogenic intracranial complications. It was a well-conducted study of lateral sinus thrombosis of otitis media in children. We would like to present some comments on this problem based on our experience and literature review. Authors presented seven cases of lateral sinus thrombosis (LST) in children as complications of acute otitis media (AOM)—four cases and chronic otitis media (COM)—three cases. LST is a rare intracranial complication of otitis media which contributes to lack of clear guidelines of how to manage this entity, i.e. the time of introduction of antibiotic therapy, whether to remove clot from the sinus or to ligate internal jugular vein (IJV), etc. In case of sigmoid sinus thrombosis as a complication of chronic otitis media with cholesteatoma in children, it is necessary to remove the clot from the sinus and ligate IJV in most of the cases with symptoms of sepsis. I believe that that this is an unquestionable guideline. However, the treatment of this complication without these symptoms has changed to less invasive one. Introduction of new imaging techniques (MRI) enabled early diagnosis of this entity. Effectiveness of clotting drugs may be monitored constantly. Only the mere cause, the etiological factor responsible for acute mastoiditis, may remain difficult to identify. Our observations indicate that septic form of sigmoid sinus thrombosis in children is a rare occurrence nowadays. Clot in this sinus in the course of acute mastoiditis are found more often. In our retrospective series between 1968 and 2008, we treated only 10 children with sigmoid sinus thrombosis (three with Symonds’ syndrome) as complications of acute otitis media . Lee et al. in his paper published this year also presented five cases of LST (including an 8 years old child) treated primarily with antibiotics and anti-clot drugs and subsequently surgically (mastoidectomy without internal jugular vein ligation) with good outcome. Along with the alteration of the clinical presentation of LST in children, the nature of diagnosis has also changed . Introduction of computed tomography and magnetic resonance imaging with venography (MRV) facilitated the process of cerebral venous sinus thrombosis diagnosis. Symptoms of LST in the course of acute otitis media often occur with a delay. Antibiotics administration in patients with AOM may alter or mask completely the clinical picture . A separate problem in LST in children is coexistence of neurophthalmological signs. Their occurrence in patients with acute mastoiditis should direct our attention to a possible complication within cerebral venous sinuses. In the material described by Christensen et al. in four of seven cases abducens nerve palsy and in two cases of seven papilledema were found. Abducens nerve palsy occurrence in patients with acute mastoiditis and LST may be explained by the anatomical route of the nerve. The abducens nerve is in close proximity to the petrous apex as it runs through Dorello's canal, which results in inflammation of the nerve and an ipsilateral rectus palsy. In the material here discussed only three patients out of seven presented fever. None of those had fever characteristic for septic thrombophlebitis sinus sigmoidei (the so-called picket fence). Recently, due to antibiotics administration the picket fence pattern is very rarely seen . In clotting complications in cerebral venous sinuses very important is supplementary testing. CSF opening pressure measured in a flexed lateral decubitus position in children is 10–28cm H2O (65–195mm H2O) and can be unmeasurable or even negative. Christensen et al. discovered that in four of six cases the opening pressure of CSF was elevated (average 56cm H2O) Microbiologic examination is very important in an attempt to establish the etiologic factor of the complication. Christensen et al. have found that only in two cases cultures were positive, (Staphulococcus aureus or Peptostreptococcus sp.). Was it a result of antibiotic therapy or the infection of a viral origin? Our observations indicate that in cases of acute mastoiditis the inflammatory factor is difficult to identify. Molecular testing like PCR may be a solution to the problem. The treatment of non-septic LST still remains controversial. Surgical procedures vary from simple ventilation tube insertion to mastoidectomy, canal wall down or radical mastoidectomy . The authors of this paper treated the patients with antibiotics (one patient with oral amoxycillin alone, the remaining six with intravenous ceftriaxone either alone or in combination with ampicillin/sulbactam). We have to agree with the authors’ opinion that intravenous antibiotics in children with LST should be administered prior to surgical treatment. In the authors’ material only one child was anticoagulated with enoxaparin or warfarin. Five of seven children underwent surgery (mastoidectomy), four patients also underwent ventilation tube placement. Neither the clot was removed in any of the cases nor was the jugular vein ligated. We share the authors’ view that the surgical treatment should be limited to mastoidectomy with broadening of the entrance to the mastoid antrum, removal of the cells and bony laminae in the region of sigmoid sinus with drainage of the tympanic cavity on condition there is no septic clot in the sigmoid sinus. Internal jugular vein ligation without symptoms of sepsis is not advocated . IJV ligation indications have been limited to cases with septic LST or persisting septicemia or pulmonary complications despite initial treatment with antibiotics and surgery . According to data from the article two children were readmitted to the hospital due to headache, nausea, vomiting and papilledema. In these cases mild intracranial hypertension syndrome was diagnoses and treated with acetazolamide with good effect. Other two patients had long-term mild lateral gaze diplopia and sensorineural hearing loss. Six of seven children had long-term follow up imaging. Four of six children with LST showed recanalization of sigmoid sinus. From our experience recanalization of the sigmoid sinus in patients with LST may take place within six months since the completion of the treatment ().

Lateral sinus thrombosis: A review of seven cases and proposal of management algorithm

Nathan Christensen — 2010-04-01

The comments by Dr Kuczkowski and his colleagues regarding our recent case series of lateral sinus thrombosis patients from the University of Rochester are timely and appreciated. They highlight important findings, such as the evolution of the presentation and diagnosis of this clinical entity due the broad use of antibiotics and new and effective diagnostic techniques. In addition, their own experience reinforces the finding that this is an unusual disease with few cases, so clinical suspicion must be high .

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