Brian W. Herrmann

The minimum speech test battery in profound unilateral hearing loss.

Objective Individuals with monaural hearing experience disadvantages compared with normal hearing counterparts because of the loss of the head shadow effect, the squelch effect, and binaural summation. In this study the Minimum Speech Test Battery (MSTB), a battery designed to document word recognition in bilaterally hearing impaired cochlear implant candidates, was administered to unilaterally hearing-impaired and normal hearing subjects to study its possible use in measuring hearing difficulty in monaural subjects. Study Design Repeated measures design with the MSTB administered in sound-field in a sound-isolated booth in 1) quiet; 2) speech toward good ear, noise (+10 dB S/N) toward impaired ear; 3) speech toward impaired ear, noise toward good ear; and 4) bilateral speech and noise. Setting Academic otologic practice. Patients Ten adults with normal hearing and 10 adults with normal or near-normal hearing in one ear and profound hearing loss in the contralateral ear. Main Outcome Measures The MSTB, composed of the Consonant-Nucleus-Consonant (CNC) test and the Hearing In Noise Test (HINT). Results As expected, performance differences between the groups were not found in quiet conditions. Analysis of variance and regression analysis confirmed that the impaired group performed significantly worse than control subjects on HINT testing when noise was directed toward the good ear. Analysis of variance and regression analysis confirmed that the impaired group performed significantly worse than control subjects on CNC testing when noise was directed toward the good ear and in bilateral noise. Conclusions The MSTB may be useful in measuring the hearing difficulty of patients with monaural hearing.

Intracranial complications of pediatric frontal rhinosinusitis

Background The aim of this study was to review the presentation and management of children admitted for intracranial complications arising from frontal rhinosinusitis. We performed a retrospective case series review at two academic tertiary care childrens hospitals. Methods This study consisted of children <18 years old who presented with intracranial complications from frontal rhinosinusitis between January 1, 1990 and December 31, 2002. Relevant literature was reviewed with the assistance of Medline. Presentation, type of intracranial complication, radiographic evaluations, response to treatment, and prognosis were evaluated. Results Sixteen patients were identified with intracranial complications due to frontal rhinosinusitis. Patients were usually older (mean age, 14 years and 3 months), of male gender (M/F, 4.3:1.0), and African American (AA/W, 3.0:1.0). Headache, nasal congestion, and visual changes were the most common early symptoms and neurological findings indicated advanced disease. Subdural (56%), epidural (44%), and cerebral abscesses (19%) were the most common complications. Meningitis alone was identified in 13% and was associated with another intracranial complication in 6%. Multiple intracranial complications were noted in 31%. Polymicrobial cultures were obtained in 50% of patients. Although CT was excellent in identifying orbital pathology, MRI was superior for characterization of intracranial disease. Conclusion Intracranial complications of frontal rhinosinusitis are rare in children. Early symptoms often are nonspecific, with neurological findings more commonly seen in advanced disease. Adolescent African American male patients were found to be at highest risk for intracranial complications from frontal rhinosinusitis. Headache and orbital complaints associated with rhinosinusitis in older children failing to respond to initial therapy should prompt an aggressive evaluation including MRI.

Sinonasal posttransplant lymphoproliferative disorder in pediatric lung transplant patients

OBJECTIVE: To evaluate sinonasal manifestations of posttransplant lymphoproliferative disorder (PTLD) in the pediatric lung transplant population. STUDY DESIGN AND METHODS: Case series of children less than 18 years presenting with PTLD after pulmonary transplantation at St Louis Childrens Hospital between Jan 1, 1990 and Dec 31, 2003. RESULTS: Two hundred eighty-two lung transplants were performed in 246 children. Thirty-two cases of histopathologically confirmed PTLD were identified with 8 (25%) presenting in the head and neck. Sinonasal PTLD was the most common site of head and neck involvement (63%), with 40% of patients presenting with occult disease. All patients with sinonasal PTLD had longstanding nasal polyposis related to cystic fibrosis (P = 0.07). CONCLUSIONS: This is, to our knowledge, the first report identifying an increased frequency of sinonasal PTLD after pediatric pulmonary transplantation, particularly in children with cystic fibrosis and associated nasal polyposis. Because sinonasal PTLD may be asymptomatic, this region should receive close scrutiny on surveillance evaluations.

Visual loss in a child due to allergic fungal sinusitis of the sphenoid.

Acute blindness due to allergic fungal sinusitis (AFS) is rare and, to our knowledge, has not been previously reported in a child. We present a pediatric case of acute, complete unilateral vision loss related to AFS involving the sphenoid sinus. An otherwise healthy, 11-year-old female presented to St. Louis Children’s Hospital with acute left-sided blindness after a 6-week history of nasal congestion with headaches, photophobia, and right infraorbital hypesthesia occurring the week prior to admission. When the patient noted intermittent blurriness in the vision of her left eye, she was evaluated by her pediatrician and diagnosed with migraine headaches after normal sinus and chest x rays were obtained. Treated symptomatically, her headaches improved but her left-sided visual changes became more pronounced and persistent, with her contralateral vision also becoming blurry. The morning of admission, the patient reported no vision in her left eye, prompting her parents to seek emergent treatment. No pupillary response to light or to accommodation was noted in the left eye and her visual acuity was 20/40 in the right eye. Mild proptosis was noted bilaterally, but no limitations in extraocular muscle motion were identified. Hypesthesia in the distribution of the right infraorbital nerve was also confirmed. The rest of her physical examination was normal. An orbital CT scan was obtained, which demonstrated an expansile lesion involving the sphenoid and posterior ethmoid sinuses bilaterally. Numerous calcifications within the sphenoid sinus were noted and both orbital apices appeared compressed by lateral bony remodeling. (Fig 1). The patient was started on high-dose corticosteroids and

A preliminary report on the effects of paclitaxel-impregnated stents on sheep nasal mucosa

Introduction Traditional frontal sinus stents serve only as mechanical devices. It has been proposed that stents also may serve as drug-delivery systems for the topical application of drugs that minimize postoperative scarring. Paclitaxel (Taxol), which has recognized antiscarring effects, may be incorporated via a polymeric formulation into standard rubber stents. The impact of topically applied paclitaxel on the morphology of the nasal mucosa is unknown. Methods An adult sheep model was used for this study. A modified rubber T-tube stent (incorporating paclitaxel at varying dosages) was secured to each side of the septum in four animals (eight sides). An unmodified T-tube was placed on each side of one animal, a T-tube with the drug carrier (but no paclitaxel) was placed on each side of the second animal, and T-tubes with varying paclitaxel were placed on each side of the final two animals. After 4 weeks, animals were killed and the nasal mucosa was harvested. The nasal mucosa was sectioned and stained with hematoxylin and eosin. A pathologist then assessed the nasal mucosa for vascular congestion, glandular atrophy, chronic inflammation, mucosal metaplasia, and mucosal ulceration. Results No consistent histopathological differences were noted in the specimens. All specimens showed varying degrees of vascular congestion, glandular atrophy, chronic inflammation, and mucosal metaplasia; the paclitaxel-impregnated stents were not consistently associated with more severe mucosal injury. Finally, mucosal ulceration was noted to be very rare in all specimens. Conclusion This preliminary report describes the impact of paclitaxel-impregnated stents on sheep nasal mucosa, which tolerated these stents very well. Because paclitaxel minimizes scarring reactions at very low concentrations, paclitaxel-impregnated stents may prove useful in clinical situations in which frontal sinus stenting is deemed necessary. Additional investigations with animal models, as well as clinical trials, may be warranted.