Carla M. Giannoni

Intracranial complications of sinusitis: a pediatric series.

Intracranial complications of sinusitis (ICS) (cerebral, epidural, and subdural abscesses, meningitis, and dural sinus thrombophlebitis) remain a challenging and contemporary topic. The progressive pneumatization and continued development of the sinuses after birth and the late appearance of the frontal and sphenoid sinuses imply that some infections would not appear until later childhood. We reviewed the records at a large pediatric hospital between 1986 and 1995 and found 10 children with 13 ICS (cerebral abscess, 5; extra-axial empyema, 5; and meningitis, 3). Of 43 children with cerebral abscess and 16 with extra-axial abscesses treated in this period, 12% of cerebral and 63% of extra axial abscesses were due to a sinogenic source. Multiple intracranial and extracranial complications of sinusitis in a single patient were common. The average age of children with ICS was 12.2 years old. We present these 10 cases and discuss their presentation, microbiology, and clinical course. Although the majority presented with a classic picture of headache, altered mental status, and fever, a few had symptoms that were more subtle. One child had recurrent meningitis, believed to be due to skull base dehiscence after endoscopic sinus surgery (ESS). He has required multiple otolaryngologic and neurosurgical procedures in an effort to prevent further episodes of meningitis. Ultimately, nine of 10 patients survived with an average hospital stay of 27.8 days (median of 17 days). The diagnosis of ICS requires a high index of suspicion, imaging of the brain and paranasal sinuses, and aggressive intervention.

Gastroesophageal reflux association with laryngomalacia: a prospective study

OBJECTIVE To identify the incidence and clinical role of gastroesophageal reflux (GER) in patients with laryngomalacia. DESIGN Prospective evaluation of consecutive infants with a new diagnosis of laryngomalacia with an initial questionnaire, a barium esophagram or 24 h pH probe and record of their subsequent clinical course. SETTING A large, tertiary pediatric referral center and its associated outpatient clinic. PATIENTS New diagnosis of laryngomalacia in 33 consecutive infants were evaluated by questionnaire and 27 of these were evaluated for GER. RESULTS GER was observed in 64% of patients and was significantly associated with severe symptoms and complicated clinical course (P = 0.0163). The presence of smokers in the infants household negatively impacted his or her clinical course and symptomatology (P = 0.013) as did the presence of other major, concurrent medical problems (P = 0.065). CONCLUSIONS In patients with laryngomalacia, GER was significantly associated with severe symptoms (a complicated clinical course), as was smoking in an infants household and other significant medical problems.

The risk of adenoid hypertrophy in children with allergic rhinitis

BACKGROUND Adenoid hypertrophy (AH) may cause significant morbidity in children but its relationship to allergic rhinitis (AR) has not been studied. OBJECTIVE To determine the risk factor of AH in patients with AR. METHODS We studied 315 children (ages 1 to 18 years) who had AH and AR. We compared them with 315 age-matched controls who had AR alone. To identify risk factors, they were divided into four groups according to age and clinical parameters, including the prevalence of otitis media, sinusitis, lower respiratory infection, exposure to smoking, sleep disorders, use of antihistamine/decongestants, and results of allergy skin testing. RESULTS The prevalence of upper or lower respiratory infections was higher in the group with AR and AH, but not in all age groups. A high prevalence of exposure to smoking and skin test reactivity against house dust mites were found in both groups. However, the prevalence of positive reactivity to molds was significantly higher in the group with AH and AR (P ranged from 0.013 to <0.0001 and the relative risk ranged from 1.609 to 2.375). Further, the risk of AH was positively correlated with number of skin test reactivity to mold spores (P ranged from 0.0035 to 0.0001). Positive skin test reactivity to animal danders or seasonal allergens failed to predict the risk of AH. CONCLUSIONS Sensitivity to mold allergens is an important risk factor for AH in children with AR; therefore, early prevention of exposure to molds may help reduce occurrence of AH.

Impact of resistant pneumococcus on rates of acute mastoiditis

OBJECTIVE To determine whether the rate of acute mastoiditis is rising, specifically as a result of antibiotic-resistant strains of Streptococcus pneumoniae. METHODS A retrospective chart review of all patients with a discharge diagnosis of acute mastoiditis between July 1, 1987, and June 30, 1997, was performed at our academic, tertiary-care medical center. There were no interventions, and the main outcome measures included the number of cases of acute or coalescent mastoiditis, stratified by pathogen, per year. RESULTS The rate of acute mastoiditis as a proportion of yearly otorhinolaryngology admissions increased linearly over time (P = 0.024). Pneumococcal-related rates of acute mastoiditis, expressed as a proportion of yearly hospital and otorhinolaryngology admissions, increased linearly over time (P = 0.002, P = 0.002). All but 1 case of pneumococcal mastoiditis during the past 3 years were caused by penicillin-resistant strains. CONCLUSIONS The emergence of antibiotic-resistant S pneumoniae may be responsible for an increasing rate of acute mastoiditis.

c-erbB-2/neu oncogene and Ki-67 analysis in the assessment of palatal salivary gland neoplasms.

To evaluate the role of the Ki-67 proliferation antigen and c-erbB-2/neu oncogene expression in the clinical assessment of salivary gland tumors, we followed up 71 patients with minor salivary tumors of the palate. All benign neoplasms (n = 18) showed low Ki-67 scores (< 12%), whereas 26% (14 of 53) of malignant neoplasms manifested high Ki-67 scores (> 12%). A significant statistical difference between Ki-67 scores for benign and malignant neoplasms was observed (p < 0.001). Ki-67 index also correlated significantly with malignant tumor grade (p = 0.04) and patient survival (p = 0.02). Only 1 of the 18 benign tumors had c-erbB-2/neu oncogene overexpression. A significant difference between c-erbB-2/neu overexpression in benign and malignant tumors was observed (p = 0.01). Overexpression of c-erbB-2/neu oncogene was noted in 38% (16 of 42) of malignant tumors and was significantly associated with aggressive tumor behavior (p < 0.001). Multivariate analysis of significant factors revealed that gender, tumor stage, and c-erbB-2/neu oncogene overexpression were jointly predictive of survival. Our data indicate that although the Ki-67 proliferating antigen and c-erbB-2/neu oncogene expression may reflect certain intrinsic biologic properties of these neoplasms, only c-erbB-2/neu overexpression is significantly associated with their biologic aggression.

Multimodality Imaging of Tracheobronchial Disorders in Children

The trachea and bronchial airways in children are subject to compromise by a number of extrinsic and intrinsic conditions, including congenital, inflammatory, infectious, traumatic, and neoplastic processes. Stridor, wheezing, and respiratory distress are the most common indications for imaging of the airway in children. Frontal and lateral chest and/or neck radiography constitute the initial investigations of choice in most cases. Options for additional imaging include airway fluoroscopy, contrast esophagography, computed tomography (CT), and magnetic resonance (MR) imaging. Advanced imaging techniques such as dynamic airway CT, CT angiography, MR angiography, and cine MR imaging are valuable for providing relevant vascular and functional information in certain settings. Postprocessing techniques such as multiplanar reformatting, volume rendering, and virtual bronchoscopy assist in surgical planning by providing a better representation of three-dimensional anatomy. A systematic approach to imaging the airway based on clinical symptoms and signs is essential for the prompt, safe, and accurate diagnosis of tracheobronchial disorders in children.

Ocular Motility Complications after Endoscopic Sinus Surgery with Powered Cutting Instruments

OBJECTIVE: The purpose of this study was to describe 2 unique cases of ocular motility dysfunction after powered endoscopic sinus surgery and identify potential risk factors for extraocular muscle injury. STUDY DESIGN: Interventional case series. RESULTS: Patient 1 developed a restrictive global ophthalmoplegia after inadvertent entry into the medial orbit during powered endoscopic sinus surgery. Patient 2 had complete loss of adduction of the left eye as a result of transection of the medial rectus muscle by a powered cutting instrument. CONCLUSIONS: Despite advances in endoscopic sinus surgery technique and instrumentation, serious ophthalmic complications may still occur. Inadvertent entry into the medial orbital wall can result in ocular motility complications. Furthermore, it is possible that attraction of orbital contents into the tip of a powered cutting instrument may occur without significant entry into the orbital cavity. SIGNIFICANCE: It is important for endoscopic sinus surgeons to be aware of the intimate anatomical relationship between the orbit and sinuses, as well as the potential risks of the current instruments used in endoscopic sinus surgery.

Recurrent meningitis in the pediatric patient--the otolaryngologist's role.

OBJECTIVE To assess the etiology of recurrent meningitis in the pediatric patient. DESIGN Retrospective case series and literature review. SETTING Tertiary-care pediatric hospital. PATIENTS Children (< 17-years-old) with recurrent meningitis, treated at Texas Childrens Hospital (TCH) between 1984 and 1995. RESULTS A review of 463 cases of bacterial meningitis over an 11 year period revealed six children aged 3 months to 15 years with the diagnosis of recurrent meningitis. The patients age, number of episodes of meningitis, diagnostic investigations performed and etiologies of recurrent meningitis were recorded. Fifteen episodes of meningitis were identified in these six patients; Streptococcus pneumoniae represented the bacteriology in 73% of the cases. Two patients were diagnosed with temporal bone abnormalities, two children with immunological deficiencies and no underlying etiology for the recurrent meningitis was identified in the remaining two patients. In this series, one-third of patients had an otolaryngologic etiology for their recurrent meningitis. These six patients, along with a review of the recent literature, will highlight the need for otolaryngological assessment and the importance of considering immunological investigations when managing recurrent meningitis in the pediatric patient. CONCLUSION We propose that children with recurrent meningitis of unknown etiology undergo: (1) an audiological evaluation; (2) a CT scan of the temporal bones, skull base and paranasal sinuses; and (3) an immunological evaluation.

Doxycycline sclerotherapy as the primary treatment for head and neck lymphatic malformations.

Surgical resection has been the standard therapy for lymphatic malformations. Because of the infiltrative nature of these lesions and involvement of important anatomic structures, total extirpation is usually not possible. Additional treatment options have been investigated, with percutaneous sclerotherapy gaining favor. Several reports have shown promising results using the sclerosant OK-432 for macrocystic lymphatic malformations, with relatively few side effects. However, this agent has yet to gain Food and Drug Administration approval and is available in a research capacity only. Doxycycline has been shown to be effective for benign lymphoepithelial cysts of the parotid gland, and Molitch et al showed improvement in five patients with lymphatic malformations in varying areas of the body. In the present article, we report our experience using doxycycline percutaneous sclerotherapy as the primary modality of treatment for pediatric head and neck macrocystic lymphatic malformations.

Does Dexamethasone with Preemptive Analgesia Improve Pediatric Tonsillectomy Pain

OBJECTIVE: The study goal was to determine whether the combination of dexamethasone with preemptive analgesia has an additive effect in further improving recovery. STUDY DESIGN: We conducted a prospective, randomized, double-blinded trial of 50 children undergoing tonsillectomy at a university ambulatory surgery center. One study group received 1 intravenous dose of dexamethasone, and another group received 1 dose of saline solution. All patients received tonsillar fossa injections of ropivacaine plus clonidine before tonsil excision. RESULTS: The 2 study groups were similar in main outcome measurements. Pain intensity and quality of life were not statistically different between the groups. There was a small trend to less trismus and less cumulative codeine use in the steroid group. Overall, there was a very low incidence of nausea and vomiting in both groups, which may have been due to the preemptive analgesia. CONCLUSION: Dexamethasone does not significantly improve the morbidity of pediatric tonsillectomy when preemptive analgesia with ropivacaine and clonidine is used concurrently.