Catherine P. Winslow

Clinical practice guidelines for the management of chronic sinusitis in children

Chronic sinusitis in children is a common and vexing disease for clinicians and the public. There are insufficient data in the literature to develop an evidence-based clinical guideline. Experience in managing pediatric chronic sinusitis has been gained through a multidisciplinary clinic at our institution during the past 3 years. A panel of experts was formed, and with the guidance of a guideline methodologist, the development of a rigorous outcome-based guideline was undertaken. Symptom-improvement and recurrence estimates for a variety of medical and surgical treatments were assessed. Wide probability estimates were made by the panelists in most cases. Although we refrained from making specific recommendations, we developed a ranked series of practical treatment options taking into account side effects and costs.

Bilateral bifid inferior turbinates.

Anatomic variations of the nasal turbinates are being reported with greater frequency and are of heightened significance because of the improvement of imaging techniques and the increasing predominance of endoscopic intranasal procedures. These variations are important to recognize in order to avoid potential complications during endoscopic nasal surgery. While abnormalities and duplications of the superior and middle turbinates are comparatively common, a secondary or bifid inferior turbinate is a very rare anatomic variation of the nasal cavity. An extensive review of the literature has revealed only a single report of a bifid inferior turbinate, which was unilateral only. I We report what we believe to be the first case of bilateral bifid inferior turbinates.

Persistent rhinosinusitis in children after endoscopic sinus surgery.

The efficacy of endoscopic sinus surgery (ESS) in children is insufficiently addressed in the medical literature. We report a cohort of 14 children (mean age 7.7 years, median age 5.1 years) seen at our multidisciplinary clinic for refractory rhinosinusitis during a 30-month period who continued to have rhinosinusitis despite previous ESS. Prior ESS procedures were performed by 11 surgeons in 3 states. The first ESS was performed when the children were a mean age of 4.6 years, and in 10 of 14, it was performed when they were younger than 4.8 years. This cohort required a disproportionately high rate of subsequent surgical intervention, 50%, versus a 9% surgical rate in the remaining clinic population (P = 0.0002). Osteomeatal scarring was the single most difficult surgical complication. Significant morbidity, in the form of persistent disease, is encountered after ESS in young children. Although chronic rhinosinusitis after ESS, to a certain degree, can still be managed by medical therapy, judicial use of ESS, especially in the very young, is recommended.

Hypocalcemia as a complication of radioiodine therapy

A 38-year-old woman presented to the otolaryngology clinic 1 month after delivery of a healthy baby. During the pregnancy, the patient noted an enlarged neck mass that was slightly more prominent on the right side. She was asymptomatic, and thyroid function tests were within normal limits. Examination of the neck revealed a 6 X 4-cm mass of the right thyroid lobe and a Zx 4-cm mass of the left lobe. A fine-needle aspiration was performed on the mass, and papillary carcinoma was diagnosed. After discussing the options, the patient elected to undergo subtotal thyroidectomy, which was performed on March 6, 1997. A firm, 1.5cm lymph node was palpated in the right paraesophageal region and was excised. Both recurrent laryngeal nerves and three parathyroid glands were identified and preserved. The patient did well following surgery and experienced no immediate complications. Pathology showed a multifocal papillary carcinoma involving both lobes. The right lobe excisional margin was positive for tumor as well. The excised paratracheal lymph node was positive. No parathyroid glands were identified in the specimen. The patient’s calcium levels were followed during her hospital stay. Twelve hours into her

Clavicular osteomyelitis as a complication of head and neck surgery.

Clavicular osteomyelitis is a rare but important entity that should be familiar to all head and neck surgeons as a potential complication. Prevention and early diagnosis will lead to successful outcomes. Aggressive surgical attention is of primary importance, and appropriate antibiotic therapy will assist in complete recovery. A lO-year retrospective chart review was performed at 2 major medical centers (local university and Veterans Administration hospitals) to determine the incidence and outcome of clavicular osteomyelitis in particular, those cases caused by head and neck surgery. Four cases of clavicular osteomyelitis were identified; 2 of these were attributed to antecedent head and neck surgery. and tenderness over the inferior stoma and extending to the right superior thorax. The pharyngocutaneous fistula was still patent. The patient was given intravenous vancomycin hydrochloride in the ED, refused admission, and left against medical advice. The following day he returned to the ED and allowed himself to be admitted. Intravenous antibiotics were administered and a chest radiograph was obtained, which was suspicious for right pneumonia. A computed tomography (CT) scan revealed a right sternoclavicular joint abscess and was suspicious for mediastinitis (Fig 1). The patient underwent debridement of the sternoclavicular joint September 6, 1996. The patient did well postoperatively with no further problems, and left against medical advice on September 12.