Earl H. Harley

Acute Mastoiditis in Children: A 12-Year Retrospective Study

We undertook a retrospective study to examine our experience with acute mastoiditis over a 12-year period. Fifty-eight cases were identified in children aged 3 months to 15 years. Acute mastoiditis was the first evidence of otitis media in 54% of our patients. Pain and fever lasting for more than a median period of 4 days were most likely to be the harbingers of incipient acute mastoiditis. Streptococcus pneumoniae was the most common organism recovered from the cultures. All children were treated with intravenous antibiotics; 41 children were managed with an adjunctive drainage procedure. No statistically significant differences were observed between the cure rates and failure rates for children treated surgically with myringotomies with or without tubes and children managed more aggressively with mastoidectomies. One infant had bacterial meningitis. Cholesteatoma was diagnosed in two children. We conclude from our study that acute mastoiditis occurs mainly in young children and may be the first evidence of ear disease. Pain and fever that persist despite appropriate treatment for acute otitis media are the two most important symptoms. Intravenous antibiotics combined with myringotomy with or without tube insertion are as appropriate as intravenous antibiotics with mastoidectomy for initial management of acute mastoiditis in the absence of a subperiosteal abscess or central nervous system extension.

Ibuprofen for tonsillectomy pain in children: Efficacy and complications

We designed a prospective, randomized, double-blind study to test the efficacy and safety of ibuprofen compared with acetaminophen with codeine for pediatric posttonsillectomy/adenotonsillectomy patients. Twenty-seven children, aged 6 to 16 years, were enrolled. We collected information on pain control, return to normal sleep pattern, return to normal diet, and duration for which medication was required. Coagulation profiles were measured before surgery and on postoperative day 3. Acetaminophen with codeine was more effective in controlling pain on days 1 and 3 (p = 0.0475 and 0.0328, respectively). However, we detected no difference between the treatment groups (p = 0.2216) with regard to pain control on day 5. The ibuprofen group required medication for a longer period (p = 0.0464). We detected no statistically significant differences between groups with regard to return to normal diet (p = 0.2346) and return to normal sleep pattern (p = 0.9554). The postoperative hemorrhage rate was 0% in the acetaminophen-with-codeine group and 12.5% in the ibuprofen group. The ibuprofen group demonstrated a mean increase in bleeding time of 2.07 minutes on the third postoperative day (p = 0.0379). The mean change in postoperative bleeding time between the two groups was statistically significant (p = 0.0140). We found no statistically significant differences in prothrombin time and partial thromboplastin time between groups. On the basis of the findings of this pilot study, we conclude that acetaminophen with codeine is safer and more efficacious than ibuprofen in the management of posttonsillectomy/adenotonsillectomy pain in children.

Group A Streptococcus intranasal infection promotes CNS infiltration by streptococcal-specific Th17 cells

Group A streptococcal (GAS) infection induces the production of Abs that cross-react with host neuronal proteins, and these anti-GAS mimetic Abs are associated with autoimmune diseases of the CNS. However, the mechanisms that allow these Abs to cross the blood-brain barrier (BBB) and induce neuropathology remain unresolved. We have previously shown that GAS infection in mouse models induces a robust Th17 response in nasal-associated lymphoid tissue (NALT). Here, we identified GAS-specific Th17 cells in tonsils of humans naturally exposed to GAS, prompting us to explore whether GAS-specific CD4+ T cells home to mouse brains following i.n. infection. Intranasal challenge of repeatedly GAS-inoculated mice promoted migration of GAS-specific Th17 cells from NALT into the brain, BBB breakdown, serum IgG deposition, microglial activation, and loss of excitatory synaptic proteins under conditions in which no viable bacteria were detected in CNS tissue. CD4+ T cells were predominantly located in the olfactory bulb (OB) and in other brain regions that receive direct input from the OB. Together, these findings provide insight into the immunopathology of neuropsychiatric complications that are associated with GAS infections and suggest that crosstalk between the CNS and cellular immunity may be a general mechanism by which infectious agents exacerbate symptoms associated with other CNS autoimmune disorders.

Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: Evolving principles in diagnosis and management

To review the demographics, presentation, interventions, and outcomes of acute supraglottitis in the post–Haemophilus influenzae type B (Hib) vaccination era and make updated recommendations for treatment.

A retrospective review of frenotomy in neonates and infants with feeding difficulties

OBJECTIVES To measure maternal breast feeding benefit after infant frenotomy. To investigate if timing of neonatal/infant frenotomy affects outcome. STUDY DESIGN Cohort survey and retrospective review. METHODS Medical records of neonates and infants suspected to have ankyloglossia between April 2006 and February 2011 were reviewed. Patient demographic data was compiled. A telephone survey was conducted to gather data on this cohort of patients. RESULTS Neonatal and infant consultations (N=367) were performed for feeding difficulties due to suspected ankyloglossia, 302 of these infants underwent frenotomy for ankyloglossia. A total of 91 mothers agreed to participate in a follow-up telephone survey regarding the intervention. Results showed that 80.4% of mothers strongly believed the procedure benefited their childs ability to breastfeed, and 82.9% of mothers were able to initiate/resume breastfeeding after the procedure was performed. The belief that frenotomy significantly benefitted an infants ability to feed significantly differed in patients that had the procedure performed in the first week of life (86%) as compared to infants that had the procedure performed after the first week of life (74%) (p<0.003). CONCLUSIONS Based on maternal observations, when frenotomy is performed on neonates with ankyloglossia and feeding difficulties in the first week of life, there is more benefit than when it is performed after the first week of life. The population of patients with ankyloglossia is predominantly male with a high familial/genetic correlation associated with the phenotypic trait. Frenotomy for ankyloglossia demonstrates a high degree of maternal satisfaction, is well tolerated and has been shown to improve breastfeeding and decrease pain and difficulty associated with breastfeeding.

Osteoma of the middle ear

Osteomas are rare in the temporal bone. Most commonly, they occur in the external auditory canal. A review by Dénia et al was notable for the absence of these lesions in the middle ear. In their report on osteoma of the temporal bone, none of 53 patients had middle ear involvement. A recent paper noted that only nine cases with middle ear involvement have been previously described. This report adds another case to the body of literature.

Clothing Hanger Injuries Pediatric Head and Neck Traumas in the United States, 2002-2012

Objective To discuss pediatric clothing hanger injuries and review the National Electronic Injury Surveillance System to elucidate frequency and promote increased public awareness among pediatric otolaryngologists. Study Design Cross-sectional analysis of a national database. Study Setting National Electronic Injury Surveillance System Database. Methods A retrospective review of the National Electronic Injury Surveillance System provided a nationally weighted sampling estimate of 394 pediatric incident reports involving clothing hangers. Each incident report was analyzed for impalement, facial laceration, and contusion injuries to the mouth, face, and head. In addition, hospital disposition and location of the described incident were also obtained. Results Upon review of the National Electronic Injury Surveillance System, incident rates of pediatric oral impalement (95% confidence interval [CI], 0.10-0.41), facial laceration (95% CI, 0.22-0.41), and facial abrasion injuries (95% CI, 0.15-0.44) frequently involved the metal clothing hanger design. In addition, most of the reported injuries occurred within the home and involved lacerations to the oral cavity. Conclusions This is the first multiyear, nationally representative study to analyze clothing hanger injuries in the pediatric population. We demonstrate that these injuries occur more frequently than the medical literature currently reports and also elucidate that children are more likely to obtain laceration injuries by metal clothing hangers within the home. Furthermore, we provide a recommendation for standardization of the National Electronic Injury Surveillance System such that product safety analysis may occur and reduce further pediatric incidents.

Pediatric Head and Neck Complications of Streptococcus pneumoniae before and after PCV7 Vaccination

Objective To discuss pediatric head and neck complications of pneumococcal infections before and after the introduction of the PCV7 vaccine. Study Design Cross-sectional analysis of a national database. Study Setting Kids National Inpatient Database. Methods A retrospective review of the Kids National Inpatient Database yielded 31,738 pediatric reports involving complications of meningitis, mastoiditis, periorbital cellulitis, and Bezold abscesses due to Streptococcus pneumoniae diagnoses. Each report was analyzed for incidence, length of stay, mean hospital cost, and inpatient admittance from the emergency department. Finally, we calculated the expected annual incidence of each complication via variance-weighted analysis to determine the expected incidence if the vaccine was not administered. Results We identified a significant decrease in the incidence of several complications after the introduction of the PCV7 vaccine and also when comparing these findings to our predicted incidence calculations if the vaccine was not administered. Inpatient admittance from the emergency department for Bezold abscess, periorbital cellulitis, mastoiditis, and meningitis was significantly increased in the pediatric age group (ages 1-4; P < .05). Furthermore, there was a significant increase in the cost to provide care for each of the described conditions (P < .05). Conclusions The PCV7 vaccine produced a measurable reduction in head and neck complications associated with S pneumoniae. However, our data suggest that these benefits were also met with increased inpatient admittance from the emergency department, hospital costs, and length of stay, each of which may be attributed to the selection of a more pathogenic subtype.

Management of subglottic cysts with Mitomycin-C—A case series and literature review

OBJECTIVES To describe the management and outcomes of seven infants with subglottic cysts. To assess the role of Mitomycin-C in the management of subglottic cysts. To discuss the relationship of subglottic cysts with gastro-esophageal reflux. To extensively review the literature on subglottic cysts. DESIGN Retrospective case series and literature review. METHODS Case series of seven children with subglottic cysts at a tertiary care hospital. Charts were reviewed to determine birth history, gender, intubation history, comorbidities, age at presentation, presenting symptoms, interventions and follow-up. RESULTS Between 2001 and 2009, seven patients aged 4-13 months were diagnosed with and treated for subglottic cysts. All children had a history of intubation and had evidence of gastro-esophageal reflux. All children were treated with endoscopic marsupialization (CO(2)-laser, cupped forceps) or bronchoscopic rupture; with or without concomitant topical Mitomycin-C therapy. Infants were followed clinically and with interval endoscopy with a minimum follow-up of 6 weeks. No patients receiving topical post-marsupialization Mitomycin-C (0/4) had cyst recurrence. Those patients who did not receive Mitomycin-C therapy recurred more frequently (66% - 2/3). Cysts ruptured with the bronchoscope tip recurred (66% - 2/3) more often than cysts undergoing endoscopic marsupialization (0/6). The one bronchoscopic rupture case that did not recur was the one in which Mitomycin-C was used concomitantly. Patient follow-up was at 2, 4 and 6 weeks post-procedure. CONCLUSION Endoscopic marsupialization is the treatment of choice for subglottic cysts. Gastro-esophageal reflux has a strong association with subglottic cysts. The post-marsupialization application of Mitomycin-C may have a role in reducing the recurrence rate and scarring after surgical treatment of subglottic cysts.

Parental perception of speech and tongue mobility in three-year olds after neonatal frenotomy

OBJECTIVES The goal of this study was to evaluate parental speech outcomes and tongue mobility in children with ankyloglossia who underwent frenotomy by an otolaryngologist during the neonatal period. STUDY DESIGN Cohort study and retrospective telephone survey. STUDY SETTING University Hospital. SUBJECTS AND METHODS Neonates previously diagnosed with congenital ankyloglossia were separated into Surgical Intervention (N=71) and No Surgical Intervention (N=15) Groups. A Control Group (N=18) of patients was identified from the hospital medical record database, which were not diagnosed with congenital ankyloglossia. A survey provided by a certified speech pathologist utilized a Likert scale to assess speech perception and tongue mobility by parental listeners. The questionnaire also analyzed oral motor activities and the medical professionals that identified the ankyloglossia shortly after birth. Statistical analyses were performed with the Wilcoxon Rank Sum Test and Fischers Exact Test in order to determine an effect size=1. RESULTS There was significantly improved speech outcomes designated by parents in the Surgical Intervention Group when compared to the No Surgical Intervention Group [p<0.0001, p<0.0001], respectively. Furthermore, parents designated no difference in speech outcomes between the Surgical Intervention Group when analyzed against the Control Group [p=0.3781, p<0.2499], respectively. CONCLUSIONS There was a statistically significant improvement in speech outcomes and tongue mobility in children who underwent frenotomy compared to individuals who declined the operation. As a result of the data presented within this study, there appears to be a long-term benefit beyond feeding when frenotomy is performed in newborns with ankyloglossia.