Glenn Isaacson

Selective non-surgical management of subperiosteal abscess of the orbit: computerized tomography and clinical course as indication for surgical drainage☆

Subperiosteal abscess of the orbit (SPA) in childhood is an uncommon but serious sequela of sinusitis, with partial or complete visual loss as the most common complication. Traditional management of SPA has combined systemic antibiotics with immediate surgical drainage. The records of 120 children admitted from 1982-1986 with the diagnosis of periorbital or orbital cellulitis were reviewed. Ten cases of SPA were documented by CT scan (8%). Antecedent ethmoid sinusitis was present in all cases. Five SPA patients were managed with intravenous antibiotics and nasal decongestants alone. All had complete clinical and radiographic resolution without complication. The remaining 5 patients underwent surgical drainage. Two patients required immediate drainage due to total ophthalmoplegia upon presentation. One case of postoperative epidural abscess occurred one week after external fronto-ethmoidectomy among these two patients. The remaining 3 patients did not respond adequately to medical therapy alone and underwent surgical drainage without complication. Length of hospital stay in both medical and surgical groups was similar. We conclude that SPA can be safely managed by medical therapy alone in selected cases. Criteria for surgical intervention of documented SPA while on optimal medical therapy should include: worsening of visual acuity or ocular motility, or failure to improve clinically within 48 h. The presence of SPA alone should no longer be considered an absolute indication for surgery.

Patterns of Sinusitis in Cystic Fibrosis

It has been pediatric dogma that most children with cystic fibrosis (CF) have pansinusitis and few are symptomatic. To reassess this premise, we compared symptoms, clinical examinations, radiographic and surgical findings, and results of treatment in 19 children with cystic fibrosis who had undergone computed tomography at St. Christophers Hospital (Philadelphia) from 1991 to 1994. We found two distinct patterns of sinus disease: chronic sinusitis (n = 3) and polyposis (n = 12). Two of the patients with polyposis had ethmoid mucoceles and 1 child had no sinus disease at all. Children with chronic sinusitis had headache as a major complaint, while those with polyposis suffered nasal obstruction alone unless a mucocele was present. Surgery provided marked and lasting improvement in the 14 patients who were operated on.

Effect of Sinus Surgery on Pulmonary Function in Patients With Cystic Fibrosis

The impact of sinus surgery on the pulmonary status of cystic fibrosis patients is unknown. This retrospective study reviewed the charts of the cystic fibrosis patients presenting to our institutions cystic fibrosis center with nasal obstruction, recurrent sinusitis, and nasal polyposis. This group subsequently underwent endoscopic ethmoidectomy and antrostomy. Fourteen of the 15 patients, ages 5‐24 years, received preoperative and postoperative pulmonary function testing obtained by spirometry. The data were compiled and analyzed statistically. Our results suggested no significant improvement in the pulmonary function of cystic fibrosis patients after sinus surgery.

Worldwide Distribution of Waardenburg Syndrome

To clarify the multiracial occurrence of Waardenburg syndrome, we present a case series and literature review. A computerized review of the English-language literature was conducted to assess the distribution of reported occurrences of Waardenburg syndrome in populations around the world. We detail the clinical features of 2 family cohorts: one of Western European origin and the other from South Asia. A computerized literature review found sporadic cases of the syndrome in many ethnic groups, including Japanese, Taiwanese, and Middle Eastern families. The highest reported incidence is among Kenyan Africans. Waardenburg syndrome accounts for between 2% and 5% of cases of congenital deafness. It was first described in Northern European cohorts and is widely identified in fair-skinned populations. We hope to raise awareness of the worldwide distribution of this important cause of hearing loss.

CARE OF THE CHILD WITH TYMPANOSTOMY TUBES

More than two million tympanotomy tubes are placed annually in the United States, making this operation the most common performed on children. This article provides an overview of the applications of tympanotomy tubes for the treatment for otitis media in childhood. The indications for tube placement are discussed; a visual guide for managing children with tympanostomy tubes is presented; an approach to dealing with tube complications is outlined; and guidelines for referral to a pediatric otolaryngologist are suggested.

Natural History of Sigmoid Sinus Thrombosis

To demonstrate the evolution of sigmoid sinus thrombosis, we performed a prospective observational study on a 6-year-old girl who presented with mastoiditis, epidural abscess, and occipital osteomyelitis from multiple drug–resistant Streptococcus pneumoniae. She underwent mastoidectomy and partial occipital craniectomy. This procedure produced a window in the occipital bone that allowed serial ultrasonography of the sigmoid sinus during medical treatment. Computed tomography was performed, followed by weekly Doppler ultrasonography used to monitor resolution of sigmoid sinus thrombosis. The natural history of a treated episode of sigmoid sinus thrombosis was illustrated. Venous occlusion resolved over a 4- to 6-week period without surgical drainage or venous anticoagulants. Collateral flow, reversal of normal venous flow, and ultimate return to normal venous transport characterized the period of resolution. We conclude that an occluded sigmoid sinus from mastoiditis can naturally recanalize. Aberrant venous flow can be demonstrated during the period of resolution. This case supports a conservative approach to management of the occluded sinus and suggests that 4 to 6 weeks of antibiotic therapy after removal of perisinus infection is sufficient for cure.

SINUSITIS IN CHILDHOOD

There is much to be learned about sinusitis in children. The appropriate choice and timing of diagnostic tests, correct type and duration of antibiotic treatment, role of allergy management and adjuvant drugs, and indications for and limits of endoscopic sinus surgery remain to be defined. Technological advances have been introduced and accepted as standard with little validation. Well-thought-out, controlled studies of diagnostic and treatment modalities are needed to address these issues and to better understand the function of the sinuses in health and illness.

Innominate Artery Compression of the Trachea: Diagnosis and Treatment by Anterior Suspension a 25-Year Experience:

Suspension of the innominate artery to the sternum has been a widely accepted therapy for the relief of tracheal compression. Recently, reimplantation of the innominate artery has been advocated as a superior operative procedure. While generally successful, arterial transfer carries the risk of early bleeding and stroke, and the potential for late stenosis at the anastomotic site. Between 1969 and 1994, 25 infants and children at our institution received diagnoses of innominate artery compression and were treated by anterior suspension. All presented with stridor and one third had a history of suspected or proven apnea. Twenty-four children had excellent results, while 1 required resuspension after stridor returned. There were no major complications. Our series strongly supports the belief that anterior suspension of the innominate artery is a successful and reliable operation with minimal morbidity and mortality. More complex procedures are rarely indicated.

Mr Imaging of Fetal Brain

Magnetic resonance (MR) imaging was used to evaluate normal fetal intracranial anatomy in axial, coronal, and sagittal planes. The T1 and T2 weighted images (WI) of aborted fetuses of varying gestational ages were correlated with anatomic sections. In the premature fetus three distinct intensity zones were seen on MR that were not visualized on gross specimens. Unmyelinated white matter displays low intensity on T1 W1 and high intensity on T2 W1. Maturational changes of the brain were observed with advancing fetal age.

Otoendoscopy for Improved Pediatric Cholesteatoma Removal

Our objective was to determine the usefulness of intraoperative rigid endoscopy in detecting incompletely removed cholesteatomas, and to learn whether “second-look” procedures are still needed in children. We used 30°, 2.7-mm endoscopes to evaluate the middle ears of 14 children (29 procedures) with cholesteatomas once all visible disease had been removed under the operating microscope. If residual cholesteatoma was seen, removal continued until all disease visualized with the endoscope was removed. If the cholesteatoma was not removed intact, planned exploratory surgery was performed. The rigid endoscope detected incompletely removed cholesteatomas at surgery in 7 of the 29 cases (24%). In 2 of the 11 cases (18%) judged free of cholesteatoma by both otomicroscopy and otoendoscopy, residual disease was found at planned exploratory procedures. While otoendoscopy is clearly useful in detecting incompletely removed cholesteatoma, a substantial rate of residual disease following “complete” removal suggests the continued need for planned exploratory procedures.