Jerome W. Thompson

Deep neck infection.

Deep neck infections present significant morbidity and mortality, particularly when associated with predisposing factors that impair a functional immunologic response. Familiarity with deep neck spaces and fascial planes is critical, because these form the basis for the emergent nature of the disease process. Common and potentially life-threatening complications include airway obstruction, jugular vein thrombosis, descending mediastinitis, sepsis, acute respiratory distress syndrome, and disseminated intravascular coagulation. The most common primary sources of deep neck infection are odontogenic, tonsillar, salivary gland, foreign body, and malignancy. Microbiology typically reveals mixed bacterial flora, including anaerobic species, that can rapidly progress to a fulminating necrotizing fasciitis. The treatment cornerstone remains securing the airway, providing efficient drainage and appropriate antibiotics, and improving immunologic status. A prolonged hospital stay should be anticipated.

PRELIMINARY RESULTS OF THE USE OF INDOLE-3-CARBINOL FOR RECURRENT RESPIRATORY PAPILLOMATOSIS

OBJECTIVE: We report the preliminary results of a phase I trial using indole-3-carbinol for the treatment of recurrent respiratory papillomatosis. Indole-3-carbinol is a chemical that is found in high concentrations in cruciferous vegetables and has been shown to alter the growth pattern of recurrent respiratory papillomatosis cell cultures and to be effective in an in vivo animal model of recurrent respiratory papillomatosis. METHODS: Eighteen patients were treated with oral indole-3-carbinol and had a minimum follow-up of 8 months and a mean follow-up of 14.6 months. All patients received indole-3-carbinol, and outcome measures included a change in papilloma growth rate and the need for surgery during treatment compared with before treatment. All patients had serial examinations with videoendoscopy to document papilloma location and growth rate. RESULTS: Thirty-three percent (6 of 18) of the study patients had a cessation of their papilloma growth and have not required surgery since the start of the study. Six patients have had reduced papilloma growth rate, and 6 (33%) patients have shown no clinical response to indole-3-carbinol. Indole-3-carbinol affects the ratio of hydroxylation of estradiol; changes in the ratios of urinary 2-hydroxylation and 16-hydroxylation of estradiol caused by indole-3-carbinol correlated well with clinical response. No major complications or changes in the childrens growth curve were noted. CONCLUSIONS: The preliminary results of treating recurrent respiratory papillomatosis with indole-3-carbinol holds promise. Longer follow-up of this patient group and a blinded, controlled trial are required. We conclude that indole-3-carbinol appears to be safe and well tolerated and may be an efficacious treatment for recurrent respiratory papillomatosis. (Otolaryngol Head Neck Surg 1998;118:810–5.)

Successful Medical Therapy for Deeply Invasive Facial Infection Due to Pythium insidiosum in a Child

Pythiosis occurs in animals and humans who encounter aquatic habitats that harbor Pythium insidiosum. Drug therapy for deeply invasive infections with this organism has been ineffective in humans and animals; patients have been cured only by radical surgical debridement. A 2-year-old boy developed periorbital cellulitis unresponsive to antibiotic and antifungal therapy. The cellulitis extended to the nasopharynx, compromising the airway and necessitating a gastrostomy for feeding. P. insidiosum was isolated from surgical biopsy specimens of the affected tissue. On the basis of in vitro susceptibility studies of the isolate, the patient was treated with a combination of terbinafine and itraconazole. The infection resolved over a period of a few months. The patient remained well 1.5 years after completing a 1-year course of therapy. Cure of deep P. insidiosum infection is feasible with drug therapy.

Laryngeal Paralysis in Children A Long-Term Retrospective Study

The charts of 100 children with laryngeal paralysis were reviewed. The patients in this study had either unilateral or bilateral abductor vocal cord paralysis. The literature and pathophysiology are reviewed. A statistical analysis of each group of patients according to etiology is reported. The follow-up, progress and recovery are detailed. The need for observation and conservative therapy is reinforced by the tendency for spontaneous recovery. Suggestions regarding treatment are given.

Retropharyngeal abscess in children: A retrospective and historical analysis

The charts of 65 pediatric patients with the diagnosis of retropharyngeal abscess were reviewed. These represented a 36‐year experience with the disease. The findings were compared with those documented at the turn of the century and were also compared with findings over the last four decades. The data suggests that retropharyngeal abscess may be occurring later in childhood and may not always be preceded by a major detectable infection. Classic diagnostic findings of retropharyngeal bulge and neck stiffness were present in less than half of the patients. Gram‐negative and anaerobic organisms are being documented on culture more frequently than in the past. We theorize that liberal use of oral antibiotics prior to admission may have brought about these changes.

Inverting papillomas of the nose and paranasal sinuses

Inverting papilloma of the nose and paranasal sinuses can sometimes be very difficult to distinguish from other nasal tumors, and the confusion ranges from allergic nasal polyposis to carcinoma. They are also certainly characterized by multiple recurrence, particularly after limited operations.

Plastic bronchitis occurring late after the Fontan procedure : Treatment with aerosolized urokinase

Objective To describe the use of aerosolized urokinase in a patient with plastic bronchitis after a Fontan procedure. Design Case report. Setting Pediatric intensive care unit in a university-affiliated children’s hospital. Patients Report of one patient with acute respiratory failure secondary to plastic bronchitis. Interventions Aerosolized urokinase, multiple bronchoscopies, corticosteroids, mucolytics, bronchodilators, and atrial pacing. Measurements and Main Results Airway obstruction secondary to recurring casts improved with the treatments. Histologic analysis of the casts demonstrated less fibrin after treatments with aerosolized urokinase. No adverse events were noted. Conclusions The addition of aerosolized urokinase to this patient’s treatment regimen helped to resolve life-threatening airway obstruction secondary to fibrin casts.

Papilloma of the larynx and tracheobronchial tree in children. A retrospective study.

One hundred and forty cases of papilloma of the larynx and tracheobronchial tree are documented in the records of the Childrens Hospital of Los Angeles. The records of 90 patients were available and were reviewed intensively. The method of direct laryngoscopy with general anesthesia using apneic technique in most patients and intubation in some was an adequate method of treating patients with laryngeal papillomata. A general anesthetic was never used where obstruction was severe and the airway could not be controlled. The low incidence of papilloma of the tracheobronchial tree and an absence of parenchymal lung seeding in this series is attributed to the avoidance of a tracheotomy and fewer intubation anesthetics thus avoiding trauma to the trachea and bronchi. The immediate removal of the tracheotomy tube seems an alternative if the surgical procedure had been performed. In the patients in this series decannulation was accomplished in a very short period of time. The establishment of an airway seems to be a priority in the treatment of this disease and this can be accomplished by repeated endoscopic procedures rather than tracheotomy. Statistics are given, and prognosis based on the type of lesion and histopathology is documented.

Intracranial Complications of Pediatric Sinusitis

OBJECTIVE: To study intracranial extension of pediatric sinusitis, an infrequent but potentially fatal complication. STUDY DESIGN AND SETTING: Ten-year retrospective review at a tertiary childrens hospital identified 21 cases of intracranial complications of sinusitis. RESULTS: Thirteen males and eight females with mean age of 13.3 years were identified. Overall 18 of 21 (81%) exhibited abscess formation, most commonly epidural. Only 3 of 21 (14%) had meningitis alone. All but 4 patients were managed surgically, requiring craniotomy in 13 of 21 (61.9%) and endoscopic sinus surgery (ESS) in 10 of 21 (48%). Seven patients (33%) required multiple operations during admission. Nineteen patients (90%) had a total of 30 organisms cultured. Oral flora was observed in 12 of 21 (57%). Polymicrobial infections, seen in 9 of 21 (43%), were significantly associated with the need for craniotomy (P = 0.02). Mean hospital stay was 15 days, and mean length of IV antibiotic was 5 weeks. CONCLUSIONS: Intracranial complications of pediatric sinusitis often require craniotomy. Oral flora and polymicrobial infections were prominent in this series. EBM rating: C-4

Juvenile arthritis and autoimmunity to type II collagen.

OBJECTIVE Joint inflammation in juvenile rheumatoid arthritis (JRA) is sometimes associated with an autoimmune response to type II collagen (CII), a cartilage-specific protein. To test the hypothesis that down-regulation of autoimmunity to CII can be accomplished in JRA by oral administration of CII, an open-label study of CII was performed in 9 patients with JRA. METHODS Seven rheumatoid factor-negative JRA patients with polyarticular disease and 2 JRA patients with pauciarticular disease (1 with early onset and 1 with late onset) were treated for 3 months with oral bovine CII. Patients were examined for disease activity and underwent routine laboratory testing at monthly intervals. Two of the patients had flares of disease when treatment was discontinued, and these patients were re-treated for an additional 3 months. To test the hypothesis that oral tolerance induces an immune deviation of T cells, peripheral blood mononuclear cells from patients were collected before and after treatment and cultured with CII. Supernatants and RNA were collected and analyzed for the presence of various cytokines. RESULTS Eight patient trials met the criteria for clinical improvement outlined by Giannini and coworkers in 1997. None of the patients had any side effects from the treatment. In 6 of the 8 patients who improved, interferon-gamma production decreased after oral CII therapy, correlating with clinical improvement, while 6 patients had increases in levels of transforming growth factor beta3. CONCLUSION These results are encouraging. The possible beneficial effect of oral CII in JRA merits further investigation.