John E. McClay

Complications of Acute Sinusitis in Children

OBJECTIVE: To review the demographic, microbiologic, and outcome data for children with complications of acute sinusitis. STUDY DESIGN AND SETTING: Retrospective review of children admitted with complications of acute sinusitis from January 1995 to July 2002 to a tertiary care childrens hospital. RESULTS: One hundred four patients were reviewed with the following complications: orbital cellullitis (51), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis (1), and Potts puffy tumors (3). Sixty-six percent were males (P < 0.001), and 64.4% presented from November to March (P < 0.001). Patients with isolated orbital complications were younger than patients with intracranial complications (mean, 6.5 versus 12.3 years), had a shorter stay (mean, 4.2 versus 16.6 days), and had shorter duration of symptoms (mean, 5.4 versus 14.3 days; all P < 0.0001). Complete resolution was documented for 54/55 patients with restricted ocular motility, 7/8 with visual loss, 3/3 patients with a nonreactive pupil, 7/7 with neurological deficits, and 2/4 with seizures. The most common organism isolated was Streptococcus milleri (11/36 patients with surgical cultures). No mortalities occurred, and persistent morbidity occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits on presentation, permanent morbidity was low. Streptococcus milleri is a common pathogen with complications of sinusitis in children.

Evaluation of Pediatric Sensorineural Hearing Loss With Magnetic Resonance Imaging

OBJECTIVE To evaluate the incidence and type of intracranial and inner ear abnormalities in children with sensorineural hearing loss (SNHL) identified with magnetic resonance imaging (MRI) and stratified by the degree and type of SNHL. DESIGN Retrospective review of medical records and MRIs. SETTING Tertiary care childrens hospital. PATIENTS A total of 227 children aged 1 month to 17 years (mean age, 5.3 years; male to female ratio, 1:1) with a diagnosis of SNHL underwent MRI from June 1,1996, to June 1, 2002. Of these children, 170 had clinical information available and technically adequate MRIs and were included in the study. INTERVENTION Magnetic resonance imaging. MAIN OUTCOME MEASURE Identification of an abnormality of the intracranial contents, inner ear, and cochlear nerve. RESULTS Of the 170 children, 101 (59%) had bilateral SNHL and 69 (41%) had unilateral SNHL, comprising 271 ears with SNHL. Abnormalities of the inner ear were found in 108 ears (40%) with 87 (32%) having abnormalities of the cochlea, which were considered mild in 63 (23%) and moderate to severe in 24 (9%). Forty-nine of 271 ears (18%) with SNHL demonstrated an either absent (26/49 [53%]) or deficient (23/49 [47%]) cochlear nerve. Ears with severe and profound SNHL had more abnormalities than ears with mild and moderate SNHL (66/138 [48%] vs 23/80 [29%]; P = .006), and children having ears with unilateral moderate, severe, or profound SNHL had more inner ear abnormalities than children with bilateral moderate, severe, or profound SNHL (28/45 [62%] vs 54/144 [38%]; P = .004). CONCLUSIONS The overall incidence of inner ear abnormalities in ears of children with SNHL evaluated by MRI is 40%. The most common abnormalities seen were an abnormal cochlea and abnormal cochlear nerve. Children with severe and profound SNHL have a greater percentage of inner ear anomalies than children with mild or moderate SNHL. Children with unilateral hearing loss have a greater percentage of inner ear anomalies than children with bilateral SNHL.

HspE7 treatment of pediatric recurrent respiratory papillomatosis: Final results of an open-label trial

Objectives: We sought to evaluate the effectiveness of HspE7, a recombinant fusion protein of Hsp65 from Mycobacterium bovis BCG and E7 protein from human papillomavirus 16, to improve the clinical course of pediatric patients with recurrent respiratory papillomatosis. Methods: An open-label, single-arm intervention study was conducted in 8 university-affiliated medical centers. Twenty-seven male and female patients with recurrent respiratory papillomatosis, ages 2 to 18 years, were enrolled and followed up to 60 weeks. Before enrollment, these patients required surgery on average every 55 days. After a baseline debulking surgery, the patients received HspE7 500 μg subcutaneously monthly, for 3 doses over 60 days. The primary end point was the length of the interval from the last surgery during the treatment period until the first debulking surgery in the posttreatment period, compared with the median intersurgical interval (ISI) of the 4 surgeries before the treatment. Results: The mean of the first posttreatment ISI increased 93% (from 55 days to 106 days; p < .02). The median ISI for all surgeries after treatment was similarly prolonged (mean, 107 days; p < .02), indicating a sustained treatment effect, and was associated with a significant decrease in the number of required surgeries (p < .003). Unexpectedly, the treatment effect was most striking in the 13 female patients, who had statistically significant increases in both the first posttreatment ISI (142%; p < .03) and the median ISI (147%; p < .03). The most common adverse events were mild-to-moderate injection site reactions. Conclusions: Treatment with HspE7 appears to significantly improve the clinical course in pediatric patients with RRP insofar as it reduces the frequency of required surgeries. These results warrant a confirmatory phase III trial.

Age of Child, More than HPV Type, Is Associated with Clinical Course in Recurrent Respiratory Papillomatosis

Background RRP is a devastating disease in which papillomas in the airway cause hoarseness and breathing difficulty. The disease is caused by human papillomavirus (HPV) 6 or 11 and is very variable. Patients undergo multiple surgeries to maintain a patent airway and in order to communicate vocally. Several small studies have been published in which most have noted that HPV 11 is associated with a more aggressive course. Methodology/Principal Findings Papilloma biopsies were taken from patients undergoing surgical treatment of RRP and were subjected to HPV typing. 118 patients with juvenile-onset RRP with at least 1 year of clinical data and infected with a single HPV type were analyzed. HPV 11 was encountered in 40% of the patients. By our definition, most of the patients in the sample (81%) had run an aggressive course. The odds of a patient with HPV 11 running an aggressive course were 3.9 times higher than that of patients with HPV 6 (Fishers exact p = 0.017). However, clinical course was more closely associated with age of the patient (at diagnosis and at the time of the current surgery) than with HPV type. Patients with HPV 11 were diagnosed at a younger age (2.4y) than were those with HPV 6 (3.4y) (p = 0.014). Both by multiple linear regression and by multiple logistic regression HPV type was only weakly associated with metrics of disease course when simultaneously accounting for age. Conclusions/Significance Abstract The course of RRP is variable and a quarter of the variability can be accounted for by the age of the patient. HPV 11 is more closely associated with a younger age at diagnosis than it is associated with an aggressive clinical course. These data suggest that there are factors other than HPV type and age of the patient that determine disease course.

Antibiotic therapy for nontuberculous mycobacterial cervicofacial lymphadenitis

Objectives/Hypothesis: To evaluate the efficacy of antibiotic treatment of nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis, both as an alternative and as adjuvant to surgical excision.

Clinical Presentation of Allergic Fungal Sinusitis in Children

Objective To compare the differences in the clinical and radiographic presentation of allergic fungal sinusitis in children and adults.

Chloroma of the masseteric muscle

Chloroma (leukemic infiltrate or granulocytic sarcoma) is a localized extramedullary mass of immature granulocytic cells. They are uncommon tumors that usually occur in patients with leukemia, mostly of the myeloid type. Involvement in the head and neck region is rare. Granulocytic sarcomas of the face, maxilla, paranasal sinuses, temporal bone, and pharynx have all been documented in the past. We present the first reported case of a granulocytic sarcoma involving the masseteric muscle in an 8-month-old white male diagnosed with acute myeloid leukemia (AML). The lesion resolved with chemotherapy but the patient subsequently died. This case reaffirms the importance of including chloroma in the differential diagnosis of lesions in patients with AML and the prognostic value they hold.

The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses

OBJECTIVES: To examine the incidence of methicillin-resistant Staphylococcus aureus (MRSA) in pediatric neck abscesses and compare these with abscesses caused by methicillin-susceptible Staphylococcus aureus (MSSA) and other organisms (non-SA). STUDY DESIGN: Retrospective review of 245 children who underwent incision and drainage of neck abscesses from January 1, 2001, to December 1, 2005. RESULTS: The yearly incidence of MRSA increased from 9 percent to 40 percent during the study period. Abscesses in medial locations were less common in the MRSA group (P < 0.01) and MSSA group (P < 0.001) compared with the non-SA group. Average patient ages were MRSA 18.9 months, MSSA 18.7 months, and non-SA 47.6 months. Complication rates were MRSA 8 percent, MSSA 5 percent, and non-SA 5 percent. CONCLUSIONS: The incidence of MRSA in pediatric neck abscesses is increasing dramatically. MRSA and MSSA usually infect younger patients in the lateral locations. Clinical courses were similar in all groups.

Pedunculated Neurilemmoma of the Tongue Base

Aneurilemmoma, also referred to as a schwannoma or neurimoma, is a benign, encapsulated tumor of the Schwann cells of the nerve sheath. Of the extracranial neurilemmomas, 25% affect the head and neck, with the lateral cervical region and mouth being the most common sites. Intraoral neurilemmomas may arise from both soft tissue and bone. The soft tissue lesions usually present as an asymptomatic, submucosal swelling in the tongue, lip, cheek, and palate. We report the case of a 9-year-old boy who presented with a symptomatic, exophytic, and pedunculated lesion at the tongue base, appearing papillomatous. Complete excision and pathologic evaluation revealed a neurilemmoma.

Endoscopic Cauterization of Congenital Pyriform Fossa Sinus Tracts: An 18-Year Experience

IMPORTANCE Congenital pyriform fossa sinus tracts predispose to neck masses and neck abscesses in pediatric and occasionally adult patients. Traditional management involves open excision with substantial potential morbidity. Endoscopic management allows an alternative, less morbid treatment approach. OBJECTIVE To evaluate the long-term effectiveness of endoscopic cauterization as definitive treatment for pyriform fossa sinus tracts. DESIGN, SETTING, AND PATIENTS Retrospective review of the medical records of 23 children (aged 7 months to 14 years) with pyriform fossa sinus tracts treated with endoscopic cauterization between 1995 and 2013 at a tertiary care childrens hospital. INTERVENTION Endoscopic electrocauterization of pyriform fossa sinus tract opening. MAIN OUTCOMES AND MEASURES Recurrence of symptoms after endoscopic treatment. RESULTS Twenty-one of 23 patients experienced no recurrence after their first endoscopic electrocauterization of the sinus tract. The 2 patients with recurrence experienced symptoms within 1 month of cauterization and were treated with either open excision or recauterization. Endoscopic cauterization was able to definitively treat 9 patients whose treatments with incision and drainage or open excision had failed. Mean (range) follow-up for the 15 patients with follow-up was 7.4 (0.10-14.2) years. No procedure-related morbidity was reported. CONCLUSIONS AND RELEVANCE Endoscopic cauterization seems to be an effective and potentially permanent treatment for congenital pyriform fossa sinus tracts.