John J. Manoukian

Role of toll-like receptor 4 in protection by bacterial lipopolysaccharide in the nasal mucosa of atopic children but not adults.

BACKGROUNDnExposure to bacterial products in early life could protect against development of atopy. We examined the effect of bacterial lipopolysaccharide on allergic inflammation and expression of cytokines and lipopolysaccharide receptor (toll-like receptor 4 TLR4) in nasal mucosa of 15 atopic children and ten atopic adults.nnnMETHODSnExplanted mucosa was cultured with allergen with or without lipopolysaccharide (0.1 mg/L) for 24 h. Immunocytochemistry and in-situ hybridisation were used to phenotype the cells and cytokines.nnnFINDINGSnIn explants from atopic children, lipopolysaccharide prevented allergen-induced T-helper type 2 (Th2) inflammation and upregulated Th1 cytokine reactivity and expression. These effects were blocked by antibody to interleukin 10. In children but not in adults, lipopolysaccharide caused increases of three times in T-cell reactivity, five times in T-cell proliferation, and four times in expression of interleukin 10 compared with mucosa stimulated with allergen alone. This difference in response was mirrored by lipopolysaccharide-induced increases in TLR4 reactivity in children but not adults. TLR4 receptor was expressed by CD3-positive T cells, and TLR4-positive cells contained interleukin 10. Lipopolysaccharide increased expression of cells positive for both CD3 and TLR4; both TLR4 and interleukin 10; and both CD4 and CD25.nnnINTERPRETATIONnLipopolysaccharide inhibits allergic inflammation in nasal mucosa of atopic children by skewing local immune responses from Th2 to Th1 and upregulating production of interleukin 10. These effects are mediated by TLR4. Our results emphasise an important difference between adults and children in their ability to respond to bacterial products. These differences could have a role in normal maturation of the immune system.

Do Systemic Corticosteroids Effectively Treat Obstructive Sleep Apnea Secondary to Adenotonsillar Hypertrophy

To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypertrophy (ATH) could be treated by a short course of systemic corticosteroids, we conducted an openlabel pilot study in which standardized assessments of symptomatology, OSAS severity, and adenotonsillar size were performed before and after a 5‐day course of oral prednisone, 1.1 ± 0.1(± SE) mg/kg per day. Outcome measures included symptom severity, adenotonsillar size, and polysomnographic measures of OSAS. Selection criteria included age from 1 to 12 years, ATH, symptomatology suggesting OSAS, an apnea/hypopnea index (AHI) ≥ 3/hour, and intent to perform adenotonsillectomy. Only one of nine children showed enough improvement to avoid adenotonsillectomy. Symptomatology did not improve after corticosteroid treatment but did after removal of tonsils and adenoids. Polysomnographic indices of OSAS severity did not improve after corticosteroid treatment. After corticosteroids, tonsillar size decreased in only two patients, adenoidal size was only marginally reduced, and the size of the nasopharyngeal airway was not significantly increased. These results suggest that a short course of prednisone is ineffective in treating pediatric OSAS caused by ATH.

Adenoidectomy: Selection Criteria for Surgical Cases of Otitis Media†

Objective: Nasopharyngeal adenoids may serve as a mechanical obstruction to the eustachian tube and contribute to the pathophysiology of otitis media (OM). The purpose of this study was to determine whether abutment of adenoids laterally against the torus tubaris affects the outcome of patients requiring pressure equalization tubes (PET) for OM.

Increased expression of interleukin-9, interleukin-9 receptor, and the calcium-activated chloride channel hCLCA1 in the upper airways of patients with cystic fibrosis.

Objectives/Hypothesis Mucus overproduction is commonly found in airway disease in patients with cystic fibrosis. Interleukin‐9 (IL‐9) has been shown to mediate airway hyper‐responsiveness and mucus overproduction. Recently, the calcium‐activated chloride channel hCLCA1 has been described to be upregulated by IL‐9 and has been thought to regulate the expression of soluble gel‐forming mucins. We sought to examine the expression of IL‐9, interleukin‐9 receptor (IL‐9R), and hCLCA1 in the upper airway of patients with cystic fibrosis in comparison to healthy control subjects and to demonstrate the relationship of IL‐9, IL‐9R, and hCLCA1 expression with mucus production.

Intraoral Drainage: Recommended as the Initial Approach for the Treatment of ParapHaryngeal Abscesses:

OBJECTIVE: We sought to compare the efficacy, safety, and cost of intraoral drainage (IOD) of parapharyngeal abscesses (PPAs) in the pediatric population with those of the more commonly used external neck drainage (END). PATIENTS AND STUDY DESIGN AND SETTING: An 11-year retrospective review was conducted of all patients admitted to a tertiary-care, university-affiliated, pediatric hospital with a diagnosis of PPA. Patients were divided into 2 groups according to the treatment received (IOD or END) and were followed to 1 month postoperatively. All children referred to our institution with a final diagnosis of PPA were included in the study. OUTCOME: Outcome measures were duration of anesthesia, duration of postoperative intravenous antibiotics (DPOIA), length of postoperative hospital stay (LPOHS), and occurrence of complications. RESULTS: Fifteen patients underwent IOD, and 10 patients, END. IOD shortened anesthesia time by 31.7 minutes compared with END (P = 0.0003). IOD was associated with a decrease in DPOIA and LPOHS by 1.1 days (P = 0.1931) and 1.6 days (P = 0.0649), respectively. The cost of treatment was thereby reduced. No complications were encountered in either group. CONCLUSIONS: IOD is a safe and effective treatment for PPA in the pediatric population. It leads to decreased morbidity, shortened anesthesia time, and reduced economic burden. (Otolaryngol Head Neck Surg 2004;130:676-80.)

Granular cell tumor of the trachea in a child.

Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly the tongue. They have, however, been described in all areas of the body. Their presentation in the trachea is exceedingly rare, with their presence in the pediatric trachea being an even rarer occurrence. We describe a case of a granular cell tumor of the trachea in a 10-year-old boy with a dramatic, almost lethal, presentation. This is followed by a review of the literature, including pathology and treatment options.

Hyalinizing trabecular adenoma versus papillary thyroid carcinoma in a child

Hyalinizing trabecular adenoma (HTA) of the thyroid gland is a rare, benign neoplasm predominantly diagnosed in middle-aged women. There is mounting evidence in the medical literature, however, to suggest that HTA may represent an encapsulated variant of papillary thyroid carcinoma (PTC). This report describes an unusual case of PTC in a child initially diagnosed as HTA. Establishing an accurate diagnosis has important management implications for the pediatric patient.

Pediatric temporal bone fractures: A case series

OBJECTIVESnTemporal bone fractures are relatively common findings in patients with head trauma. The aim of this study was to evaluate the characteristics of temporal bone fractures in the pediatric population.nnnSTUDY DESIGNnRetrospective case series. Tertiary care pediatric academic medical center.nnnMETHODSnThe medical records of patients aged 18 years or less diagnosed with a temporal bone fracture at the Montreal Childrens Hospital from January 2000 to August 2014 were reviewed. Patient demographics, clinical presentation, mechanism of injury and complications were analyzed. Imaging studies and audiograms were also evaluated.nnnRESULTSnOut of 323 patients presenting to the emergency department with a skull fracture, 61 presented with a temporal bone fracture. Of these, 5 presented with bilateral fractures. 47 patients had associated fractures, and 3 patients deceased. We observed a male to female ratio of 2.8:1, and the average age was 9.5 years. Motor vehicle accidents were the primary mechanism of injury (53%), followed by falls (21%) and bicycle or skateboard accidents (10%). The most common presenting signs included hemotympanum, decreased or loss of consciousness, facial swelling and nausea and vomiting. 8 patients had otic involvement on computed tomography scans, and 30 patients had documented hearing loss near the time of accident with a majority being conductive hearing loss. 17 patients underwent surgical management of intracranial pressure.nnnCONCLUSIONnIn children, fractures of the temporal bone were most often caused by motor vehicle accidents and falls. It is common for these patients to have associated fractures.

Hearing loss in pediatric temporal bone fractures: Evaluating two radiographic classification systems as prognosticators

INTRODUCTIONnTemporal bone fractures (TBF) are traditionally classified by their angle of fracture relative to the petrous ridge, and more recently by whether or not they violate the otic-capsule. This study compared rates of hearing loss (HL) and signs of otologic dysfunction among fracture types of both classification systems, within the pediatric population.nnnMETHODSnPediatric patients were retrospectively characterized from a previously identified cohort of TBF patients, diagnosed from 2000 to 2014. CT scans were reviewed and TBFs were classified first as longitudinal (L), transverse (T) or mixed (M), and then as otic-capsule sparing (OCS) or otic-capsule violating (OCV). Medical records were reviewed, and rates of HL and presenting signs were compared among L, T and M fractures, and OCS and OCV fractures.nnnRESULTSnForty-three patients with 47 TBFs met the inclusion criteria. Eighteen, 4 and 25 TBFs were classified as L, T and M fractures, respectively. Thirty-three and 9 were classified as OCS, and OCV, respectively. Among 24 cases of HL: 20, 3, and 1 were conductive HL (CHL), sensorineural HL (SNHL) and mixed HL, respectively. Two cases of SNHL were found among OCV fractures, with none in OCS fractures (estimated difference 0.22; 95% confidence interval 0.01-0.60). Similar rates of CHL were found across L, T and M fractures (range 36-50%), and across OCV and OCS fractures (range 42-44%). Hemotympanum was the most common presenting sign, found in 68% of TBFs and 80% of CHL cases. There were no significant differences in the incidence of signs or symptoms between fracture types.nnnCONCLUSIONSnIn our cohort, both the traditional and otic-capsule radiographic classification systems failed to predict the incidence of CHL and other otologic signs in the pediatric population. Though OCV fractures conferred an increased risk for developing SNHL, we found a lower incidence than anticipated given violation to the bony labyrinth.