John S. Supance

Perilymph Fistulas in Infants and Children

During the years 1975 through 1981 we performed exploratory tympanotomies on 33 infants and children (44 ears) to verify the presumptive diagnosis of perilymph fistula (PLF). A PLF was identified at the round window, oval window, or both in 29 (66%) of the 44 ears explored. After surgery hearing was unchanged in 86%, improved in 5%, and worsened in 9% of the ears in which PLFs had been observed. Complaints of vertigo subsided in all children in whom a PLF was repaired. Preoperative factors determined to be highly suggestive of the presence of a PLF included the following: sudden onset of sensorineural hearing loss (SNHL), congenital deformities of the head, and abnormal findings on tomograms of the temporal bones, especially Mondini-like inner ear dysplasias. Middle ear abnormalities (primarily congenital) were observed in 20 of the 44 ears. Abnormal results of preoperative vestibular function studies, which included a fistula test, and sex were not consistently found to be associated with an observed PLF at tympanotomy.

Antibiotics and Steroids in the Treatment of Acquired Subglottic Stenosis A Canine Model Study

The efficacy of a combination of systemic antibiotics and a steroid in the prevention of acquired subglottic stenosis (ASGS) was evaluated employing a previously developed canine animal model. Thirty-five healthy, postweanling mongrel puppies aged 5 weeks were each intubated for 14 days with an uncuffed polyvinyl endotracheal tube. Twenty puppies received intramuscular dexamethasone (1 mg) daily, and procaine penicillin (100,000 IU) and dihydrostreptomycin (0.125 g) in two divided doses on the day of intubation and each day thereafter until the completion of the study. The remaining 15 puppies served as a control group and received no medical therapy. Animals from both groups were killed at 5, 7, 12, 15, 20, 30, and 56 days following intubation. Comparative examinations of the laryngotracheal complexes of treated and control dogs showed that there was no significant difference between the two groups in the ultimate degree of ASGS attained, as determined by intraluminal cross-sectional area analysis, or in the extent of the lesion as documented by gross and microscopic histology. This investigation showed that the specific systemic combination of two antibiotics and a steroid used in the study was not efficacious in the prevention of ASGS in a canine animal model; for this reason we question the benefit of analogous medical regimens employed to prevent ASGS in infants and children who require long-term endotracheal intubation.

An Animal Model of Acute Otitis Media Consequent to β-Lactamase-Producing Nontypable Haemophilus Influenzae

A chinchilla model of acute otitis media with effusion consequent to β-lactamase-producing nontypable Haemophilus influenzae was developed using the method of direct inoculation of 145 colony-forming units (CFU) or 252 CFU of β-lactamase—producing nontypable H influenzae into the right superior bullae of 40 chinchillas. The course of the disease was documented longitudinally by otomicroscopy, tympanometry, and periodic culturing of the middle ears. Onset of the disease occurred in 100% of the animals between two and six days postinoculation and resolution was complete in all ears by day 36. Results of rechallenge with the same organism support the combined effect of a local and weaker systemic middle ear protective mechanism rendering resistance to reinfection with a homologous organism in the chinchilla.

Longitudinal Study of the Efficacy of Ampicillin in the Treatment of Pneumococcal Otitis Media in a Chinchilla Animal Model

A chinchilla animal model was used to determine the effects of early antibiotic treatment with ampicillin on the local and systemic protective mechanisms during pneumococcal acute otitis media with effusion (AOME). The right bullae of 74 chinchillas were inoculated with 170 colony-forming units (CFU) of Streptococcus pneumoniae type 7F, and animals were randomly assigned to 1 of 2 groups; early (24 hours postinoculation) and late (12 days postinoculation) initiation of ampicillin treatment. During the first challenge, 52 chinchillas died within a I-month period, apparently from suppurative complications of AOME. Following the resolution of AOME in their right ears, all surviving animals were challenged for the second time by bilateral bullar inoculations using 130 CFU of the same organism. All 10 animals in the early ampicillin treatment group developed severe bilateral AOME, whereas only 3 of the 12 animals in the late ampicillin treatment group developed a recurrence of AOME in the right ear. Significantly, 8 of the 12 animals in this group developed severe left AOME. These findings suggest the presence of a local middle ear defense system and support the results of previous similar studies in which S pneumoniae types 3 and 6A were used. The results of the present study also suggest that in the chinchilla the early administration of a systemic antibiotic (ampicillin) interferes with this defense mechanism.

Craniofacial resection for ethmoid carcinoma in children.

The combined craniofacial resection is a well-established method of managing invasive primary malignant nasoethmoidal disease in adults, and serves as an excellent surgical technique for the en bloc eradication of these lesions [6]. The nasoethmoid region is a relatively uncommon site for the development of primary carcinoma. Less than 3% of cancers involving the adult upper aerodigestive system arise in this area [11,13]. Because similar lesions occur in the pediatric population even less frequently, there has been little opportunity to gain the knowledge necessary to develop a standardized treatment of this disease in children. We report the use of a combined therapeutic regimen consisting of cobalt-60 radiotherapy, surgery and chemotherapy, to manage a primary malignant undifferentiated carcinoma of the ethmoid complex in an adolescent. Since the initiation of treatment at the Cincinnati Childrens Hospital, the child has remained free of tumor for 24 months. The techniques of craniofacial resection for the removal of certain tumors in the nasoethmoid complex of adults may be easily adapted for use in the pediatric population, and should be included in the surgical armamentarium of the otolaryngologist providing this type of health care for children.

1044 LOCAL PROTECTION OF THE MIDDLE EAR DURING RECURRENT OTITIS MEDIA

A series of longitudinal studies of otitis media secondary to three strains of bacterial pathogens were conducted in the chinchilla animal model in order to define the importance of local and systemic mechanisms for the protection of the middle ear. The three strains of bacteria used were: Streptococcus pneumoniae type 6A and type 7F, and β-lactamase producing non-typable Haemophilus influenzae. Initially, the bacteria were inoculated unilaterally into the epitympanic bulla. Following the resolution of the induced otitis media with effusion, bacterial challenges were repeated ipsilaterally and contralaterally. Middle ear condition was assessed employing otomicroscopy, tympanometry and periodic direct inspection and culture. The results for the three strains of bacteria were similar. The ipsilateral middle ear was resistant to subsequent infection whereas the contralateral middle ear evidenced a disease course similar to that induced by the initial challenge. Thus resistance to subsequent infection appears to be a local phenomenon with little systemic participation.