Jorge Spratley

Acute mastoiditis in children: review of the current status

BACKGROUND acute mastoiditis is the most common intratemporal complication of otitis media. Its management is still a challenge due to potentially serious consequences. This study was designed to evaluate the recent experience with pediatric acute mastoiditis at our institution and to determine if the incidence of this entity is changing over time. MATERIAL AND METHODS retrospective review of records of children with acute mastoiditis treated at the hospital of the Medical School at the University of Porto, Portugal, between July 1993 and June 1998. Criteria for the diagnosis of acute mastoiditis were postauricular swelling and erythema, protrusion of the auricle, and evidence of co-existent or recent otitis media. RESULTS 43 patients fulfilled the entry criteria. Most were boys (69%). Ages ranged from 8 months to 14 years and 4 months; infants represented 40% of the total. Acute mastoiditis was the first recognized sign of otitis media in 48% of patients. More recent years of the study saw an increase in the number of children referred with acute mastoiditis. Upon admission, 56% were under antibiotic treatment, with an average intake of 5.8 days. All patients were hospitalized; 26 cases recovered after intravenous antibiotics plus myringotomy, and the rest required an additional surgical procedure. The most common organisms recovered from cultures were Streptococcus pneumoniae and Streptococcus pyogenes. In our series, associated complications occurred in 13.9%; facial paralysis in one, and involvement of the central nervous system in five. CONCLUSIONS pediatric acute mastoiditis continues to be a potentially dangerous infection in the antibiotic era. The incidence of this complication may be increasing recently in the community studied. Great care is required of clinicians to reach an early diagnosis in order to promote adequate management and prevent inherently severe complications.

Topical Ascorbic Acid Reduces Myringosclerosis in Perforated Tympanic Membranes a Study in the Rat

Myringosclerosis, a common finding after myringotomy, has been recently associated with an increased production of oxygen free radicals. Ascorbic acids proposed actions include collagen synthesis, antioxidation, and free radical scavenging. The effects of topical ascorbic acid on healing tympanic membranes were studied. Particular attention was given to detecting the presence of myringosclerosis. Twelve Sprague-Dawley rats were bilaterally myringotomized. Their ears were randomized into group A, which received topical ascorbic acid in Gelfoam, group B, which received topical saline solution in Gelfoam, and group C, which received no treatment. The tympanic membranes were harvested on day 13, after routine otomicroscopy. Under light microscopy, the connective tissue layer of the untouched side of the pars tensa was distinctly thicker in group A than in group B or group C. At this level, the extent of sclerotic lesions was significantly less in the ascorbic acid—treated group. It is inferred that topical ascorbic acid reduces the occurrence of myringosclerosis following tympanic membrane perforations in the rat.

Tracheal resection with primary anastomosis: 10 years experience

OBJECTIVE The aim of the study was to review clinical, imagiologic, and surgical outcomes of tracheal resection in the management of laryngotracheal stenosis. METHODS The study used a retrospective analysis of adult patients managed in a tertiary academic hospital who underwent thyrotracheal, cricotracheal, or tracheal end-to-end anastomosis between 1997 and 2006. RESULTS Twelve patients, aged 15 to 79 years old, were included. Prolonged tracheal intubation was the leading cause of stenosis (11 patients) that was classified according to Myer-Cotton (Ann Otol Rhinol Laryngol. 1994;103:319-323) classification as follows: grade II (25%), grade III (58%), and grade IV (17%). The stenosis extension ranged from 1 to 6 cm. Surgeries varied from tracheal end-to-end anastomosis (n = 5), cricotracheal anastomosis (n = 4), and thyrotracheal anastomosis (n = 3). Extubation was achieved in 11 patients (92%). One patient maintains a T tube stent. The most common complication was the presence of granulation tissue in the anastomosis region (33%). There was no mortality associated. CONCLUSIONS Tracheal resection with primary anastomosis appears to be a successful and safe procedure mainly due to its high decannulation rate and few complications associated.

Evolving Indications for the EXIT Procedure: The Usefulness of Combining Ultrasound and Fetal MRI

The EXIT procedure (EX utero Intrapartum Treatment) encompasses a multidisciplinary approach to situations in which airway obstruction is anticipated. Uteroplacental circulation is maintained to avoid neonatal hypoxemia while intubation is attempted. Not only is it useful in congenital diaphragmatic hernia with intrauterine tracheal occlusion, but new indications have been proposed. We present two cases in which EXIT procedure was adopted (huge cervical mass with tracheal compression and a highly vascularized cephalocervical mass) for the same purpose on different grounds. Our two cases stress once more the importance of combining fetal ultrasound and magnetic resonance imaging in the characterization of cervical masses and its usefulness in programming the procedure with a multidisciplinary team.

Tympanic membrane vessel revisited: a study in an animal model.

Hypothesis The present study aimed at elucidating whether there are blood vessels in the semitransparent portion of the tympanic membrane. Background The normal semitransparent portions of pars tensa show strikingly few, small-caliber vessels under the otomicroscope. The major portion of a pars tensa seems to be devoid of blood vessels. In inflammatory conditions of the middle ear, the vascular pattern of the tympanic membrane is dramatically altered, and blood vessels traversing the pars tensa can be discernable. Methods The study was performed in rats with healthy tympanic membranes and in tympanic membranes obtained from animals with purulent otitis media evoked by inoculation of Str. pneumoniae. The tympanic membrane vessels were dilated by injection of adenosin, and directly afterwards the animal was perfused with china ink. Vessels were also revealed by immunohistochemistry with antibodies for Thy-1 and the von Willebrand factor as well as by detection of carbon particles at an ultrastructural level. Results Adenosin caused a marked dilation of the mallear and annular vessels. However, no preexisting vasculature was revealed in the normally transparent portions of the pars tensa except single vessels in the posterior quadrant and in the lower quadrants. In Str. pneumoniae–induced acute otitis media, the tympanic membrane thickened, bulged, and discolored. Even then, at 12 hours after inoculation, no vessels could be distinguished in the normally transparent portions of the tympanic membrane. However, at 4 and 7 days of acute purulent otitis media, vessels developed in those areas, most probably through ingrowth of newly formed vessels. Conclusion The results support the view that the semitransparent portions of the pars tensa lack vascularity. In inflammation, new vessels are formed in pars tensa to meet the demand for an increased blood supply.

Early Structural Tympanic Membrane Reactions to Myringotomy: A Study in an Acute Otitis Media Model

Myringotomy (Myr) is one of the most frequently performed surgical procedures in children. However, events occurring in the early phases, i.e. a matter of hours, following Myr in the acute otitis media (AOM) model have not been described. The aim of the present study was to evaluate the early otomicroscopic and histopathologic reactions of the tympanic membrane (TM) after Myr during the course of AOM (AOM-Myr). The left tympanic bulla from 36 healthy Sprague-Dawley rats was inoculated with Streptococcus pneumoniae type 3. Forty-eight h later, at Day 0, 4 randomized animals were immediately sacrificed and the remaining animals were treated with bilateral Myr. Otomicroscopy and sacrifices were performed in series of 4 animals at 3, 6, 9, 12, 24 and 48 h, and 4 and 7 days. The AOM-Myr TMs were compared to non-infected Myr TMs (non-AOM-Myr). The TMs were then dissected free and routinely processed for light and electron microscopy. AOM developed in all inoculated ears at Day 0. In the pars tensa of the AOM-Myr TMs the reaction of the keratinocyte layer of the perforation border was already evident at 6 h. The lamina propria exhibited a strong inflammatory reaction, which became more organized from 12 h onwards. At Day 4 the perforations were closed in three-quarters of cases. At Day 7 all perforations were healed with a distorted scar. In the non-AOM Myr TMs a strong degranulation of mast cells and edema were found in the pars flaccida at 6 h. A keratin spur at the perforation border was not seen until 24 h. All perforations were patent on Day 7 and myringosclerotic deposits were abundant in these TMs. The infected TMs regenerated faster and closed their perforations at an earlier stage. These findings favor the hypothesis that there is a low risk of chronic perforations when myringotomizing AOM TMs.

Panel 3: Recent Advances in Anatomy, Pathology, and Cell Biology in Relation to Otitis Media Pathogenesis

Background and Objectives The pathogenesis of otitis media (OM) involves a number of factors related to the anatomy, pathology, and cell biology of the middle ear, the mastoid, the Eustachian tube, and the nasopharynx. Although some issues of pathogenesis are fairly well established, others are only marginally indicated by current knowledge, and yet others remain undisclosed. The objective of this article is to provide a state-of-the-art review on recent scientific achievements in the pathogenesis of OM, as related to anatomy, pathology, and cell biology. Data Sources PubMed, Ovid Medline, and Cochrane Library. Review Methods Articles published on the pathogenesis of OM and the anatomy, pathology, and cell biology of the middle ear, the mastoid, the Eustachian tube, and the nasopharynx between January 2007 and June 2011 were identified. Among almost 1900 abstracts, the authors selected 130 articles for full article review and inclusion in this report. Results New knowledge on a number of issues emerged, including cell-specific expression and function of fluid transportation and innate immune system molecules, mucous cell metaplasia, mucin expression, bacterial adherence, and epithelial internalization, as well as the occurrence, composition, dynamics, and potential role of bacterial biofilm. In addition, the potential role of gastroesophageal reflux disease and cigarette smoke exposure has been explored further. Conclusions and Implications for Practice Over the past 4 years, considerable scientific progress has been made on the pathogenesis of OM, as related to issues of anatomy, pathology, and cell biology. Based on these new achievements and a sustained lack of essential knowledge, suggestions for future research are outlined.

Panel 8 Complications and Sequelae

Background and Objectives Although serious complications of otitis media (OM) such as brain abscess are rare, sequelae of OM such as tympanic membrane perforation and atelectatic tympanic membrane are quite common. Inner ear sequelae can cause hearing loss and speech and language problems. The objectives of this article are to provide a state-of-the-art review on recent articles on complications and sequelae of OM in different anatomic locations, from the tympanic membrane to intracranial sites, as well as hearing loss and speech and language development. Data Sources Primarily PubMed supplemented by Ovid MEDLINE and the Cochrane Database. Review Methods All types of articles related to OM complications and sequelae published in English between January 2007 and June 2011 were identified. A total of 127 relevant quality articles are summarized and included in this report. Results Key findings are summarized based on the following major anatomic locations and categories: tympanic membrane; cholesteatoma; ossicular problems; mucosal sequelae; inner ear sequelae; speech and language development; extracranial areas, including mastoiditis and facial nerve paralysis; intracranial complications; and future research goals. New information and insights were gained to prevent complications and sequelae. Conclusion and Implications for Practice Over the past 4 years, progress has been made in advancing the knowledge on the complications and sequelae of OM, which can be used to prevent and treat them effectively. Areas of potential future research have been identified and outlined.

Parapharyngeal abscess in children: five year retrospective study

UNLABELLED Lateropharyngeal and retropharyngeal abscesses are potentially life threatening infections in children AIM To review the etiologic, clinical, and imaging signs of lateropharyngeal and retropharyngeal abscesses in children as well as treatment-outcomes and complications using a surgical trans-oral approach. METHOD Retrospective analysis of 11 children, hospitalized in the last 5 years, with a diagnosis of lateropharyngeal (n = 8) and retropharyngeal (n = 3) abscesses, ages ranging from 0 to 12 years old. Charts and CT scans were reviewed. RESULT The average age of presentation was 3.3 years. Neck stiffness (64%) and odynophagia (55%) were the most common symptoms. Fever (64%), stiff neck (64%), bulging of the oropharyngeal wall (55%), mass in the neck (55%) and lymphadenopathy (36%) were the most prevalent physical findings. All these patients were submitted to surgical drainage using a trans-oral approach in the first 48 hours after admission. About 82% of the patients showed improvement after 48 hours, and 100% after 72 hours, without any complications. CONCLUSION Based on the good clinical outcomes and low incidence of complications, the present study suggests that antibiotic therapy complemented with a timely surgical treatment, is a valid treatment option in refractory parapharyngeal abscesses.

Myringotomy Delays the Tympanic Membrane Recovery in Acute Otitis Media: A Study in the Rat Model†

Background/Hypothesis Acute otitis media is a major cause of visits to pediatric health care providers. Myringotomy in uncomplicated acute otitis media is debatable today. The study addressed this problem through the otomicroscopic and histopathological observations of the events occurring in the tympanic membrane during the first week after myringotomy.