Joseph E. Kerschner

Adenoid Reservoir for Pathogenic Biofilm Bacteria

ABSTRACT Biofilms of pathogenic bacteria are present on the middle ear mucosa of children with chronic otitis media (COM) and may contribute to the persistence of pathogens and the recalcitrance of COM to antibiotic treatment. Controlled studies indicate that adenoidectomy is effective in the treatment of COM, suggesting that the adenoids may act as a reservoir for COM pathogens. To investigate the bacterial community in the adenoid, samples were obtained from 35 children undergoing adenoidectomy for chronic OM or obstructive sleep apnea. We used a novel, culture-independent molecular diagnostic methodology, followed by confocal microscopy, to investigate the in situ distribution and organization of pathogens in the adenoids to determine whether pathogenic bacteria exhibited criteria characteristic of biofilms. The Ibis T5000 Universal Biosensor System was used to interrogate the extent of the microbial diversity within adenoid biopsy specimens. Using a suite of 16 broad-range bacterial primers, we demonstrated that adenoids from both diagnostic groups were colonized with polymicrobial biofilms. Haemophilus influenzae was present in more adenoids from the COM group (P = 0.005), but there was no significant difference between the two patient groups for Streptococcus pneumoniae or Staphylococcus aureus. Fluorescence in situ hybridization, lectin binding, and the use of antibodies specific for host epithelial cells demonstrated that pathogens were aggregated, surrounded by a carbohydrate matrix, and localized on and within the epithelial cell surface, which is consistent with criteria for bacterial biofilms.

Role of Extra-Esophageal Reflux in Chronic Otitis Media with Effusion†

Objectives/Hypothesis: Otitis media with effusion (OME) is the most common cause of childhood hearing loss. Despite its prevalence, the enormous health care expenditures resulting from its treatment, and the increasing therapeutic challenges imposed by antimicrobial resistance, very little is known regarding the cellular and molecular immunologic and inflammatory events in this disease process. Extra‐esophageal reflux (EER) has been implicated in the pathogenesis of chronic OME. The objective of this study was to confirm that children with OME have EER into the middle ear as measured by the presence of pepsin in middle ear effusions (MEE) removed during tympanostomy tube (TT) placement.

Pediatric External Auditory Canal Foreign Bodies: A Review of 698 Cases:

OBJECTIVE: The study goal was to determine the relationships between patient management factors and patient outcomes in pediatric patients with external auditory canal foreign bodies. STUDY DESIGN AND SETTING: Retrospective analysis was conducted of 698 consecutive cases of pediatric external auditory canal foreign bodies (n = 605 patients) who presented to a tertiary care pediatric referral center during a 6-year period. RESULTS: Emergency physicians frequently removed foreign bodies under direct visualization while otolaryngologists primarily used otomicroscopy. Both of these methods had high success rates overall (77% and 86%), but attempts under direct visualization had lower success rates with removing spherical objects, objects touching the tympanic membrane, and objects in the canal for more than 24 hours. Failed removal attempts resulted in higher complication rates. CONCLUSION: Certain foreign body and patient characteristics are associated with poor outcomes with removal attempts made under direct visualization. These cases should be referred directly to otolaryngologists for otomicroscopic removal.

Pediatric vocal fold paralysis after cardiac surgery : Rate of recovery and sequelae

Objective To determine the rate of recovery of pediatric vocal fold paralysis (VFP) after cardiac surgery. Study Design and Setting Retrospective case series from January 2000 to 2005 at 4 tertiary care pediatric hospitals. Results A total of 109 children with VFP were identified. Of 80 patients with follow-up >3 months, 28 (35%) recovered vocal fold function with a median time to diagnosis of recovery of 6.6 months. Fifty-two (65%) patients had persistent vocal fold paralysis with a median follow-up time of 16.4 months. Twenty-five (45%) of 55 patients demonstrated aspiration or laryngeal penetration with modified barium swallow. Twenty-nine (27%) of the 109 patients underwent surgical intervention for their airway, feeding, or voice. Conclusions Pediatric VFP is not an uncommon complication after cardiac surgery and can result in serious sequelae. This study demonstrates a 35% rate of recovery, 45% rate of aspiration, and 27% rate of complications that require surgical intervention.

Mucin Gene Expression in Human Middle Ear Epithelium

Objectives: To investigate the expression of recently identified human mucin genes in human middle ear epithelial (MEE) specimens from in vivo middle ear (ME) tissue and to compare this mucin gene expression with mucin gene expression in an immortalized cell culture in vitro source of human MEE.

Pierre Robin Sequence: Secondary Respiratory Difficulties and Intrinsic Feeding Abnormalities

Objective: There is considerable variation in opinion regarding the optimal management of patients with Pierre Robin sequence (PRS). No single method of airway intervention or feeding strategy is universally appropriate and effective. This study was performed to examine methods used for airway and feeding management and to identify specific problems encountered.

Mucin Gene Expression in Human Laryngeal Epithelia: Effect of Laryngopharyngeal Reflux

Objectives: We sought to document the mucin gene profile in normal human laryngeal epithelium and compare it with that in patients with reflux-attributed laryngeal injury or disease. We also investigated the effect of low pH with or without pepsin on mucin messenger RNA levels in vitro. Methods: Laryngeal biopsy specimens were obtained from 3 patients with clinically diagnosed laryngopharyngeal reflux and from 2 control subjects who had no signs or symptoms of reflux. Signs and symptoms were assessed by the Reflux Finding Score and the Reflux Symptom Index, respectively. Reverse transcription–polymerase chain reaction (RT-PCR) was performed to establish the mucin gene profile. Human hypopharyngeal epithelial cells were exposed to pH 7, 5, 4, and 2 with and without pepsin (0.1 mg/mL) for 20 minutes at 37°C, and expression of selected mucins was analyzed via real-time RT-PCR. Results: Mucin 1–5, 7, 9, 13, 15, 16, and 18–20 transcripts were detected in normal laryngeal epithelium, whereas mucin 6, 8, and 17 transcripts were not. Mucins 2, 3, and 5 were expressed at reduced levels in patients with reflux-attributed laryngeal injury or disease. These mucin genes were up-regulated after exposure to low pH in vitro (p < 0.005). Pepsin inhibited this up-regulation (p < 0.001). Conclusions: Reflux laryngitis is associated with down-regulation of mucin gene expression.

Reconstruction After Temporal Bone Resection

Reconstruction of soft tissue defects after temporal bone resection can vary from simple closure of the external auditory canal to complex flap coverage of extensive defects. Between 1987 and 1996, 34 patients underwent lateral skull base resections and reconstruction for invasive carcinoma of the temporal bone. Seven underwent sleeve resection and/or radical mastoidectomy. Sleeve resection was managed with tympanoplasty, canalplasty, or obliteration of the external auditory canal (10). There were 24 lateral temporal bone resections and four subtotal temporal bone resections. Larger defects created by lateral and subtotal temporal bone resections required closure with a combination of temporalis flaps and local rotational cutaneous flaps (13). Lower island trapezius flaps (five), free flaps (four), and pectoralis major flaps (two) were also used. Indications and efficacy of each method are discussed, and treatment outcomes are presented.

Uvulopalatopharyngoplasty with tonsillectomy and adenoidectomy as a treatment for obstructive sleep apnea in neurologically impaired children

RATIONALE Children with neurologic impairment often present with airway obstruction that may require intervention. No single method of airway intervention is universally appropriate and effective in this patient population. This study was performed to examine the effectiveness of using adenotonsillectomy and uvulopalatopharyngoplasty (UPPP) in resolving obstructive apnea (OA) in patients with neurologic impairment. METHODS A retrospective chart review of 15 patients with neurologic impairment and OA treated with adenotonsillectomy and UPPP between 1986 and 1998 at Childrens Hospital of Wisconsin (CHW) was performed. All patients in the series had their primary area of obstruction in the posterior oropharynx involving the soft palate, pharyngeal walls and base of tongue. Post-operative improvement following adenotonsillectomy and UPPP was examined. Measures of improvement were based primarily on recorded lowest oxygen saturations, but clinical parameters, flexible upper airway endoscopy and polysomnography were used as well. RESULTS Patient improvement was documented in 87% of patients treated with this modality. For the group, the mean lowest recorded oxygen saturation demonstrated a statistically significant improvement from 65% pre-operatively to 85% post-operatively (P = 0.005). In long-term follow-up of these patients, 77% (10 of 13) of those showing initial improvement have done well and have required no further airway intervention. However, 23% of these patients demonstrated the need for further airway intervention during follow-up. CONCLUSIONS Adenotonsillectomy with UPPP is worthy of consideration in certain neurologically impaired patients with moderate to severe OA, limited primarily to the posterior pharyngeal area. Initial improvement may not be permanent and close long-term follow-up of patients is imperative.

Mediastinitis associated with foreign body erosion of the esophagus in children

OBJECTIVE Timely and experienced intervention for esophageal foreign bodies generally allows for removal with minimal morbidity. However, esophageal foreign bodies present a risk for esophageal perforation and subsequent mediastinitis, especially if the diagnosis of the foreign body is delayed. Although much has been written about the management of esophageal foreign bodies and their complications, little has been mentioned in recent literature about the specific complication of mediastinitis. This review was performed to examine our experience with this uncommon complication of esophageal foreign bodies. METHODS A retrospective review of the esophageal foreign body database at Childrens Hospital of Wisconsin from 1987 to 1997 was performed to identify patients with esophageal foreign bodies and subsequent mediastinitis. RESULTS Four patients with esophageal perforation with associated mediastinitis secondary to retained esophageal foreign bodies were identified. Three of the four patients were treated with conservative measures consisting of foreign body removal, intravenous antibiotics and discontinuing of oral nutrition. These patients all achieved resolution of their mediastinitis and esophageal perforation with subsequent return to normal diets and no significant morbidity. One patient, with vascular erosion, required aggressive, invasive therapy. CONCLUSION From review of this limited number of patients, in the absence of major vascular erosion, conservative methods of treating children with foreign body esophageal perforation and subsequent mediastinitis appears to be effective.