Kuo-Sheng Lee

Solitary maxillary central incisor and congenital nasal pyriform aperture stenosis

Abstract Solitary maxillary central incisor (SMCI) and congenital nasal pyriform aperture stenosis (CNPAS) have been reported as an isolated morphogenic defect or associated with pituitary deficiency, holoprosencephaly, ocular coloboma, or chromosomal abnormalities. We report two cases and analyse 40 cases of SMCI and 24 cases of CNPAS, including 15 cases of combined SMCI and CNPAS, obtained from the literature. Of the patients with SMCI, 69% had short stature, 48% growth hormone deficiency or hypopituitarism, 23% pituitary absence or hypoplasia, and 17% had del (18p-) or r(18). Of the patients with CNPAS, 63% had SMCI, 75% were short, 43% had hypopituitarism or growth hormone deficiency, 36% had pituitary or CNS anomaly, and 33% had del (18p), r(18), or del (13q). Conclusions Solitary maxillary central incisor and congenital nasal pyriform aperture stenosis can be a diagnostic clue to pituitary hypofunction, CNS, ophthalmological and cytogenic anomalies.

Acute suppurative thyroiditis in children.

Background. Acute suppurative thyroiditis in children is rare and is often related to a pyriform sinus fistula or thyroglossal duct remnant, especially when it is recurrent. Methods. From January, 1985, through December, 2000, 15 children with acute suppurative thyroiditis were treated. Their clinical, laboratory and radiologic findings were reviewed and analyzed. Results. There were 8 girls and 7 boys, with a mean age at diagnosis of 6.1 ± 2.9 years (range, 1.5 to 9.8). A thyroid mass was present on the left in 13 and on the right in 2 (P < 0.05). Fever, neck pain and swelling were the most common symptoms and signs. Seven patients (46.7%) had recurrent disease. Needle aspiration for Gram stain and bacterial cultures were done, and pathogenic organisms were identified on culture in 8 patients but were found only on Gram stain in 2 patients. In one-half of the patients with positive cultures, mixed pathogens were found. The most common organisms isolated were streptococcal species (50%). Barium esophagography was performed in all patients, and 5 (33.3%) had a pyriform sinus fistula on the left. Only 1 of the recurrent patients had a fistula. Thyroid scans were performed in 13 patients, of whom 12 (92.3%) had decreased radioactive uptake. Thyroid function tests were normal in all 15. Conclusions. Acute suppurative thyroiditis is usually caused by oropharyngeal flora, resulting in mixed pathogens on culture. Broad spectrum antibiotics should be given once cultures have been obtained. Imaging studies might be helpful in the diagnosis of acute suppurative thyroiditis.

Management of foreign body ingestion in children: experience with 42 cases.

Ingestion of foreign bodies occurs frequently in children, but there are no definite management guidelines. We reviewed 42 pediatric cases of accidental ingestion of foreign bodies with or without symptoms during the past 10 years. In decreasing order of frequency, the foreign bodies included: coins, sharp objects (needle, pin), bones (fish and chicken bone), metal object, food, seeds, plastic material, magnets, jewelry ring, and others. The majority of children were 5 years old or younger. At the time of presentation, the vast majority of objects were located in the esophagus. Sixty percent of the patients had symptoms, such as abdominal pain, vomiting and cough. Management included observation, esophagoscopy, panendoscopy, and laparotomy. Four patients (9.5%) had complications. One patient who ingested a magnet suffered from esophageal perforation with mediastinitis. Two had deep neck abscess due to esophageal penetration by bones. Another patient had hemorrhagic gastritis after swallowing a coin. All patients discharged after treatment, and none died.

Pseudomonas aeruginosa sepsis with ecthyma gangrenosum and pseudomembranous pharyngolaryngitis in a 5-month-old boy

Pseudomonas aeruginosa infection that induced pseudomembranous laryngopharyngitis and ecthyma gangrenosum simultaneously in a healthy infant is rare. We reported on a previously healthy 5-month-old boy with initial presentation of fever and diarrhea followed by stridor and progressive respiratory distress. P. aeruginosa sepsis was suspected because ecthyma gangrenosum over the right leg was found at the emergency department, and the diagnosis was confirmed by the blood culture. Fiberscope revealed bacterial pharyngolaryngitis without involvement of the trachea. Because of early recognition and adequate treatment, including antimicrobial therapy, noninvasive ventilation, incision, and drainage, he recovered completely without any complications.

Epidemiological and microbiological characteristics of culture-proven acute otitis media in Taiwanese children

BACKGROUND/PURPOSE Acute otitis media (AOM) is one of the most common diseases in children. Here, we describe the epidemiological and microbiological characteristics of AOM in Taiwanese children over a 10-year period. METHODS We retrospectively enrolled pediatric patients with culture-proven AOM who were treated at Mackay Memorial Hospital, Taipei between 1999-2008. The data include demographic characteristics, clinical history, and microbiological characteristics. RESULTS Six hundred and fourteen patients were included. The male:female ratio was 1.4 (p<0.001). Greater than three-fourths of the patients (476 [77.5%]) were < 5 years of age, and most patients were 1-2 years of age. The most common isolated pathogen was Streptococcus pneumoniae (419 patients [68.2%]), followed by nontypeable Haemophilus influenzae (NTHi; 118 patients [19.2%]). The distributions of age, gender, use of tympanocentesis, history of previous AOM, and use of antibiotic between patients infected with the two pathogens were not significantly different. However, the number of patients with AOM caused by S. pneumoniae, but not NTHi, decreased during the study period (p=0.004). Three hundred and eighty-seven children (63.0%) with AOM developed spontaneous otorrhea. Compared with patients who underwent tympanocentesis, those with spontaneous otorrhea were younger (27.0±16.4 vs. 31.1±15.2 months of age, p=0.004), more likely to have a previous history of AOM (p=0.019), and more likely to receive more antibiotics (p=0.012). The third most common pathogen was S. pyogenes (25 patients [4.1%]). S. pyogenes occurred more often in children > 5 years of age and was associated with spontaneous otorrhea (p<0.001). CONCLUSION S. pneumoniae and NTHi are common causes of culture-confirmed AOM in Taiwanese children. Although S. pyogenes is not as common, it usually causes AOM in children > 5 years of age and is associated with spontaneous otorrhea.

Bacterial etiology of acute otitis media in the era prior to universal pneumococcal vaccination in Taiwanese children

BACKGROUND Acute otitis media (AOM) is one of the most frequent bacterial infections in children. Streptococcus pneumoniae and nontypeable Haemophilus influenzae (NTHi) are the two major bacterial pathogens. Pneumococcal conjugate vaccine was introduced into Taiwan in 2005 and only some children were vaccinated. This retrospective study assessed the bacterial etiology of AOM and its antimicrobial susceptibility in the era prior to universal pneumococcal vaccination in Taiwan. METHODS From December 2009 to November 2011, children presenting with AOM and having a middle ear effusion sample collected by tympanocentesis were enrolled. The study period was divided into two parts. Demographic data of patients and antibiotic susceptibility of the pathogens were collected and analyzed. Serotypes of S. pneumoniae were identified. RESULTS Among the 151 episodes, 46% of samples found bacterial pathogens. S. pneumoniae and NTHi were the leading causes of AOM, detected in 55.7% and 22.9% of bacterial AOM episodes, respectively. The prevalent serotypes of S. pneumoniae were 19 A and 19 F. Significantly more pneumococcal and serotype 19 A AOM were found in the later study period (18.4% vs. 33.3%, p = 0.0036; 10.5% vs. 24.0%, p = 0.028). Among the 39 S. pneumoniae isolates, 11 strains (28.2%) were penicillin-susceptible. Of the 16 NTHi, 10 (62.5%) were susceptible to amoxicillin/clavulanate and all were susceptible to cefotaxime. CONCLUSION S. pneumoniae and NTHi were the leading causes of AOM in Taiwanese children in the study period. An increase in patient numbers and proportion of pneumococcal and serotype 19 A AOM occurred. Antimicrobial nonsusceptibility was common in the predominant pathogens.

Mondini Dysplasia Presenting as Otorrhea without Meningitis

Mondini dysplasia is a rare inner ear malformation that is usually only diagnosed after recurrent meningitis. Surgical intervention is mandatory. This report highlights the case of a patient with Mondini dysplasia who presented with hearing impairment and otorrhea and was diagnosed and treated before the occurrence of meningitis, thus preventing morbidity and neurologic sequelae. Hearing impairment may be the only manifestation of Mondini dysplasia, and the benefit of hearing screening is emphasized. Temporal bone computed tomography should be considered in children with unilateral sensorineural or mixed-type hearing impairment.

Esophageal perforation, mediastinitis, and retropharyngeal abscess after eel intrusion.

ventive and therapeutic interventions for those patients with virus-induced recurrent wheezing. Despite the limitations of experimental models, in vitro studies and the gaps in knowledge derived from human studies, the stage is ready for well selected cohort studies to determine whether RSV persistence and/or RSV-induced immune response contribute to the development of chronic lung inflammation and recurrent wheezing in children.

Respiratory tract infections in children with tracheostomy

BACKGROUND Children with tracheostomy are at increased risk for respiratory tract infections, yet the risk involved in tracheostomy related infections is unclear. METHODS We conducted a retrospective review of the medical records of children who underwent tracheostomy between January 2002 and December 2016 at a teaching hospital in Taipei. Demographics, underlying disease, indication for tracheostomy, laboratory data and management, and long-term outcome data were collected. Infection episodes were grouped into definite, possible, non-bacterial pneumonia, and local infection groups. RESULTS Ninety patients were enrolled. Forty-two (46.7%) patients had infections that required hospitalization. Definite bacterial pneumonia accounted for 12 (8.5%) episodes, 113 episodes (80.1%) were possible bacterial pneumonia, 12 (8.5%) were non-bacterial pneumonia, and 4 (2.8%) were local infections. Patients with definite and possible bacterial pneumonia were found to have a longer hospital duration than patients with non-bacterial pneumonia (p=0.024), with mean hospitalization stays of 8.83±5.59 days and 5.67±2.55 days, respectively. The median duration from tracheostomy to bacterial pneumonia was 1.78 years (range, 0.04- 11.38) whereas for the non-bacterial pneumonia group it was 0.57 years (range, 0.04-6.61). Cerebral palsy (CP) (adjusted odds ratio [AOR] 3.65; 95% confidence interval [CI]: 1.11-11.99; p=0.033) and gastroesophageal reflux disease (GERD) (AOR 2.84; 95% CI: 1.09-7.38; p=0.033) were independently associated with respiratory tract infections in these children. CONCLUSION In this study, CP and GERD were associated with infections in children with tracheostomy. Bacterial and non-bacterial pneumonia are difficult to differentiate clinically which may lead to unnecessary antibiotics use.

Acute otitis media caused by Streptococcus pneumoniae serotype 19A ST320 clone: epidemiological and clinical characteristics

BACKGROUND Streptococcus pneumoniae serotype 19A ST320, a highly multiresistant and virulent clone, has emerged as a common pathogen causing acute otitis media (AOM) in children. METHODS Patients aged 0-18 years with AOM who presented at Mackay Memorial Hospital, Taipei, Taiwan were prospectively enrolled between December 1, 2009, and November 30, 2012. For each patient, a specimen of middle-ear fluid was obtained and cultured. S. pneumoniae isolates were tested by serotyping, antibiotic-resistance profiling, and multilocus sequence typing. Demographic characteristics and clinical history of patients with pneumococcal AOM were recorded. RESULTS Pneumococcal AOM was observed in 108 (24.8%) of 436 episodes. One hundred and four isolates of S. pneumoniae were available for study. The most common serotypes were 19A (67 isolates, 64.4%), followed by 19F (16 isolates, 15.4%), and 3 (7 isolates, 6.7%). Among the 85 sequence-typed isolates, Serotype 19A ST320 (50, 58.8%) was the most frequent. Children with AOM caused by Serotype 19A ST320 were younger (33.9 ± 21.4 months vs. 46.7 ± 35.9 months, p = 0.04) and had a higher rate of spontaneous rupture of the tympanic membrane (64.0% vs. 40%, p = 0.05) than those caused by isolates of other sequence types. Serotype 19A ST320 caused 90% of AOM episodes in children aged ≤ 12 months and had had higher resistance rates to penicillin according to meningeal breakpoints (p = 0.011), amoxicillin (p < 0.001) and trimethoprim/sulfamethoxazol (p < 0.001). CONCLUSIONS It is better to use pneumococcal conjugate vaccine effective against Serotype 19A in early infancy to prevent the first and subsequent episodes of AOM in children in Taiwan.