Laurie A. Ohlms

A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding.

The study was designed to compare intravenous ketorolac to rectal acetaminophen for analgesia and bleeding in pediatric patients undergoing tonsillectomy.We studied 50 patients, aged 2-15 yr undergoing tonsillectomy with or without adenoidectomy. In a randomized, prospective double-blind fashion, patients were assigned to receive either ketorolac (1 mg/kg) or rectal acetaminophen (35 mg/kg). Bleeding was evaluated by measuring intraoperative blood loss and noting extra measures required to obtain hemostasis. Bleeding times were also measured before and during surgery. Pain was evaluated using a standard objective pain score for the first 3 h. Persistent pain was treated with morphine, acetaminophen, and codeine and recorded for 24 h. Blood for determination of acetaminophen levels was drawn at 20 and 40 min after the administration of study drugs. Pain scores were not significantly different between the ketorolac and acetaminophen groups. The majority of patients in both groups required additional opioid in the postoperative period. Acetaminophen levels were all less than the therapeutic range. Intraoperative bleeding times were normal in all patients, but blood loss was significantly higher in the ketorolac group (2.67 mL/kg) compared to the acetaminophen group (1.44 mL/kg), P = 0.025. Significantly more measures to achieve hemostasis were required in the ketorolac group (P = 0.012). We conclude that ketorolac is no more effective than high-dose rectal acetaminophen for analgesia in the patient undergoing tonsillectomy. Hemostasis during tonsillectomy was significantly more difficult to achieve in patients receiving ketorolac. (Anesth Analg 1995;80:226-9)

Distortion product emissions in humans. III. Influence of sensorineural hearing loss

The realization that otoacoustic emissions are sensitive to cochlear disorders has resulted in the speculation that they may have considerable clinical potential as objective measures of hearing. To assess the clinical utility of one type of emission, the distortion product emission (DPE), a study was undertaken in individuals with hearing impairments representing a number of common otologic disorders. The results of this investigation provided evidence that tests of DPEs promise to satisfy a number of requirements important to clinical testing, including objectivity of measurement procedures, test-retest reliability, simple subject preparation, readily available instrumentation, and relatively brief examination periods. The fine resolution of DPEs within the stimulus frequency and level domains also permits an accurate confirmation of the pattern of hearing loss. For example, tests of DPEs detected a 20-dB hearing level impairment at a single frequency in an ear exhibiting early signs of noise-induced hearing loss, and a 10-dB improvement in sensitivity following ingestion of the hyperosmotic agent glycerol in an ear displaying a mild to moderate hearing loss due to Menieres disease. Finally, the application of DPEs to the objective testing of otologic disorders suggests that the ability of these responses to assess the sensory component of a sensorineural disorder may contribute to the eventual understanding of the complicated pathogenesis of many cochlear diseases. When all the positive features of DPE testing are realized, the potential contribution that these measures can make in a clinical setting becomes apparent.

Interferon Alfa-2A Therapy for Airway Hemangiomas

Hemangioma is a well-recognized cause of airway obstruction in the infant with stridor. Corticosteroid and laser therapy are effective in stabilizing the airway in most cases. There are, however, some extensive airway lesions that are not adequately managed by these modalities. This report describes the use of recombinant interferon alfa-2a in 15 patients with life-threatening airway hemangiomas. All patients had failed corticosteroid and/or laser therapy. Multiple upper airway sites were involved, including the base of the tongue, supraglottis, subglottis, trachea, and mediastinum. Eleven patients have completed therapy and are doing well. Four patients have resolving lesions on the drug regimen. Life-threatening airway lesions unresponsive to conventional treatment should be considered for a trial of interferon alfa-2a.

Acoustic-Distortion Products: Separation of Sensory from Neural Dysfunction in Sensorineural Hearing Loss in Human Beings and Rabbits

Because distortion-product otoacoustic emissions (DPOAEs) provide a noninvasive measure of outer hair-cell (OHC) activity, they should provide a unique and sensitive indicator of the effects of agents that damage hearing. Using DPOAE methods, the present study was designed to assess the relative contributions of the cochleas outer hair cells to some common sensorineural diseases, including Menieres disease, acoustic neuroma, and noise-induced, hereditary, and sudden idiopathic sensorineural hearing loss. Parallel evaluations of DPOAEs were performed under essentially identical conditions in rabbit models of several of the human disorders, including noise-induced hearing loss, endolymphatic hydrops, and cochlear neurectomy. Animal studies were performed to assess the proficiency of DPOAEs to track a developing sensorineural deficit as well as to compare patterns of DPOAE dysfunction between clinical and experimental forms of peripheral hearing loss. Detailed measures of DPOAEs were collected in the stimulus-frequency and intensity domains as “audiograms” and response/growth or input/output functions, respectively. The outcome of analyses of both human beings and animals supported the notion that DPOAE testing is sensitive to sensory-cell disease. Thus, in combination with conventional audiometry, DPOAE measures permit a distinction between the relative contribution sensory and neural components of the cochlea make to hearing deficits.

Venous malformation of the pediatric airway

OBJECTIVE To evaluate the management of venous malformations of the pediatric airway, including diagnostic criteria and response to sclerotherapy and laser photocoagulation. DESIGN Case series analysis of eight patients diagnosed with venous malformations of the upper airway. SETTING Academic, tertiary care, childrens hospital. PATIENTS Eight patients (3 female, 5 male) with congenital venous malformations of the upper airway. INTERVENTION Each patient underwent an individualized treatment regimen of sclerotherapy, laser photocoagulation and/or surgery. RESULTS The combination of sclerotherapy and laser photocoagulation appears to cause gradual regression of the malformation. Five of the eight patients will require further therapy; two patients remain tracheotomy dependent. CONCLUSIONS Extensive venous malformations of the pediatric airway require staged therapy, with a combination of sclerotherapy and photocoagulation. Long-term follow-up is essential because of the natural history of these lesions.

Is Parental Perception an Accurate Predictor of Childhood Hearing Loss? A Prospective Study

OBJECTIVE: We performed this study to assess whether parental perception of hearing loss predicted the results of audiometric testing in children with recurrent otitis media or persistent otitis media with effusion. METHODS: As part of a larger prospective observational outcomes study of children undergoing tympanostomy tube placement, the childs parent completed a standardized questionnaire before and after tube placement. In addition, patients underwent age-appropriate audiologic threshold and tympanometry testing before and after tube placement. RESULTS: We enrolled 113 patients (median age, 2 years), and 93 (82%) completed follow-up. Before treatment, parental perception of hearing loss did not predict hearing threshold level. After tube placement, parental perception of hearing loss was also poorly correlated with change in threshold. CONCLUSIONS: Parental perception of their childs hearing loss is a poor predictor of objective audiologic findings both before and after treatment with tympanostomy tubes. These findings have important implications concerning the importance of screening for hearing loss in children with otitis media with effusion.

Establishing the etiology of childhood hearing loss

The cause of hearing loss in children is often difficult to identify. We evaluated a cohort of 114 children (47 boys, 67 girls) referred with newly diagnosed hearing loss (non–otitis media) to identify factors predictive of etiology and type of hearing loss. Clinical (history and physical examination), laboratory, and radiographic data were collected. One hundred children (87.7%) had sensorineural hearing loss, and 14 (12.3%) had conductive or mixed hearing loss. The cause of hearing loss was identified in 54 children (48%). Patients with isolated aural atresia (n = 7) or with a known diagnosis of congenital cytomegalovirus infection (n = 21) were excluded from further data analysis. We conducted statistical analysis to identify factors predictive of the cause and type of hearing loss. Clinical factors that aided in identifying a cause included abnormal physical examination findings (p= 0.001) and craniofacial anomalies (p = 0.006). Computed tomography of the temporal bones was the only diagnostic test predictive of cause (p < 0.001). Factors predictive of the type of hearing loss detected (sensorineural vs. conductive or mixed) were abnormal physical examination findings (p = 0.01) and craniofacial anomalies (p = 0.004). An exhaustive laboratory or radiographic workup did not prove beneficial in identifying the etiology of hearing loss in our series.

Malignant Laryngeal Tumors in Children: A 15-Year Experience with Four Patients

Malignant laryngeal neoplasms in children are uncommon and present diagnostic and therapeutic challenges. A 15-year retrospective review of laryngeal tumors at our institution identified four patients with malignant neoplasms. These children, 7 months to 16 years of age, were treated for squamous cell carcinoma, choriocarcinoma, rhabdomyosarcoma, and primitive neuroectodermal tumor. This report details these cases, emphasizing diagnostic approaches, treatment decisions (medical oncologic management, surgical resection), and rehabilitation measures for postlaryngectomy communication. A multi-institutional pediatric head and neck tumor registry would be a useful reference to assist with individual treatment decisions.

Clinical experience in diagnosis and management of superior semicircular canal dehiscence in children.

To identify clinical characteristics of pediatric superior semicircular canal dehiscence (SSCD) and explore suitable options of management.

USE OF AN INTERNET-BASED JOURNAL CLUB

The on-line journal club is a useful example of the educational advantages created by the combination of current Internet technology with traditional journal club methods.