Liane M. Gilbert

EFFECTS OF MIDDLE EAR EFFUSION ON THE VESTIBULAR SYSTEM IN CHILDREN

Vertigo and dizziness are not common in childhood, but are probably present more often than was formerly thought. These symptoms caused mainly by otitis media and middle ear effusion, two of the most common diseases in children, have been neglected for a long time, both in the literature and in practice, until recently. The purpose of this study was to determine objectively the incidence of balance-related symptoms in children with long-lasting middle ear effusion and to discover whether these symptoms resolve after the insertion of ventilation tubes. One hundred thirty-six children, ages 4 to 9 years, were given electronystagmographic tests and the Bruininks-Oseretsky tests for motor proficiency before and after tube ventilation of the middle ear. The results were compared with those in 74 healthy children with no history of middle ear diseases. Pathologic findings were found in 58% of the children with chronic middle ear effusion, as compared with only 4% of the control group. The symptoms and signs of balance disturbances resolved in 96% of the children after ventilation tube insertion. The results of this study indicate that balance-related symptoms often encountered in young children may result from chronic middle ear effusion and that these symptoms will resolve after evacuation of the effusion and ventilation of the middle ear.

The epiglottis and obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is caused by obstruction or narrowing of the airway at various levels. The repair of one site only will not alleviate the syndrome if there are obstructions in other sites. Epiglottis prolapse during inspiration is an unusual cause of airway obstruction and a rare cause of OSA. Twelve cases of OSAS due to an abnormal epiglottis are presented. We present our approach to the diagnosis using fibre-optic examination of the hypopharynx, and our treatment using endoscopic carbon dioxide laser partial epiglottidectomy. We found in our series that in 11.5 per cent of patients who failed the uvulopalatopharyngoplasty procedure, the reason was a narrow airway at the hypopharyngeal level caused by an abnormal epiglottis. It is our suggestion that in these cases a laser partial epiglottidectomy should be performed. The results of this study show that partial epiglottidectomy can increase the cure rate of patients with obstructive sleep apnoea syndrome by 10-15 per cent.

VENTILATION TUBES AND PERSISTING TYMPANIC MEMBRANE PERFORATIONS

Surgical management of otitis media with effusion and recurrent acute otitis media includes myringotomy and the use of ventilation tubes. Since this procedure was reintroduced by Armstrong in 1954, it has become one of the most commonly performed operations in otolaryngology. In most series perforation of the tympanic membrane in some patients has been reported after spontaneous extrusion or removal of the tympanostomy tubes. We present a retrospective review designed to examine the incidence of persisting perforations of the tympanic membrane in our series of 2604 operated ears. The study also identifies and analyzes the variables and the contributing risk factors. Perforations occurred in 3.06% of the ears: with a greater incidence in children younger than 5 years, when the indication was recurrent purulent otitis media, with the use of long-term Goode T tubes, in cases with repeated insertions of ventilation tubes, and in cases in which postoperative otorrhea was frequent.

Effect of middle ear effusion on the vestibular labyrinth

Although middle ear effusion was once described as the most common cause of vestibular disturbance in children, the association between glue ear and symptoms of dysequilibrium has never been quantified objectively. In this study the effect of middle ear effusion on the vestibular system of the inner ear was studied in a select group of children suffering from long lasting effusion in the middle ear with no evidence of infection at least one year prior to the study. The results were compared with results obtained from otitis free children, as well as from examinations of children after the insertion of ventilating tubes. The results of this study confirm the assumption that middle ear effusion has an adverse effect on the vestibular system, which can be resolved following the insertion of ventilation tubes. This effect may also contribute to the adverse effect that otitis media has on a childs development.

PROPHYLACTIC TREATMENT AFTER VENTILATION TUBE INSERTION : COMPARISON OF VARIOUS METHODS

Otitis media is recognized as one of the most common diseases of childhood. Insertion of tympanostomy tubes for the treatment of otitis media is the most frequently performed otologic operation, and postoperative otorrhea is its most common complication. Many authors have suggested various reasons for posttympanostomy otorrhea, and many different prophylactic treatments were proposed in recent years to prevent this bothersome and frustrating complication. This retrospective study was designed to investigate and compare the efficacy of various prophylactic treatments and to define the most effective method of reducing the rate of postoperative otorrhea. (Otolaryngol Head Neck Surg 1998;119:117–20.)

An objective, noninvasive method for the diagnosis of temporomandibular joint disorders.

An objective, noninvasive method for the diagnosis and monitoring of pathology referable to the temporomandibular joint is presented.

Extraction of a large tracheal foreign body through a tracheotomy

Foreign body aspiration is not uncommon in children and is a significant cause of childhood morbidity and mortality. Laryngotracheal foreign bodies, although less common than bronchial foreign bodies, are potentially more dangerous and require urgent recognition and treatment. Most of the aspirated foreign bodies are removed with the use of classic instruments like rigid bronchoscope and foreign body forceps, or more rarely with flexible fiberoptic bronchoscope, but sometimes we fail to remove them. We present a large nonasphyxiating, aspirated foreign body lodged in the subglottis of a a-year-old child, which was removed through a tracheotomy under bronchoscopic control, followed by primary suture and closure of the tracheotomy site. Under general anesthesia, bronchoscopy demonstrated a hollow conic-shaped plastic piece of a toy (Fig 2). Repeated attempts to extract the foreign body through the larynx failed because of the size of the foreign body, the fact that its larger diameter was upward, and the anatomic shape of the subglottic region. An attempt at rotation of the foreign body failed too, because of its length. The foreign body was therefore pushed to the right mainstem bronchus, and a tracheotomy was performed over the ventilating Stotz-Hopkins bronchoscope, using a superiorly based tracheal flap (Fig 3). The foreign body was then manipulated endoscopically to the stoma and removed without difficulty. The bronchoscope was replaced by an endotracheal tube, and the flap was returned to its original position and sutured to the tracheal wall.

Qualitative measurement of drugs.

It has been noted for several years that certain drugs produce abnormal test results in patients who are administered the elcctronystagmograph (ENG) test. Drug specific waveforms, termed drug evoked potentials (DEP), have been identified by using the ENG for alcohol, marijuana, cocaine, tranquilizers, amphetamines, barbiturates, opiates, hallucinogens, caffeine, aminophylline, dopamine, several gases and approximately 75 combinations of drugs (N=821). Tests for double blind diagnosis of drug intake as well as tests for repeatability within the same subject were conducted. Subjects included surgical candidates, healthy volunteers, and neonates (N=248). Drugs tested were ketamine hydrochloride, fentanyl, sodium pentothal, cocaine, dextroamphetamine, sodium seconal, morphine sulfate, phenobarbital, and meperidine. Placebos of dextrose in water and sucrose tablets were also used (N=25).

Ventilation tubes and cholesteatoma: What is the association?

Objectives: Myringotomy and ventilation tube (VT) placement is the most common otological procedure performed today in children. The incidence of posttympanostomy cholesteatoma related to the VT is relatively low, but this complication is associated with a high morbidity rate. This study was designed to examine the incidence of this complication in relation to different variants. Methods: The study consists of a retrospective analysis of VT placements performed in 2829 children (5575 ears) during the years 1978 through 1997. The following information was obtained: sex, age at which the tube was placed, indications for tube insertion, type of tube used, number of previous tube insertions, incidence of postoperative otorrhea, length of time the tube maintained its position, and the presence of cholesteatoma at or near the site of the tube insertion. Follow-up was from 1 to 20 years. Results: Sixty-two cholesteatomas related to the VT were diagnosed (1.1%). The incidence of posttympanostomy cholesteatoma was higher when the tubes were inserted in children younger than 5 years, with the use of Goode T tubes (as compared with polyethylene tubes), in cases of multiple tubes placements, when the intubation period exceeded 12 months and when there were 3 or more episodes of otorrhea while the tubes were in place. Conclusion: In light of the large number of ears studied, the many criteria used, and the prolonged follow-up period, this study provides important data regarding the risk of a cholesteatoma related to a VT and underlines the need for close and adequate follow-up of children after VT placement.

10:20 AM: Middle Ear Effusion Effects on Vestibular System in Children

Although middle ear effusion (MEE) is one of the most frequent diagnoses recorded in children, only in the past two decades have authors considered it to be an etiologic factor in balance disorders in childhood. Nevertheless, the association between MEE and vestibular dysfunction remains controversial. Electronystagmographic tests were performed on 136 children, ages 4 to 9 years, with MEE but without clinical evidence of middle ear infections, before and after ventilation tube insertions; they were also compared with 74 healthy children with no history of middle ear diseases (controls). A spontaneous, jerk-type horizontal nystagmus or positional nystagmus or both was found in 58% (79) of the children with MEE compared with 4% (3) of the controis. Clinical signs and symptoms of balance disorders were found in 50% of the children with MEE and none of the controls. Abnormal electronystagmographic findings resolved in 96% of the children after ventilation tube insertion. Follow-up of over 12 months revealed that clinical signs and symptoms of balance disorders had resolved in all of the surgically treated children. The results of this study imply that the clumsiness, stumbling, and tendency to fall often encountered in young children may result from chronic MEE, and that these symptoms will resolve following the insertion of ventilation tubes.