Louw Feenstra

The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution

Background: Feeding problems are common in infants and young children. A multidisciplinary team approach contributes to better patient care. However, few quantitative data on multidisciplinary feeding assessment of children have been published. Objectives: The first aim of this study was to characterize the etiology of feeding difficulties in 700 children referred for assessment of severe feeding difficulty. The authors differentiated medical, oral, and behavioral categories. The second aim was to assess the prevalence of prematurity and dysmaturity in the patients and their relationship to the type of feeding problem. Methods: Clinical data from 700 children aged less than 10 years who were examined for severe feeding problems were analyzed. Results: Close to 50% of the children had a combined medical and oral condition underlying their feeding difficulties. More than half of the children were examined for gastrointestinal conditions, particularly gastroesophageal reflux disease. Behavioral problems were more frequently seen in children aged more than 2 years. The results indicate that oral sensory‐based feeding problems are related to past medical intervention. Children with feeding disorders had a significantly lower birthweight for gestational age. Preterm babies were overrepresented in this population. Conclusions: A multidisciplinary team approach is essential for assessment and management because combined medical and oral problems are the most frequent cause of pediatric feeding problems. A significant relationship was found between the type of feeding problem and age. Infants born preterm and/or with a birthweight below the tenth percentile for gestational age are at greater risk for developing feeding disorders. JPGN 37:75‐84, 2003.

Treatment of Severe Laryngeal Papillomatosis With Intralesional Injections of Cidofovir ((S)-1-(3-Hydroxy-2-Phosphonylmethoxypropyl) Cytosine)

Respiratory papillomatosis is a rare and often severe disease, usually localized in the larynx. It may cause respiratory distress and even life‐threatening obstruction of the airways. Treatment is generally based on the evaporation of the lesions with a CO2 laser, but microsurgery, cytotoxic and/or cytostatic drugs, interferons, and vaccines are also used. Cidofovir [(S)‐1‐(3‐hydroxy‐2‐phosphonylmethoxypropyl)cytosine] (HPMPC) was shown to suppress the growth of tumors induced by rabbit papillomavirus as well as human papillomavirus (HPV). The efficacy of cidofovir was assessed in 17 patients with severe respiratory papillomatosis. Cidofovir at a concentration of 2.5 mg/ml was injected directly in the different laryngeal papillomatous lesions during microlaryngoscopy under general anesthesia. Biopsies were taken before the treatment was started both for anatomopathology and viral typing. HPMPC kinetics in serum was monitored in three patients, the drug levels being determined by high‐performance liquid chromatography. Complete disappearance of the papillomatosis was observed in 14 patients. Four patients relapsed and were successfully treated again with cidofovir. Of the three remaining patients, one progressed while under treatment with cidofovir, after an initial marked response. One patient had a partial remission and remained stable for more than 1 year after the last injection. He had a very aggressive and extensive disease originally. Finally, one patient was lost to follow‐up after four injections. Intratumoral injections of cidofovir for the treatment of severe laryngeal papillomatosis is a powerful new therapeutic approach for this disease. Treatment was well tolerated, and no significant side effects were noted. J. Med. Virol. 54:219– 225, 1998.

Prospective study on the incidence of chronic ear complaints related to gastroesophageal reflux and on the outcome of antireflux therapy.

Over a 2-year period (1997 to 1999), 5 consecutive adult patients with chronic refractory secretory otitis media (CSOM) and 16 with a chronic refractory feeling of pressure in the ear(s) (CRFP) thought to be related to concomitant eustachian tube dysfunction were prospectively studied for coexisting gastroesophageal reflux (GER). All patients underwent an extensive standardized otorhinolaryngological examination, ambulatory 24-hour dual-probe esophageal pH monitoring with a distal pH probe 5 cm and a proximal probe 20 cm above the lower esophageal sphincter, and upper gastrointestinal endoscopy. Most of them also underwent esophageal manometry. All patients with CSOM and 12 of the 16 patients with CRFP had evidence of GER. Only 5 patients experienced heartburn or regurgitation. All patients responded very well to antireflux therapy with omeprazole 20 mg twice per day (40 mg twice per day in 2 patients) accompanied by conservative antireflux measures, ie, complete cessation of their middle ear complaints. This study demonstrates the role of GER in the pathogenesis of refractory CSOM and CRFP and the effectiveness of sustained antireflux therapy.

The Yield of Upper Gastrointestinal Endoscopy in Patients with Suspected Reflux-Related Chronic Ear, Nose, and Throat Symptoms

OBJECTIVES:It is well established that various ENT disorders and symptoms may be a manifestation of gastroesophageal reflux disease (GERD). Erosive esophagitis is considered a rare finding in ENT patients and therefore upper gastrointestinal (GI) endoscopy is not recommended in the diagnostic work-up. However, large prospective studies underscoring this policy are lacking. The aim of the present study was to investigate the prevalence and severity of esophagitis in patients with suspected GERD-related chronic ENT symptoms.METHODS:Endoscopy was performed in 405 ENT patients with suspected GERD and 545 typical GERD patients. The presence of erosive esophagitis, Barretts esophagus, hiatal hernia, peptic ulcer, and Helicobacter pylori infection on biopsies was determined and compared with the results of a symptom questionnaire.RESULTS:The prevalence of erosive esophagitis (52.3%vs 38.4%; p < 0.05), mainly grade 1 (31.9%vs 22.7%; p < 0.05), and of peptic ulcer (8.4%vs 4.3%; p < 0.05) was significantly higher in patients with GERD-related ENT symptoms compared to typical GERD. Barretts mucosa occurred in, respectively, 4.9% and 4.5% of the patients (NS). Esophagitis prevalence was highest in patients with predominant cough and lowest in globus pharyngeus and throat symptoms. The presence of esophagitis was associated with significantly higher rates of symptom relief during the first 8 wk of proton pump inhibitor (PPI) therapy.CONCLUSIONS:Patients with suspected GERD-related ENT symptoms have a high prevalence of esophagitis and this is associated with better response to antisecretory therapy.

Characteristics and clinical relevance of proximal esophageal pH monitoring

OBJECTIVE:It is well established that various ENT disorders and symptoms may be a manifestation of gastroesophageal reflux disease (GERD). Measuring proximal esophageal acid exposure might be useful in the evaluation of patients with suspected reflux-related ENT manifestations, but the limited available data are conflicting. The aim of the present study was to study the determinants of proximal esophageal acid exposure (PR) and to evaluate the clinical usefulness of ambulatory proximal pH monitoring.METHODS:Twenty healthy controls and 346 patients with suspected reflux disease underwent typical and atypical GERD symptom assessment, endoscopy, esophageal manometry and ambulatory combined dual esophageal pH, and Bilitec duodeno-gastro-esophageal reflux exposure (DGER) monitoring. The presence of pathological PR and its relation to symptom pattern and distal esophageal acid exposure (DR) and DGER exposure were analyzed.RESULTS:Fifty-seven patients (16%) had pathological PR. Demographic characteristics, symptom pattern, and manometric findings did not differ in patients with normal or pathological PR. Patients with pathological PR had significantly higher DR and DGER. The multivariate analysis identified only pathological DR as an independent risk factor for the presence of pathological PR (odds ratio 4.515, 95% CI 2.48–8.23, p < 0.0001). Only 20 patients (6%) had pathological proximal reflux without pathological distal acid reflux.CONCLUSION:The findings of the present article do not support routine proximal esophageal pH monitoring as a clinical tool: PR does not differentiate patients with typical or atypical GERD manifestations and depends mainly on DR.

Experimental tracheal allograft revascularization and transplantation

The feasibility of tracheal allotransplantation with a fascial vascular carrier was examined in three groups with varied dose sequences of immunosuppression. A control group (group 1) received no medication. The three experimental groups were given daily cyclosporine intramuscular doses of 5 mg/kg (group 2), 5 mg/kg plus 3 mg/kg methylprednisolone (Solu-Medrol) (group 3), and 10 mg/kg (group 4) for 6 weeks or until death. Grafts were assessed by silicone dye infusion of the artery of the fascial flap to examine their microcirculation and by quantitative histologic study. Group 1 evidenced complete rejection after a heterotopic revascularization period of 14 days. The allografts of the experimental groups remained viable after 14 days of revascularization and could be transplanted orthotopically after this period. After transplantation, the viability of group 2 tracheas was unpredictable with changes ranging from mild to complete rejection. Group 3 evidenced well-preserved transplant viability with infection-induced necrosis at the anastomoses caused by the corticosteroid component. All group 4 animals survived the follow-up period with normal allograft viability. Cyclosporine in a dosage of 10 mg/kg per day can effectively suppress the immune response after transplantation of vascularized tracheal allografts. This experimental model will allow future studies to examine airway wall immunogenicity.

Chronic middle ear disease and gastroesophageal reflux disease : A causal relation?

Objective To describe one patient with a puzzling therapy-resistant unilateral chronic otitis media, analyze his diagnosis, and describe three similar patients with the same symptoms and signs, i.e., a chronic ear problem together with gastroesophageal reflux disease (GERD). Study Design Thorough analysis of one patient with a chronic ear problem and GERD, both of which responded favorably after antireflux therapy consisting of omeprazole and conservative antireflux measures (raising the head of the bed by 20 to 25 cm, avoiding meals and drinks 3 hours before retiring, and other dietary and lifestyle modifications), and a search for more patients with similar coexisting conditions. Setting Tertiary referral center. Methods Patients with chronic ear problems and GERD were thoroughly analyzed by the otorhinolaryngologist and the gastroenterologist. The latter used endoscopy and Savary-Millers classification of esophagitis, a 24-hour ambulatory dual esophageal pH monitoring, and esophageal manometry. Results Four patients were identified who had a chronic ear problem and simultaneous GERD. It is reasoned that the GERD leads to nasopharyngitis and this to a chronic ear problem. All the patients responded favorably to anti-GERD therapy. Conclusions GERD may manifest itself as an extraesophageal manifestation, such as nasopharyngitis, leading to ear disease. Therapy-resistant chronic middle ear disease may be caused by GERD.

Hereditary otovestibular dysfunction and Ménière's disease in a large Belgian family is caused by a missense mutation in the COCH gene

Objective To report the clinical, auditory, and vestibular characteristics of a nonsyndromic otovestibular dysfunction in a large Belgian family caused by a missense mutation of the DFNA9 gene: COCH. Study Design Retrospective study of the clinical, audiologic, and vestibular data of 60 genetically affected cases. Setting Tertiary referral center. Patients All members of a Belgian kindred who carry the genetic (P51S) defect linked to the inherited hearing and vestibular impairment. Interventions Diagnostic otologic, audiometric, and vestibular analysis and imaging. Main Outcome Measures Pure tone audiometry, supraliminary audiometry. and vestibular investigation. Results The autosomal dominant inherited impairment was characterized by peripheral degeneration of the inner ear, leading to total deafness and bilateral vestibular areflexia. Conclusions The genetically affected persons of a Belgian family shared a progressive sensorineural hearing loss starting between the third and sixth decade. Vestibular symptoms started at about the same age as the hearing loss. The vestibular symptoms consisted of instability in darkness, a tendency to fall sideways, light-headiness, a drunken feeling, and attacks of vertigo. Most of the patients reported tinnitus, and half of them reported pressure in the ears. Clinically, 9 of the 60 patients met the criteria for definite Ménières disease, and another 13 and 17 patients met the criteria for probable or possible Ménières disease, respectively. All 9 were older than the age of 35, but only 1 was older than 55 years, so more than 30% of the patients were between 35 and 55 years old. A specific pattern could be recognized in the evolution of the otovestibular impairment. Under the age of 35 years, almost all the affected family members had normal hearing, whereas above the age of 55 years, the hearing loss was at least moderate, and vestibular hypofunction occurred. In between, there was a transition period of two to three decades, when deterioration of the cochleovestibular function occurred, with a temporary audiometric and vestibular asymmetry.

Spiral CT of the temporal bone: value of image reconstruction at submillimetric table increments

Axial spiral CT of the temporal bones with a nominal slice thickness of 1 mm and 180° linear interpolation was performed in 13 patients. In 18 temporal bones, the spiral data set was used to reconstruct overlapping axial images with a table increment of 0.1 mm. These images gave additional information in four cases: in two by examining the heavily overlapping axial images themselves, and in two by obtaining supplementary information from secondary image reconstructions. In two cases less information was obtained than by using the conventional incremental images. This study shows that reconstructing overlapping slices can be useful, even if the temporal bone is scanned at 1 mm nominal slice thickness.

Systemic Cidofovir in Papillomatosis

An 8-year-old patient with severe recurrent respiratory papillomatosis and pulmonary spread was treated by systemic administration of cidofovir in association with laser treatment for tracheal lesions. Complete disappearance of the lesions in the pharynx and larynx and a significant yet incomplete regression in the bronchi and lung parenchyma were observed without deleterious side effects. This is the first case report of systemic use of cidofovir to treat recurrent respiratory papillomatosis.