Mark Nagy

Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment

Forty‐seven children presented with the diagnosis of a deep neck infection‐either cellulitis or abscess‐between January 1991 and July 1996. Forty‐four (94%) had contrast‐enhanced computed tomography (CT) imaging consistent with this diagnosis. Three patients with no CT scan had confirmation of an abscess at surgical drainage. Parenteral antibiotics alone were effective in the treatment of 24 of 47 infections (51%): seven parapharyngeal, one retropharyngeal, and 16 combined. By CT scan these infections represented cellulitis in 17 of 24 (71%), an abscess in three of 24 (13%), and incomplete abscess in four of 24 (17%). The average duration of hospitalization for this group was 4.8 days, with symptomatic improvement usually seen within 24 hours. Surgical drainage was performed on 23 of 47 infections (49%): three parapharyngeal, 17 combined, and three of unknown specific location. In 22 of these 23 children (96%), transoral drainage of the abscess was used as the primary surgical approach. In 21 of these 22 (95%) there was complete resolution without complications or recurrence; one abscess required a subsequent external approach. CT scanning with contrast revealed that all deep neck infections were located medial (usually anteromedial) to the great vessels. Abscesses with volumes estimated to be greater than 2000 mm3 were more likely to undergo surgery, but these differences were not statistically significant. The use of contrast‐enhanced CT scanning provides information regarding abscess size, location, and relative position of the great vessels for safe and successful transoral drainage. Thus we recommend CT‐assisted transoral drainage for combined retropharyngeal/parapharyngeal abscesses and selected isolated parapharyngeal abscesses that do not respond to parenteral antibiotics.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease.

Objective To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

Comparison of the sensitivity of lateral neck radiographs and computed tomography scanning in pediatric deep-neck infections

Objective: To compare the sensitivity of lateral neck films and computed tomography (CT) scanning with contrast in evaluating children with a high index of suspicion for a deep‐neck infection, either retropharyngeal, parapharyngeal, or combined based in clinical presentation. Study Design: A retrospective chart review of children presenting to the Childrens Hospital of Buffalo, New York, with the diagnosis of a deep‐neck infection between January 1991 and November 1997 was conducted. In total, 57 children were included in the study, ranging in age from 12 to 119 months (1–10 y). Methods: Charts were reviewed for presenting signs, symptoms, and laboratory values and included only those children with the presence of fever, limited neck range of motion, a lateral neck mass, dysphagia, and a leukocyte count greater than 15,000 cells/mm 3 . Results of lateral neck radiographs and CT scanning with contrast were evaluated and compared when available. Results: Lateral neck radiographs were found to have a sensitivity of 83% for determining the presence of a pediatric deep‐neck infection, whereas CT scanning with contrast had a sensitivity of 100%. Conclusion: Lateral neck radiographs were found to offer no benefit in the workup of children strongly suspected of having a deep‐neck infection based on clinical presentation. Despite the higher cost, CT scanning with contrast is the recommended radiologic test in such cases. This single study allows the determination of size, type, and location of the infectious process and is invaluable in treatment planning for pediatric patients with infection in deep‐neck spaces.

Head and neck dog bites in children

Objectives: 1) Demonstrate patterns of dog bite injury to the head and neck in children. 2) Identify treatment outcomes of dog bite injuries to the head and neck. Study Design: Case series with chart review. Subjects and Methods: Children aged 0 to 19 years, treated for head and neck dog bites at our tertiary care childrens hospital (1999-2007), were included. Demographics, dog breed and ownership, seasonal incidence, wound location, characteristics, management, and complications were recorded. Results: Eighty-four children, aged 10 months to 19 years (mean, 6.19 years) underwent primary repair of head and neck dog bite injuries. The cheek (34%) and lips (21%) were involved most commonly. Average wound length was 7.15 cm. Dog bite incidence peaked during summer months. Infection occurred in 10.7 percent. Pulsed dye laser was used to improve cosmesis. Conclusions: Children are vulnerable to head and neck dog bite injuries. Wound healing is excellent despite a contaminated wound. Infections occur infrequently. Pulsed dye laser improves cosmesis.

Clinical presentation as a guide to the identification of GERD in children.

OBJECTIVE to determine if there is a correlation between common otolaryngologic symptoms and presence of gastroesophageal reflux disease (GERD) in children. METHODS charts of 295 children presenting with suspicion of GERD were reviewed for presenting symptoms including: (1) airway symptoms: stertor, stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, blue spells, hoarseness, throat clearing; (2) feeding symptoms: wet burps, globus sensation, frequent emesis, dysphagia, choking/gagging, sore throat, halitosis, food refusal, stomach aches, arching, drooling, chest pain, irritability, and failure to thrive. At least one positive test of barium esophagram, gastric scintiscan, pH probe or esophageal biopsy resulted in inclusion in the GERD positive group. RESULTS 214 children had GERD diagnosed while 81 had no positive tests for GERD. Between the GERD positive and GERD negative groups, the significantly different symptoms were stertor (P=0.040), cyanotic spells (P=0.043), frequent emesis (P=0.007), failure to thrive (P=0.006), and choking/gagging (P=0.044). Three pooled variables were created: airway flow (stertor, stridor, cyanotic spells), airway irritation (frequent cough, recurrent croup, throat clearing), and feeding (dysphagia, failure to thrive, frequent emesis). GERD patients who were 2 years or less were compared to those older than 2 years and all three of these pooled variables were significantly different between these groups (P<0. 001). CONCLUSION children who present with a certain constellation of airway or feeding symptoms are more likely to have a positive GERD test. Children 2 years old or less are more likely to present with airway symptoms or feeding difficulties while children older than 2 years are more likely to present with airway irritation.

Success rates in paediatric tympanoplasty

OBJECTIVE To determine if the success of paediatric tympanoplasty is dependent on certain criteria, which are determinable prior to surgery. DESIGN Retrospective chart review. SETTING An academic paediatric otolaryngology department. PATIENTS Seventy-seven patients who had undergone tympanoplasty with or without ossicular reconstruction, but without mastoidectomy, between April 1997 and May 1999. MAIN OUTCOME MEASURES Status of the repaired tympanic membrane at last follow-up visit measured by otoscopic examination and with tympanometry. RESULTS Eighty-nine tympanoplasties were performed during this period. The age range was 2.9 to 22 years. The success rate was 75% overall. For patients younger than 11 years (n = 43), the success rate was 82%, and for those 11 to 18 years (n = 44), it was 74%, which was not significantly different. In 18 patients 7.5 years or younger, the success rate was 79%. Perforation location, size, presence of myringosclerosis, status of the other ear or nose, history of the perforation, surgical approach, middle ear findings, canal packing, and gender were not shown to be significantly different between successful and unsuccessful tympanoplasty groups. CONCLUSION These young patients had a good success rate post-tympanoplasty, which we believe reflects less severe disease. These results mitigate against delaying tympanoplasty in young children.

The relationship of tonsil bacterial concentration to surface and core cultures in chronic tonsillar disease in children.

Fifty-five tonsils removed for chronic tonsillar disease (chronic tonsillitis and obstructive tonsillar hyperplasia) underwent surface swab and quantitative core cultures in order to identify the relationship between core bacterial concentration and the presence of aerobic bacteria on the tonsil surface. The accuracy of a single core culture was further established by quantitative cultures of 9 sections per tonsil in an additional 19 tonsils. The results indicate that many (61.5%) but not all aerobic bacteria which were found in the tonsil core were cultured from the surface of the tonsil. Conversely, the tonsil core bacteria with the highest bacterial concentrations are more likely to be present on the tonsillar surface and the greater the bacterial concentration, the more likely the bacteria are to be found in most if not all areas of the tonsil core. Therefore, the core bacterial concentration appears to be related to the presence of aerobic bacteria on the tonsillar surface. Surface bacteria may not, however, be truly representative of the core bacterial environment. Implications for the management of chronic tonsillar disease will be discussed.

Effectiveness of adenoidectomy and laser tympanic membrane fenestration.

Objective Adenoidectomy alone or with tonsillectomy (A±T) is an effective surgical intervention in the management of otitis media in children, especially when it is performed in conjunction with insertion of pressure equalization tubes (PETs). Otorrhea and persistent tympanic membrane (TM) perforation are frequent complications. This study evaluates the effectiveness of intermediate duration middle ear ventilation using laser tympanic membrane fenestration (LTMF) without tube insertion and as an adjunct to adenoidectomy in resolving middle ear disease within the first 90 days after surgery.

Hemangiomas and Vascular Malformations: Analysis of Diagnostic Accuracy †

Objectives To evaluate the diagnostic accuracy and satisfaction of patient or family (or both) in the evaluation of hemangiomas and other vascular malformations.

P154: Head and Neck Dog Bites in Children: A Retrospective Study

Objectives: Demonstrate facial laceration patterns of dog bites to the head & neck area in children. Identify treatment outcomes of dog bite injury repair in the head and neck region. Methodology: We performed a retrospective chart review (1999-2006) of children, age 0-19 years, who were treated at our tertiary care children’s hospital after dog bite injuries to the head and neck. Patient demographics, dog bread and ownership, location of bite injury, seasonal incidence, wound characteristics and management, and complications were recorded. Results: Primary repair of dog bite injuries (<24 hrs) to the head & neck region were performed on 84 children. Median age at time of injury was 4.7 years. 50% of patients were less than 5 years old at the time of injury. The most common location for injuries were: cheeks 34%, and lips 21%. Wound patterns included: complex 45%, linear 32%, avulsion 18%, and puncture 4%. Average length of wounds was 7.15 cm (range 1 – 39 cm). Most injuries occurred during warmer months peaking in July (28%). All wounds were cleaned and repaired within 24 hours of injury. Post-operative antibiotics were used in all patients. Post-operative wound infections occurred in 10.7%. Long term wound management involved pulsed-dye laser therapy for persistent hyperemia and hypertrophic scars in a few patients (14%). There were no mortalities. Conclusions: Young children are particularly vulnerable to dog bite injuries to the head and neck area. Overall, wound healing is excellent regardless of the extent of injury. Despite a contaminated wound, infections occur infrequently and resolve with local wound care and antibiotics. Pulsed-dye laser may be useful to improve cosmesis for hypertrophic, hyperemic scars. 1. Sacks JJ, Kresnow M, Houston B: Dog Bites: How big a problem? Injury Prev. 2:52-54, 1996. 2. Weiss HB, Friedman, Coben JH: Incidence of dog bites treated in emergency departments. JAMA. 279(1), 51-53, 1998. 3. Miller PM, Hertler CH et al: Re-implantation of the amputated nose. Arch Otolaryngol Head Neck Surg. 124:907-910, 1998. 4. Liew SH, Murison M. Dickson WA: Prophylactic treatment of deep dermal burn scar to prevent hypertrophic scarring using the pulsed dye laser: A preliminary study. Ann Plast Surg. 49:472-475, 2002. Bibliography The American Pet Products Manufactures Association reports that there are 74.8 million dogs in the United States in 2007. A national survey by the Center for Disease Control in Atlanta, GA reported that dogs bite nearly 2% of the US population annually(1). Dog bites result in approximately 44,000 facial injuries treated in US hospitals each year. This represents about .5% to 1.5% of all emergency room visits. In children under 10 years of age, the face is the most common target, representing 77% of injuries. The middle third of the face is most frequently involved. The majority of biting dogs belong to the family or friend of the victim (2). As reported in our study, Pit Bull Terriers are the most common breed causing the injury. The incidence of dog bite injury in our study is highest during warmer weather. This may be due to increased exposure of playing children to dogs in the summer months or due to irritability of the dog because of increased ambient temperature. After careful wound irrigation and debridement, primary repair of head and neck wounds caused by dog bites achieves good results. A multiple layer closure using an absorbable, subcutaneous suture and a non-absorbable synthetic, monofilament cutaneous suture was performed in the majority of our patients. Broad spectrum antibiotics were used in all cases. Despite a contaminated wound, infection rates are low. In only one case was avulsed tissue not re-implanted (Case 2). Re-implantation of avulsed tissue was unsuccessful in all of our patients. Re-implantation of this non-vital tissue acts as a biological dressing and can help decrease wound size (3). In this study, all patients who underwent PDL treatments for persistent hyperemic and hypertrophic scars showed clinical improvement. Case 3 illustrates cosmetic improvement following only 1 PDL treatment. The exact mechanism of action of the PDL is unknown. Laser induced selective photothermolysis of microvasculature leading to hypoxia and collagenesis from decreased microvascular perfusion is a plausible explanation (4). We recommend PDL treatments on select patients with persistent hyperemic, hypertrophic scars following repair of dog bites to the head and neck. Discussion Eighty-four children were treated for dog bites to the head and neck over a 7 year period. Mean age at presentation was 4.7 years (Figure 1). Forty-six patients were male and 38 were female. Median follow-up after injury was 37 days (range 4 days to 4.4 years). Several wound patterns were noted (Figure 2). Some patients suffered wounds to more than one location (Figure 3). Most injuries occurred during warmer ambient temperatures (Figure 4) and were due to family pets (Figure 5). Pit Bulls were responsible for a large proportion of the injuries (Figure 6). Forty-nine wounds were repaired in the ER under local anesthesia with IV sedation and 35 under general anesthesia. Despite local irrigation/debridement, antibiotics, and primary closure, infections occurred in 9 patients (Figure 7). Avulsed tissue that was surgically re-attached as a free graft was completely lost in all 4 cases, but served as a biologic dressing to help promote wound healing. Hypertrophic and hyperemic scars persisted in 14% of patients. The pulsed-dye laser (PDL) was used successfully to improve cosmesis and pliability of these scars. Case Studies Figure 3 Distribution and Location of Dog Bite Injuries