Michael J. Biavati

Correlation of clinical sinusitis signs and symptoms to imaging findings in pediatric patients

The purpose of this study was to determine the correlation between signs and symptoms of upper respiratory tract disease and sinus images in a convenience sample of sixty pediatric patients scheduled for computed tomography or magnetic resonance imaging of the head for non-sinus diagnoses over a 2-year period. The study was carried out in a tertiary pediatric referral center. Each patient underwent rhinoscopy and otoscopy just prior to imaging, and each patients parent was asked to fill out a questionnaire regarding recent symptoms of upper respiratory tract infection; a blinded comparison was then made between respiratory signs and symptoms and images of the paranasal sinuses. Forty-seven percent of patients had abnormalities of their sinus images, and a significant (P < 0.05) correlation was found between the presence of absence of respiratory signs and symptoms and the presence or absence of abnormalities of sinus images, especially in younger patients. In conclusion, a large percentage of pediatric patients undergoing imaging procedures of the head for non-sinus diagnoses have sinus image abnormalities. In the population studied these imaging abnormalities appear to reflect ongoing or resolving upper respiratory tract viral or allergic inflammation.

Clinical Presentation of Allergic Fungal Sinusitis in Children

Objective To compare the differences in the clinical and radiographic presentation of allergic fungal sinusitis in children and adults.

Postoperative Care following Single-Stage Laryngotracheoplasty

Single-stage laryngotracheoplasty (SSLTP) provides a method of correcting mild-to-moderate laryngotracheal stenosis while avoiding the risks of prolonged laryngeal sten ting. Pediatric patients are orally intubated for 5 to 7 days postoperatively to ensure an adequate airway while edema resolves and healing begins. During this period, continuous neuromuscular blockade has been advocated in infants and young children to avoid endotracheal tube trauma to the fresh graft and potentially life-threatening accidental decannulation. Pulmonary atelectasis is the most common morbidity associated with prolonged neuromuscular blockade. Neuromuscular weakness also may follow prolonged paralysis and prolong hospitalization. This paper compares the postoperative course of 17 patients who underwent 18 SSLTP procedures by the senior author. The first 8 patients received continuous neuromuscular blockade in the early postoperative period. To reduce perceived morbidity, the last 9 patients were managed with a protocol that incorporated daily 4- to 8-hour “interruptions” of paralysis. Seven patients tolerated this protocol modification. As a group, these patients had less postoperative pulmonary atelectasis prior to extubation (p < .05) and were extubated sooner than patients receiving continuous neuromuscular blockade (p < .05) without compromising the surgical success of the procedure. Intermittent paralysis permitted for more accurate assessment of pain control and protected against accidental drug accumulation. Although self-extubation did not occur, diligent nursing care with adequate sedation and analgesia is necessary to avoid the risk of accidental extubation.

Screening sinus CT scans in pediatric bone marrow transplant patients

OBJECTIVE To determine how sinus disease noted on pre-bone marrow transplant (BMT) screening sinus computed tomography (CT) scans relates to subsequent development of clinical and/or radiographic sinusitis and correlates with overall prognosis. METHODS A retrospective review of medical records, CT scans, and BMT database statistics was performed on all pediatric BMT recipients from January 1992 through December 1997. Fifty-four pre-BMT CT scans were performed on 51 children, aged from 2 months to 17 years. Sinus disease was staged according to criteria established by Lund and Kennedy [V.J. Lund, D.W. Kennedy, Ann. Otol. Rhinol. Laryngol. S167 (1995) 17-21.]. RESULTS The average age of BMT recipients was 6.8 years. Most common oncologic diagnoses included acute myelogenous leukemia (37%), acute lymphoblastic leukemia (17%), and stage IV neuroblastoma (13%). Screening sinus CT scans were routinely performed 1-3 months prior to BMT. On pre-BMT CT scans 48% of the patients had no evidence of sinus disease, 25.9% mild disease, 9.3% moderate disease, and 16.7% severe disease. Two-thirds (66.7%) of patients with severe sinus disease on pre-BMT CT scans experienced clinical sinusitis post-BMT. In contrast, sinus symptoms were much less common (21.4%) in those with mild disease on CT scan. Overall, 39.3% of patients with sinus abnormalities on pre-BMT CT scans had clinical sinusitis during their post-BMT course, compared to 23.1% of those with normal CT scans pre-BMT. In addition, those patients demonstrating sinus disease on their pre-BMT CT scan were more likely to have radiographic sinusitis post-BMT (25.0%) than those with no disease (7.7%). Seventy-eight percent of those with severe sinusitis had died by 2-year follow up, compared to 69.2% of patients with normal CT scans pre-BMT. CONCLUSIONS Severity of radiographic sinus disease on pre-BMT CT scans was noted to correlate with clinical and radiographic sinusitis later in the post-BMT course, and was associated with a trend toward decreased survival. Pre-BMT CT scans may be useful in determining which children need early and more aggressive intervention for clinical sinusitis post-BMT.

Congenital syringocystadenoma papilliferum of the ear and neck treated with the CO2 laser

Syringocystadenoma papilliferum (SCAP) is a rare benign skin tumor which clinically resembles papilloma. It is characterized by extensive papillary epithelial elements growing into the dermis. SCAP often presents at birth and most commonly in the head and neck. We present a case of a newborn with SCAP of the right ear and neck, treated with CO2 laser excision because the lesion was poorly amenable to excision and closure or grafting. Two CO2 laser procedures have produced a good result and reasonable cosmesis. CO2 laser excision of SCAP of the head and neck is a clinical treatment option in anatomic areas unfavorable to excision and grafting.

Techniques for improving ear definition in microtia reconstruction

Surgeons involved in microtia repair recognize the difficulty in creating a natural appearing ear. One key to successful reconstruction is to provide sufficient relief between the helix, scaphoid fossa and antihelix to create the illusion of thin skin overlying thin cartilage. Problems such as thick skin, hair-bearing skin and poor-quality cartilage serve to frustrate the surgeons attempt to achieve the desired result. Surgical techniques to improve cartilaginous framework definition in microtia repair are discussed.

Disseminated Pneumocystis Carinii Infection Involving the Neck and Nasopharynx

In summary, several points should be emphasized: 1. Adenoidal hypertrophy in a person who previously underwent adenoidectomy should lead to the suspicion of HIV infection. 2. P. carinii should be included in the differential diagnosis of adenoidal enlargement in HIV infections. 3. Extrapulmonary calcification should lead to the suspicion of P. carinii infection.

Acute frontal sinusitis and associated brain abscess due to Actinomyces pyogenes-like bacteria

leishmaniasis. The patient received parenteral glucanthime for 16 weeks with good results. After 3 weeks the lesions disappeared and he has remained symptom free for the past year. No mucous bullous lesions have been found, but a few skin lesions have occurred, which have been controlled with oral steroids. Discussion: The first patient did not have any clinical signs of active leishmaniasis but presented several nasal and oral sequelae that might have created a local susceptibility to the development of pemphigus. The second patient had clear signs of the association of both diseases and has responded well to treatment. The exact cause of pemphigus remains unknown. We are intrigued with this uncommon association.

160 Preservation of Hearing Despite Labyrinthine Destruction in Langerhans' Cell Histiocytosis

our knowledge , there have been no previous reports of hemangiopericytoma occurring in the middle ear cleft. Fifteen to twenty-five percent of hemangiopericyomas may occur in the head and neck, with the major salivary glands, paranasal sinuses, scalp, face, and auricle as the more common sites. Its clinical course varies from local invasion to distant spread via hematogenous routes. The histologic grade may vary widely and has not been shown to be predictive of the clinical behavior. The hemangiopercytoma must be differentiated from the glomus tumor. Wide local excision is the current mainstay of surgical management. There is a local recurrence rate of approximately 50%, with a high potential for distant metastatic spread. Therefore no definitive course of postoperative management of patients with this tumor has been established. We present the first documented case of hemangiopericytoma arising in the middle ear cleft. The clinical history, radiologic features, pathologic examination, surgical technique of resection, postoperative care, and a review of the pertinent literature will be discussed.

Endoscopic Sinus Surgery in the Pediatric Age Group

Educational objectives: To explain the relative indications for pediatric sinus surgery and the controversies in decision making regarding the patients selection, and to recognize the technical limitations involved in pediatric sinus surgery and be aware of recent advances in equipment in operative procedure.