Mosaad Abdel-Aziz

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: Operative problems and management

OBJECTIVE Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management. METHODS Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year. RESULTS Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Downs syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms. CONCLUSIONS Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.

Recurrent acute otitis media in infants: Analysis of risk factors

OBJECTIVE Recurrence acute otitis media (RAOM) may cause a considerable morbidity and a great parental concern. The aim of this study was to analyze the risk factors that are likely to be responsible for RAOM in infants, and their impact on treatment failure. METHODS A retrospective study on 340 infants with RAOM was conducted. Data were collected from hospital charts. A 10 days course of amoxicillin/clavulanate was used for treatment of recurrence, while surgical management in the form of adenoidectomy and/or myringotomy was reserved for patients with persistent disease. We analyzed various risk factors that may affect the prognosis of RAOM, including: age, prematurity, upper respiratory tract infections (URTI), duration of breastfeeding, use of pacifiers, parental smoking, seasonality, the presence of siblings (family size), gender, adenoid hypertrophy, allergy, and craniofacial abnormalities. RESULTS Use of pacifiers, short duration of breastfeeding, older infantile age, winter season, URTI and presence of adenoid hypertrophy were identified as risk factors for RAOM. Treatment failure may be due to adenoid hypertrophy, short duration of breastfeeding and it is more common in older age infants. We did not find a significant association between RAOM and gender, prematurity, exposure to passive smoking, the presence of siblings, allergy, craniofacial abnormalities. CONCLUSIONS Factors that may cause recurrence of the disease in infant population are use of pacifiers, short duration of breastfeeding, older infantile age, winter season, upper respiratory tract infections and adenoid hypertrophy. Also, treatment failure may be caused by adenoid hypertrophy and short duration of breastfeeding. Good understanding of these factors may help to decrease the recurrence rate and to improve the treatment of the disease.

Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern.

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair; secondary surgery may be needed to treat this condition. Pharyngeal flap is usually selected for cases with sagittal closure pattern, and sphincter pharyngoplasty is used for cases with coronal closure pattern, whereas cases with circular closure pattern may be puzzling. The objective of this prospective study was to assess the efficacy of tailoring the surgical technique to the preoperative velopharyngeal closure (VPC) pattern and to determine the success of sphincter pharyngoplasty for cases with circular closure pattern. This study was conducted on 48 patients, who presented with postpalatoplasty VPI; the cases were classified into 3 groups according to the VPC: group A of coronal VPC was treated with sphincter pharyngoplasty, group B of sagittal VPC was treated with pharyngeal flap, and group C that exhibited circular VPC was treated with sphincter pharyngoplasty. Speech analysis, nasalance score, and nasopharyngoscopic data were recorded preoperatively and 6 months postoperatively. Also, snoring and sleep apnea were assessed. There were no significant differences between the groups regarding the speech, nasometric, and nasopharyngoscopic data. Although snoring was significantly higher after pharyngeal flap, there was no significant difference regarding apnea. Selection of the surgical procedure depending on the type of preoperative VPC pattern for treatment of postpalatoplasty VPI is an appropriate method. In case of circular closure pattern, sphincter pharyngoplasty is the operation of choice as it has a lower incidence of postoperative snoring than pharyngeal flap.

Congenital aural atresia: Transmastoid approach; an old technique with good results

OBJECTIVE Congenital aural atresia prevents sound conduction to the inner ear, so the child may suffer learning problems. Transmastoid approach is a safe method to create functional pathway by which sound can reach the cochlear fluids but it leaves mastoid cavity which may be problematic. The purpose of this study is to assess the feasibility of improving hearing in those patients on the expense of mastoid cavity. METHODS Forty children with congenital aural atresia were included in this study. All had functioning cochlea on evoked response audiometry and normal cochlear morphology with pneumatized mastoid on CT scan. Transmastoid approach was used for reconstruction of the external auditory canal with covering of the newly created canal using split thickness skin graft. Reconstruction of the tympanic membrane was carried out by temporalis fascia graft. Follow-up of the patients for 3 years was carried out. RESULTS Surgical success is considered on restoration of hearing and maintenance of a patent, infection-free ear canal. This study showed a successful hearing result in 85% of patients at 3 months postoperatively, this result diminished to 65% after 3 years. The incidence of canal restenosis was 17.5%; the narrowing was in the outer cartilaginous part. No cases developed facial nerve paralysis or sensorineural hearing loss postoperatively. CONCLUSIONS Congenital aural atresia is one of the most difficult and challenging surgeries for the otologic surgeon. However, in the hands of experienced otologists, repair of this deformity can be performed safely and with predictable results using transmastoid approach.

V-Y two-layer repair for oronasal fistula of hard palate

OBJECTIVE Oronasal fistula represents a functional problem after cleft palate repair; its closure is technically difficult with a high recurrence rate after primary treatment. The aim of this study was to evaluate the efficacy of closure of oronasal fistula using 2 layers of oral mucoperiosteum in a V-Y manner. METHODS Fourteen patients were subjected for repair of their oronasal fistulas using 2 layers; the first is the oral mucoperiosteum that is elevated and inverted to close the nasal side as a hinge flap, and the second is also the oral mucoperiosteum that is elevated and sutured in a V-Y manner to close the oral side. RESULTS In all cases, the fistula was completely closed at first attempt, no cases developed operative or postoperative complications. Recurrence with not recorded in any case after a follow-up period of at least 12 months. CONCLUSION Closure of oronasal fistula of the hard palate that may develop after cleft palate repair using a two-layer closure in V-Y manner is an easy and ideal method with a high success rate.

The use of buccal flap in the closure of posterior post-palatoplasty fistula

OBJECTIVE Palatal fistulation is a common complication after cleft palate repair, it could occur at any site along the line of cleft closure. Many techniques have been proposed for its repair. However, the incidence of recurrence after initial fistula closure is high. The aim of this study is to evaluate the efficacy of closure of posterior palatal fistula using buccal myomucosal flap. METHOD Fifteen cases with posterior palatal fistulas - after cleft palate repair - were included in this study. Their fistulas were closed in two-layers; an oral mucoperiosteum hinge flap to reconstruct the nasal side and a buccal myomucosal flap from the inner surface of the cheek to reconstruct the oral side. Follow-up was carried out for 1 year. RESULTS The fistulas were completely closed in all cases (100%) with no failure or recurrence. This was a single-stage operation in all cases, with no need for further procedure to divide the pedicle of the flap. CONCLUSIONS Closure of posterior palatal fistula using buccal myomucosal flap in addition to mucoperiosteal flap is a useful method with high success rate and no morbidity.

Nasal encephalocele: Endoscopic excision with anesthetic consideration

OBJECTIVE Nasal encephalocele may presents as a nasal mass, its treatment is surgical and it should be done early in life. When removal is indicated, there are multiple surgical approaches; including lateral rhinotomy, a transnasal approach and a coronal flap approach. However, the treatment of a basal intranasal encephalocele using transnasal endoscopic approach could obviates the possible morbidity associated with other approaches. The aim of this study was to evaluate the efficacy of endoscopic removal of intranasal encephalocele, also to document the role of anesthetist in the operative and postoperative periods. METHODS Nine cases with nasal encephalocele were included in this study; CT and/or MRI were used in their examination. The lesions were removed via transnasal endoscopic approach. Preoperative evaluation, intervention and postoperative follow-up were presented with discussion of anesthesia used for those children. RESULTS The lesions of all patients were removed successfully with no recurrence through the follow-up period of at least 21 months. No cases showed morbidity or mortality intra- or post-operatively. CONCLUSIONS Endoscopic excision of intranasal encephalocele is an effective method with high success rate. Anesthetist plays an important role in the operative and postoperative period, even during the endoscopic follow up; sedation of the children is usually needed.

Asymptomatic cardiopulmonary changes caused by adenoid hypertrophy.

Adenoid hypertrophy is the most common cause of pediatric upper airway obstruction, and it can lead to cardiopulmonary complications such as pulmonary hypertension, cor pulmonale, and even heart failure. The aim of this study was to detect the asymptomatic cardiopulmonary changes that could happen in children with adenoid hypertrophy.Eighty children with adenoid hypertrophy were included in this study. Chest x-ray was used to assess the cardiothoracic ratio, whereas echocardiography was used for measuring the pulmonary arterial pressures, right ventricular diastolic filling parameters, and right ventricular end-diastolic diameters. All patients underwent adenoidectomy with or without tonsillectomy, and they were subjected again to echocardiographic assessment 6 months after the operation.No patient showed an increase in the cardiothoracic ratio on x-ray. Preoperative echocardiography showed an increase in pulmonary artery pressure (22.7 [SD, 3.8] mm Hg), a decrease in right ventricular diastolic filling parameters (E/A = 1.03 [SD, 0.17]), and an increase in right ventricular end-diastolic diameters (1.89 [SD, 0.19] cm). Postoperatively, pulmonary artery pressure decreased to 17.2 [SD, 2.1] mm Hg, right ventricular diastolic filling (E/A) increased to 1.25 [SD, 0.11], and right ventricular end-diastolic diameters decreased to 1.68 [SD, 0.12] cm. The comparison between preoperative and postoperative results for each individual parameter was statistically significant.Clinically asymptomatic cardiopulmonary changes due to adenoid hypertrophy are not rare. Early diagnosis and treatment of upper airway obstruction can prevent these serious complications. Echocardiographic examination should be recommended for these patients as a part of preoperative preparation to avoid anesthetic complications.

Epstein–Barr virus infection as a cause of cervical lymphadenopathy in children

OBJECTIVE Cervical lymphadenopathy is a common pediatric problem; reactive hyperplasia, specific infective agents, and malignancy are mainly the differential diagnosis. The aim of our study was to detect the prevalence of Epstein-Barr virus infection among children who complained of cervical lymphadenopathy and also to evaluate the clinical manifestations of the disease in pediatric patients. METHODS One hundred and sixty children presented with cervical lymphadenopathy were subjected to Epstein-Barr Virus (EBV) serology testing. Cases that showed positivity to heterophile antibody test, and/or EBV-specific antibodies; IgM against viral capsid antigen (VCA-IgM) and IgG against viral capsid antigen (VCA-IgG) were evaluated clinically for manifestations of the disease. RESULTS Twenty-four cases (15%) showed positivity to EBV serology, all of them had posterior cervical lymph nodes enlargement, 70.8% had fever, 66.6% had tonsillo-pharyngitis, 58.3% had splenomegaly, 25% had hepatomegaly, 41.6% had generalized lymphadenopathy, while skin rash was detected in 12.5%, and both palatal petechiae and palpebral edema were detected in 8.3%. CONCLUSIONS EBV infection is not a rare cause of cervical lymphadenopathy in children. Posterior cervical lymphadenopathy in pediatric age group may represent a password for suspicion of EBV infection, while other clinical manifestations of the disease may include hepato-splenomegaly, skin rash, palpebral edema and palatal petechiae.

Nodular fasciitis of the external auditory canal in six Egyptian children

OBJECTIVE Nodular fasciitis of external auditory canal may mimic a malignant tumor due to its progressive course, so it was the aim of this study to focus on a new etiology for aural masses to avoid unnecessary aggressive treatment. STUDY DESIGN Retrospective study on six children presented with aural masses that were diagnosed pathologically to have nodular fasciitis. METHODS Presentation of the cases clinically, radiologically and pathologically was carried out. Surgical excision of the lesions was done through the external canal with follow up of the cases for 1 year. RESULTS Recurrence was detected in two cases, one after 2 months and the other after 4 months. Re-excision was carried out without recurrence till the end of the follow up period. CONCLUSIONS Proper diagnosis of this lesion is mandatory to avoid aggressive treatment (radical surgery and/or radiotherapy) as the disease has favorable prognosis with local excision.