Orval E. Brown

Congenital nasal pyriform aperture stenosis.

Congenital nasal pyriform aperture stenosis is an unusual and previously undescribed cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed due to bony overgrowth of the nasal process of the maxilla. This anomaly may produce signs and symptoms of nasal airway obstruction in newborns and infants similar to those seen in bilateral posterior choanal atresia. Computed tomography confirms the diagnosis and delineates the anomaly. A series of six patients with nasal pyriform aperture stenosis is presented. Four patients were treated with surgical enlargement of the nasal pyriform aperture via a sublabial approach. One patient was repaired via a transnasal approach, and one patient did not undergo surgical intervention. Follow‐up reveals normal nasal airway and facial growth in all patients. Mildly symptomatic patients with congenital nasal pyriform aperture stenosis may be treated expectantly, while severely symptomatic patients benefit from repair via the sublabial approach.

Choanal atresia : a new anatomic classification and clinical management applications

The anatomic classification of choanal atresia is commonly quoted as 90% bony and 10% membranous. This incidence is from a review by Fraser in 1910 of 115 cases, “many of which were insufficiently described.” We have reviewed 47 computed tomography scans of choanal atresia from the literature and 16 from our clinical experience, and classified the anatomy as bony, mixed bony‐membranous, or pure membranous. Our results reveal a combined incidence of 18 (29%) pure bony, 45 (71%) mixed bony‐membranous, and no pure membranous atresia. We propose a new classification of choanal atresia to include bony, mixed, and membranous to accurately reflect the anatomic abnormalities. Our series of 11 patients under‐going transnasal microsurgical repair, a critical review of the literature, and the implications of the anatomic classification on the choice of surgical procedure are presented.

Allergic aspergillosis: A newly recognized form of sinusitis in the pediatric population

In 1983, Katzenstein, et al. first described a form of noninvasive sinusitis in adults, which was histologically identical to allergic bronchopulmonary aspergillosis, with mucin‐containing eosinophils, Charcot‐Leyden crystals, and fungal elements resembling Aspergillus species. The authors have treated six pediatric patients ages 8 to 16 who had findings typical of allergic Aspergillus sinusitis. All patients presented with nasal polyposis and progressive facial deformity. All patients had computed tomography findings of diffuse expansile sinus disease and four patients had evidence of bony erosion, raising the suspicion of malignancy. At surgery, all were found to have multiple sinuses densely packed with greenish‐black inspissated mucin. Therapy consisted of wide surgical drainage with careful follow‐up and nasal steroids.

Tympanometry and otoscopy prior to myringotomy: issues in diagnosis of otitis media

Tympanometry and pneumatic otoscopy were compared to findings at myringotomy in 86 children (163 ears). Seventy percent of the ears (115) had effusion, as revealed by myringotomy. Sensitivity and specificity for tympanometry were 90% and 86%, respectively. Sensitivity and specificity for pneumatic otoscopy were 93% and 58%, respectively. A chi-square was performed to compare the sensitivity and specificity to tympanometry to otoscopy, revealing tympanometry significantly better at determining non-effusion states. Additionally, a combined otoscopy and tympanometry sensitivity and specificity were calculated for those otoscopy and tympanometry determinations in agreement, revealing both sensitivity and specificity above 90%. A Fishers exact probability test revealed no significant differences for the accuracy of tympanometry over otoscopy when the determinations of each were not in agreement. Implications of these results are discussed.

Cor pulmonale secondary to tonsillar and adenoidal hypertrophy: management considerations☆

Eleven cases of cor pulmonale secondary to tonsil and adenoid hypertrophy and upper airway obstruction were reviewed. These patients presented with a spectrum disease ranging from mild, with only abnormal ECG or chest X-ray findings, to severe with hypercarbia, hypoxia, and right heart failure. One patient with severe disease suffered a postoperative respiratory arrest. We have successfully managed 4 patients with severe cor pulmonale with postoperative intubation and assisted ventilation. Hypoxia is the driving stimulus for respiration in patients with upper airway obstruction and hypercarbia. Relief of respiratory obstruction by tonsillectomy and adenoidectomy with postoperative oxygen administration may remove the hypoxic drive, resulting in respiratory arrest. Patients undergoing tonsillectomy and adenoidectomy for upper airway obstruction disease should be screened for cor pulmonale. Affected patients should be managed after surgery in an intensive care unit (ICU) environment with careful monitoring of the respiratory status. Patients with severe cor pulmonale can be successfully managed with planned postoperative intubation and mechanical ventilation to prevent respiratory arrest.

Auditory and temporal bone abnormalities in charge association

CHARGE association is a recently described cluster of congenital defects including ocular coloboma, heart disease, choanal atresia, retarded development and/or CNS abnormalities, genital hypoplasia, and ear anomalies. Although congenital hearing loss has been reported in CHARGE association, no information regarding the underlying temporal bone disease is available in the literature to date. The authors evaluated four patients with multiple anomalies consistent with CHARGE syndrome. Two surviving patients have bilateral severe hearing loss on auditory brain stem response testing. Two patients did not survive, and their temporal bones were obtained at autopsy for histologic examination. All four temporal bones showed severe middle ear defects including ossicular deformities, absence of the stapedius muscle, absence of the oval window, aberrant course of the facial nerve, and dehiscence of the facial nerve canal. In the more severely affected case, a Mondini-type malformation of the cochlea was present, together with multiple anomalies of the vestibular apparatus. Vestibular defects also occurred in the other case; however, the cochleae were found to be normally developed.

Antibiotic therapy for nontuberculous mycobacterial cervicofacial lymphadenitis

Objectives/Hypothesis: To evaluate the efficacy of antibiotic treatment of nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis, both as an alternative and as adjuvant to surgical excision.

Congenital abnormalities of the submandibular duct

Five newborns presented with cystic lesions of the floor of mouth. Four of these patients proved to have congenitally imperforate submandibular salivary gland ducts and the other newborn proved to have a duplication anomaly of the submandibular gland duct and gland. The patients with imperforate Whartons ducts underwent marsupialization with or without ductoplasty and have been without evidence of recurrence for up to three years. The duplication anomaly of the submandibular gland duct responded to simple excision. The diagnosis of congenital anomalies of the submandibular gland and duct can be made on physical examination. Magnetic resonance imaging can be helpful in differentiating congenital imperforate submandibular duct and duplication anomalies of the ductal system. Treatment of the former consists of duct marsupialization in the floor of mouth with or without ductoplasty. Treatment of the duplicated ductal system may best be treated with excision. A failure in diagnosis and treatment may result in ranula formation or sialoadenitis requiring more extensive therapy.

Middle Ear Pressure Variation: Effect of Nitrous Oxide

Previous studies examining middle ear pressure changes due to inhalant anesthesia, including nitrous oxide, have cited equivocal results. An investigation was performed to closely monitor changes in middle ear pressure during middle ear surgery. Baseline tympanometry was performed before anesthesia, and middle ear pressure was then documented in 1‐min time intervals. A total of 97 subjects were studied; 51 received nitrous oxide and halothane, and 46 received halothane alone. Results indicate that nitrous oxide causes significantly greater pressure fluctuations than halothane alone. There were no effects for time of surgery, type of fluid, or baseline. Pressure fluctuation was attributed to eustachian tube function. Case studies are presented to demonstrate subject variability, and suggestions for validation study procedures are presented.

Bilateral posterior choanal atresia: a morphologic and histologic study, and computed tomographic correlation.

Bilateral posterior choanal atresia is an uncommon cause of respiratory obstruction in the newborn. Although the clinical syndrome and treatment options are well known, the abnormal histology has not been well described. Computed tomography (CT) is a useful tool in the radiologic diagnosis of choanal atresia, but has not been correlated with the histopathology. Two patients with CHARGE association (congenital heart defects, choanal atresia, retarded growth and development, hypogenitalism, and aural anomalies) and bilateral posterior choanal atresia were studied with CT. The atresia plates were removed at autopsy and sectioned in an axial plane for gross and microscopic study. The histopathology is described and correlated with the CT studies. These studies show that CT accurately defines the histopathologic abnormalities found in bilateral posterior choanal atresia.