Philippe Contencin

Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis.

The etiology and mechanisms involved in determining and/or maintaining the inflammatory process along the airway mucosa remain partially obscure. The role of gastroesophageal reflux (GER) has been demonstrated in some cases of bronchitis and laryngitis especially in children. In adults, GER-related laryngitis has also been mentioned. In children, repeated rhinopharyngitis and otitis media due to GER remain a putative question. In this study, 31 infants and children underwent a day and night nasopharyngeal pH monitoring. Thirteen patients with known GER suffered from chronic or repeated rhinitis or rhinopharyngitis. Eighteen control subjects with or without GER were free of upper airway inflammatory process. In some pathological cases the pH dropped dramatically. The pH drops were more important in most of the GER/rhinitis cases than in controls. Of the reviewed criteria, the percentage of time spent below pH 6 (or pharyngeal acidity index) is the most statistically significant (P less than 0.00005). Thus, the influence of a gastro-esophago-nasopharyngeal acid reflux is strongly suggested in this common pediatric pathology, among other causes. However, the technique used does not allow us to assess the true origin of these pH changes. Further investigation with two-site pH monitoring and larger series of patients are required in order to fully assess the influence of GER on pediatric nasopharyngeal inflammation.

Aryepiglottic Fold Excision for the Treatment of Severe Laryngomalacia

Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.

Gastroesophageal reflux and ENT disorders in childhood

Among controversies in pediatric otorhinolaryngology, the role of gastroesophageal reflux (GER) in inflammatory disorders of the upper airway remains of major concern. A laryngeal involvement by GER was demonstrated in adults and a correlation with GER has been found in pediatric populations with recurrent croup. However, although considered statistically significant, these results concern a few patients only and are inconclusive for a causal relationship. In addition, pH monitoring, often considered as the gold standard for the diagnosis of GER disease, has failed in giving normal values in ENT disorders. Eventually, upper pharyngeal and nasal involvements by GER and GER-related otitis media or otalgia have been suggested by some authors. In the 6th International Congress on Pediatric Otolaryngology, the Symposium on GER was designed to help physicians in improving their knowledge of the data from the literature and their understanding of the involved mechanisms. Bearing in mind the potential severity of GER disease, the audience also heard and debated the most up-to-date methods of assessing GER and treating it in patients with possibly related otorhinolaryngological symptoms. Here is the summary of this symposium.

Acute mastoiditis in children: a retrospective study of 188 patients.

OBJECTIVE The aim of this study is to define the clinical and bacteriological characteristics of acute mastoiditis (AM) in children in order to optimize diagnostic work-up and treatment. METHODS In this retrospective study, 188 children between 3 months and 15 years of age (15±24 months; median±SD) were referred to our pediatric ENT emergency center for AM during a 7-year period (December 2001-January 2008). RESULTS Fifty seven percent were male and 43% were female. Clinical follow-up duration was 3.9±0.7 months (mean±SEM). The incidence of AM remained stable during the whole study period. Microbiological samples (n=236) were negative in 33% of cases. The most frequently isolated germs were Streptococcus pneumoniae (51%), Streptococcus pyogenes (11.5%), Anaerobes (6.5%), and coagulase-negative Staphylococcus (6.5%). Paracentesis, puncture of retro auricular abscess under local anesthesia, and peroperative samples all contributed to isolate the involved germ(s). All the patients were hospitalized and received intravenous antibiotics, and 36.2% (n=68) underwent surgery. Several surgical procedures were necessary in 4 cases (2.1%). AM recurrences requiring a second hospitalization were observed in 8 patients (4.3%). The only observed complication was lateral sinus thrombosis (n=6; 3.2%). Surgical failures, requiring more than one surgical procedure, were more frequent in case of: (i) presence of Anaerobes (p≤0.001) or Gram-negative bacteria (p≤0.05) in microbiological samples; (ii) surgical drainage without mastoidectomy (p≤0.001). Recurrences were more frequent in AM due to Streptococcus pneumoniae. CONCLUSIONS Based on our findings and on literature data, a protocol was established in order to standardize the management of pediatric AM in our center. The mains points are: no systematic surgery; if surgery is indicated, it must encompass a mastoidectomy; broad-spectrum intravenous antibiotic treatment covering the most commonly involved germs (3rd generation cephalosporin) and secondarily adapted to the results of microbiological samples. If the infection is not controlled after 48 h of intravenous antibiotherapy, a mastoidectomy had to be performed.

Laryngeal ultrasonography in infants and children: a new way of investigating. Normal and pathological findings

Ultrasound of the larynx appears as a new way of imaging the larynx in infants and children. The normal sonographic anatomy is briefly described. The pathological findings of this method, its advantages and its drawbacks are discussed. It appears to be a very interesting method for functional disorders and space-occupying lesions.

Hoarseness and gastroesophageal reflux in children

The importance of a hoarse voice or voice change in children has not been stressed in the literature in the same way as it has been in adults. We present 21 children who had been suffering from chronic hoarseness for more than three months and had on fibre-optic laryngoscopy findings suggestive of gastroesophageal reflux. None of them had complained of gastroesophageal symptoms. Twenty-four hour pH monitoring revealed that 13 (62 per cent) of these children had gastroesophageal reflux, seven (33 per cent) having gastroesophageal reflux more than three times the upper limit of normal. The pH graphs highlighted frequent refluxes, ranging from 0.4 to 37.4 refluxes per hour (median of 7.3 refluxes/hour). The majority of these refluxes occurred when the child was awake as opposed to asleep, with a median of 14.8 refluxes/hour and 0.9 refluxes/hour respectively (p = 0.0009). The refluxes were classically of short duration. This study suggests that gastroesophageal reflux plays a direct role in the pathogenesis of chronic laryngitis and hoarseness in children.

Surgical treatment for laryngeal paralysis in infants and children.

Clinical and endoscopic data of 219 cases of laryngeal paralysis in newborns, infants, and children are briefly reported. The management of severe cases of persistent dyspnea then is discussed, according to the literature. Of 219 cases, 22 young patients underwent a surgical procedure because of lack of spontaneous recovery and poor tolerance of their disease after 6 to 9 months of follow-up. Arytenoidectomy technique has been used three times and arytenoidopexy 19 times, with fair to excellent results. Other possible treatments for infants are discussed. On the basis of this important series of surgical pediatric cases, the arytenoidopexy technique is advocated, besides arytenoidectomy, to avoid the risks of a long-term tracheostomy in young patients with vocal cord paralysis and severe dyspnea.

Treatment of infantile subglottic hemangioma. A report of 49 cases

Forty-nine laryngeal subglottic hemangiomas were observed in infants over a 9-year period. The diagnosis was always confirmed by direct laryngoscopy. The outcome of 42 of these hemangiomas was studied. A total of 26 infants recovered completely after medical treatment and 16 were intubated; only 4 underwent a tracheostomy. Short-term steroid therapy was sufficient in 7 infants, but long-term administration of corticosteroids was necessary in 14 cases. In 10 of the 16 intubated cases it was possible to withdraw corticosteroids permanently. Of the 6 remaining cases, 32P contact radiation therapy was tried in 2 cases of which one was successful, CO2 laser in 2 cases without success, tracheostomy alone in one case and one child died 2 months after extubation, without dyspnea. This series leads us to recommend corticosteroids as a first therapeutic step and short-term nasotracheal intubation if unsuccessful.

Lateral cricoid cuts as an adjunctive measure to enlarge the stenotic subglottic airway: an anatomic study

The technique of laryngotracheoplasty, with an anterior approach, with or without a posterior cut, and with or without anterior or posterior cartilage grafts, has been described previously. On occasion, a severely stenotic subglottis or aberrant shape to the cricoid cartilage makes division of the lateral aspects of the cricoid cartilage desirable. In attempting to delineate the relationship of the recurrent laryngeal nerve to proposed lateral cricoid cuts, an anatomic study was conducted. Dissections of neonatal, infant, child and adult larynges and trachea were carried out, with the relative distance of a cut through the lateral cricoid cartilage to the recurrent laryngeal nerve measured and outlined. The distance was very close in the fetal larynx (measuring 1.5 mm in the 23rd week of gestational age), with an increase in dimension in the infant and child, increasing to a distance of over 1 cm in the mature adult. The clinical significance of this relationship to proposed cuts of the lateral cricoid in different age groups is discussed.

Non-endoscopic techniques for the evaluation of the pediatric airway

In children with stridor, a detailed evaluation of the airway is often required to assess precisely its anatomical and functional status. Various methods of assessment have been developed and airway management may include, as well as rigid and flexible endoscopy, the use of imaging techniques such as plain X-rays, a barium oesophagogram, ultrasound, a CT scan, a magnetic resonance image (MRI) and an angiogram, as well as respiratory function tests including acoustic rhinometry and flow volume loops or even pH monitoring. This article aims to highlight the valuable information these alternative techniques can provide.