Philomena Mufalli Behar

Atypical presentations of actinomycosis

Actinomycotic infections of the cervicofacial region are uncommon. Most major medical centers report approximately one case per year. Presenting clinical manifestations are confusing because they often mimic other disease processes. Diagnosis may be difficult due to a general lack of familiarity with the disease and the fastidious nature of the organism in culture. The cervicofacial manifestations of actinomycosis are varied, and a high index of suspicion is required to make an accurate and timely diagnosis.

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.

Medical and Surgical Management of Congenital Laryngomalacia: A Case-control Study

Objective To compare the growth of infants with moderate to severe laryngomalacia who underwent supraglottoplasty to the growth of those treated with medical therapy alone. Study Design Case-control study of patients treated between 2008 and 2013. Setting Tertiary care pediatric otolaryngology practice. Subjects and Methods Fifty-one infants newly diagnosed with moderate to severe congenital laryngomalacia. Seventeen infants underwent supraglottoplasty and 34 matched controls had medical management, which included acid suppression therapy, speech and swallowing therapy, and/or high-calorie formula. The primary outcome measure was weight percentile recorded at the second clinic visit and at the last available follow-up. The secondary outcomes were the need for primary or revision supraglottoplasty, tracheostomy or gastrostromy, or the development of or persistence of failure to thrive. Results There was no difference in the mean weight percentile between the surgical and nonsurgical groups at the time of last follow-up (P = .89). The mean change in weight percentile during the study period was 32% (95% CI, 15%-48%) in the supraglottoplasty group and 31% (95% CI, 22%-40%) in the medical group (P = .97). Five of 5 (100%) patients with failure to thrive managed surgically and 10 of 10 (100%) managed medically were above the fifth percentile at the end of the follow-up period. One (3%) patient in the medical management group required tracheostomy and gastrostomy tube placement. Conclusions Medical management and close observation of infants with moderate to severe congenital laryngomalacia may be a viable alternative to supraglottoplasty in appropriately selected infants.

A Comparison of Bipolar Electrocautery and Chemical Cautery for Control of Pediatric Recurrent Anterior Epistaxis.

Objective To compare the outcome of children with anterior epistaxis treated intraoperatively with either bipolar electrocautery or silver nitrate chemical cautery. Study Design Case series with chart review. Setting Tertiary-care pediatric otolaryngology practice. Subjects Children aged 2 to 18 years treated with either intraoperative bipolar electrocautery or silver nitrate chemical cautery of the anterior nasal septum for recurrent anterior epistaxis. Methods Any reported bleeding event after surgery was recorded. The mean time from surgery to recurrent epistaxis was compared between groups. Results Fifty patients underwent bipolar electrocautery, while 60 patients underwent silver nitrate chemical cautery. Within 2 years, 1 (2%) patient in the bipolar electrocautery group and 13 (22%) patients in the silver nitrate chemical cautery group had recurrent epistaxis (P = .003). Two years after treatment, there was no difference between treatment groups. Overall, 4 patients (8%) had recurrent epistaxis postoperatively in the bipolar electrocautery group at a mean of 4.34 years after treatment, while 17 (28.3%) patients recurred after a mean of 1.53 years of treatment in the silver nitrate chemical cautery group (P = .01). Conclusion Compared to those treated with chemical cautery, those treated with bipolar electrocautery had a longer nosebleed-free period and a lower incidence of recurrent epistaxis within 2 years of treatment. Beyond 2 years, the treatment methods are equivocal. Bipolar electrocautery may be a superior treatment in children who will not tolerate in-office chemical cautery, in those with a risk of severe bleeding, or when it can be combined with other operative procedures.

A Young Man With Enlarging Unilateral Tonsil Mass

A young man in his late teens presented to a pediatric otolaryngologist for evaluation of enlarged tonsils and recurrent tonsillitis. The patient reported 2 episodes of streptococcal tonsillitis and infectious mononucleosis over the past 8 months, as well as frequent throat soreness and associated difficulty swallowing throughout the past year. Results from a review of systems were negative for weight loss, fevers, and malaise. On physical examination, he appeared well and had 2+ cryptic tonsils. A lobular mass was noted to be extending from the inferior pole of the right tonsil. There was no cervical lymphadenopathy. The patient was scheduled for tonsillectomy for recurrent tonsillitis and tonsillar asymmetry. His surgery was delayed for several months to accommodate his college schedule. In the operating room, the tonsils were noted to be 3+ bilaterally. The right tonsil had a smooth, pedunculated, flesh-colored mass extending inferiorly. The mass had enlarged since the prior examination. Both tonsils were removed without complication. The right tonsil with the attached mass was submitted to the pathology service fresh to allow evaluation by flow cytometry. Flow cytometry revealed no lymphoid abnormality. Grossly, the polypoid oval mass measured 2 × 1 × 1 cm, weighed 8.7 g, and had a narrow 0.4-cm-long stalk connecting it to the tonsil (Figure, A). Histologic sections revealed a polypoid structure composed of a fibrovascular core covered by stratified squamous epithelium (Figure, B). A subepithelial band of lymphoid tissue was noted (Figure, C) as well as lymphatic channels accentuated by D2-40 antibody (Figure, D). No cellular atypia was identified. Surgical specimen A

Medical and Surgical Management of Congenital Laryngomalacia: A Retrospective Case-Control Study

Objectives: Compare the growth of infants with moderate to severe laryngomalacia who underwent supraglottoplasty to the growth of those treated with medical therapy alone. Methods: Retrospective case-control chart review of patients treated between 2008 and 2013 in a tertiary care pediatric otolaryngology practice. 51 infants newly diagnosed with moderate to severe congenital laryngomalacia were included. A total of 17 infants underwent supraglottoplasty and 34 matched controls had medical management, which included acid suppression therapy, speech and swallowing therapy, and/or high-calorie formula. The primary outcome measure was weight percentile recorded at the second clinic visit and at the last available follow-up. The secondary outcomes were the need for tracheostomy or gastrostromy, development or persistence of failure to thrive, surgical complications, and new onset developmental delay. The management strategy was considered a success if none of the secondary outcomes occurred. Results: There was no difference in the mean weight percentile between the surgical and nonsurgical groups at the time of last follow-up (P = .89). Twenty-nine (85%) patients in the medical management group and 12 (71%) in the surgical group were managed successfully. There were no statistically significant differences in the success rate between groups (P = .27). Conclusions: Medical management and close observation of infants with moderate to severe congenital laryngomalacia may be a viable alternative to supraglottoplasty.

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