Robert A. Weatherly

Neuropsychological and behavioral functioning in children with and without obstructive sleep apnea referred for tonsillectomy.

Adenotonsillectomy (AT) is among the most common pediatric surgical procedures and is performed as often for obstructive sleep apnea (OSA) as for recurrent tonsillitis. This study compared behavioral, cognitive, and sleep measures in 27 healthy control children recruited from a university hospital-based pediatric general surgery clinic with 40 children who had OSA (AT/OSA+) and 27 children who did not have OSA (AT/OSA-) scheduled for AT. Parental ratings of behavior, sleep problems, and snoring, along with specific cognitive measures (i.e., short-term attention, visuospatial problem solving, memory, arithmetic) reflected greater difficulties for AT children compared with controls. Differences between the AT/OSA- and control groups were larger and more consistent across test measures than were those between the AT/OSA+ and control groups. The fact that worse outcomes were not clearly demonstrated for the AT/OSA+ group compared with the other groups was not expected based on existing literature. This counterintuitive finding may reflect a combination of factors, including age, daytime sleepiness, features of sleep-disordered breathing too subtle to show on standard polysomnography, and academic or environmental factors not collected in this study. These results underscore the importance of applying more sophisticated methodologies to better understand the salient pathophysiology of childhood sleep-disordered breathing.

Polysomnography in children scheduled for adenotonsillectomy.

OBJECTIVE: Several studies suggest that a reliable diagnosis of childhood sleep-disordered breathing (SDB) requires polysomnography (PSG). We compared clinical and PSG-based diagnoses in children scheduled for adenotonsillectomy (AT). Parent responses on a validated Pediatric Sleep Questionnaire were used to determine which symptoms could help identify children with clinical diagnoses of SDB but normal PSG. STUDY DESIGN AND SETTING: Thirty-four children aged 5.0 to 12.9 years and scheduled for AT to treat clinically diagnosed sleep-disordered breathing underwent laboratory-based PSG. Results were scored by 3 different criteria: 1) >1 obstructive apnea (2 breaths or longer) per hour of sleep; 2) >5 apneas or hypopneas per hour of sleep; or 3) >1 apnea, hypopnea, or respiratory event–related arousal per hour of sleep. RESULTS: Depending on the criterion used, the PSG documented SDB from a minimum of 18/34 subjects (53%, for criterion I) to as many as 30/34 subjects (88%, for criterion III). Among symptoms studied, absence of daytime mouth breathing and habitual snoring were most helpful in identification of children who had no evidence of SDB on PSG, by criterion I (Chi-square, P < 0.05). The absence of other common symptoms, such as “loud snoring” or “trouble breathing” at night, were not helpful. CONCLUSION: Children with clinical diagnoses of SDB may not consistently meet PSG criteria for this disorder. Questions about daytime mouth breathing and habitual snoring might help clinicians recognize children who would not have SDB on objective testing. SIGNIFICANCE: Clinical identification of SDB confirmable on PSG could be improved. However, available outcome data do not yet clarify whether clinical or PSG criteria best identify children likely to suffer morbidity from SDB. EBM rating: C.

Biodegradable External Tracheal Stents and Their Use in a Rabbit Tracheal Reconstruction Model

Objectives/Hypothesis To design and develop an e‐ternal biodegradable tracheal stent for use in airway reconstructive surgery.

Parotid carcinoma as a second malignancy after treatment of childhood acute lymphoblastic leukemia.

The occurrence of second malignant neoplasms (SMN) in children who survive their primary malignancy is a major cause for concern. Two children with diagnoses of intermediate-risk acute lymphoblastic leukemia (ALL) at 22 months and 2 years of age were treated with multiagent chemotherapy and prophylactic cranial irradiation. They experienced painless parotid swelling 6 and 7 years after successful treatment of the ALL. The patients underwent total parotidectomy, and a diagnosis of mucoepidermoid carcinoma was made. Both patients experienced transient facial nerve paresis. The incidence of SMN in children successfully treated for primary malignancies is 3% to 12%. Salivary gland tumors are being increasingly described in this setting. Long-term follow-up for survivors of childhood ALL is recommended with prompt assessment and resection of parotid swellings, particularly in children who have received cranial irradiation.

Sensitive developmental periods for kanamycin ototoxic effects on distortion-product otoacoustic emissions

The developing rat is hypersensitive to aminoglycoside toxicity, which is expressed early on as a destruction of outer hair cells (OHC). In the current study, distortion-product otoacoustic emissions (DPOAE), which specifically measure the micromechanical activity of OHCs, were used to assess functional effects of administering a regimen of kanamycin to three groups of neonatal rats representing discrete postnatal developmental periods. In this manner, pigmented rats were treated at postnatal days 1-10, 11-20, and 21-30. A series of input-output (I/O) functions obtained for the 2f1-f2 DPOAE during the post-treatment period indicated that detection thresholds were significantly elevated for the animals treated on postnatal days 1-10 and 11-20, with the greatest elevations observed at the higher test frequencies.

Tracheal schwannoma presenting as status asthmaticus in a sixteen-year- old boy: Airway considerations and removal with the CO2 laser

A 16‐year‐old with clinical features of atypical asthma is presented, with a description of the workup leading to the diagnosis of an intratracheal mass. The mass was visualized with a flexible fiberoptic bronchoscope, then surgically removed through a rigid bronchoscope using a CO2 laser. We believe this is the first report of resection using this technique. A discussion of tracheal neurilemmomas (schwannoma) is included. This case reinforces the age‐old adage that “not all that wheezes is asthma.” Pediatr Pulmonol. 1998; 25:393–397.

Pharmacokinetics of kanamycin in the developing rat.

The developing rat is hypersensitive to aminoglycoside ototoxicity during the period of anatomical and functional development of the cochlea. Toxicity is expressed only after a few days of treatment when kanamycin is given during the most sensitive period for production of ototoxicity (postnatal days 11-20). In contrast, when the drug is administered after the 20th postnatal day, the same dose and duration of treatment do not produce an ototoxic effect. Only after prolonged treatment (e.g., > or = 20 days) is there an observed effect. We characterized the pharmacokinetics of kanamycin in the serum of 12- and 25-day-old rats and observed a greater than 2.5-fold increase in elimination half-life in the 12- versus 25-day-old rat. The longer duration half-life of kanamycin in younger rats may explain the hypersensitivity of immature mammals to aminoglycoside ototoxicity.

Apparently new syndrome of sensorineural hearing loss, retinal pigment epithelium lesions, and discolored teeth

We report on a family with early-onset sensorineural hearing loss, abnormal retinal pigment epithelium granularity, accumulation of creamy-white lesions at the level of the retinal pigment epithelium particularly superior to the arcade, and selective discoloration (brown) of molars or canine deciduous teeth that follows an apparent autosomal recessive inheritance pattern. This appears to be a new syndrome that can be distinguished from the known otodental, oculo-acoustic and flecked retina syndromes by the occurrence of distinct dental and ocular abnormalities.

The Microbiology of Complicated Pediatric Rhinosiniusitis

Objective To determine the pathogens causing complicated rhinosinusitis over 10 years at a tertiary pediatric hospital, with a focus on methicillin-resistent Staphylococcus aureus (MRSA). Methods Chart review for patients admitted for complicated rhinosinusitis from 1997–2007. Results 179 patients were diagnosed with complicated rhinosinusitis. Of those, 67(37.4%) required surgical treatment in addition to antimicrobials. 51 surgical cultures (76.1%) were positive. Single organisms were isolated from 28 cultures (54.9%), while 23 of 51 were polymicrobial. The most frequently isolated pathogen was from the Streptococcus anginosus/milleri/constellatus group, comprising 29.4% of positive cultures. Anaerobes were identified in 23.5% of cultures and group A streptococcus in 19.6%. Organisms common to normal human oral flora accounted for 80.3% of isolates. Staphylococci were isolated from 17 cultures (33.3%). Three (5.8%) of 51 isolates were MRSA. No MRSA isolate was part of a polymicrobial infection. All occurrences of MRSA were within the last 2 years of the review. Conclusions At our institution, MRSA accounted for 5.8% of culture positive complicated rhinosinusitis cases in the last 10 years, but all presented within the last 2 years. This suggests a potential recent increase in MRSA prevalence in this clinical presentation. Therefore, MRSA should be considered as a potential pathogen in these children, although the overall 10-year frequency is low. Most pathogens were common oral commensal organisMS This suggests that host factors play an important role in the pathogenesis of complicated rhinosinusitis.

Pediatric Sleep Questionnaire Scores Predict PostOp Improvement on PSG and Behavior

Problem: Children scheduled for adenotonsillectomy frequently also have reversible disruptive behavior disorders (DBD). We examined whether preoperative scores on a sleep questionnaire could assist in predicting postoperative improvement of both polysomnographic variables and disruptive behavior disorders. Methods: Sixty children, (mean age, 8.3 years) were studied. Behavior assessment, a sleep questionnaire, and nocturnal polysomnography were completed shortly before and 1 year after adenotonsillectomy. Psychiatric evaluation was performed by a child psychiatrist. The Sleep Disordered Breathing Subscale Questionnaire included questions pertaining to symptoms of nocturnal obstruction and behavior items. Obstructive apneas and hypopneas were defined as 2 breaths or longer in duration. Rates of respiratory event-related arousals plus apneas and hypopneas defined the respiratory disturbance index (RDI). Results: Severity of SDB generally improved after adeno-tonsillectomy. DBDs were initially diagnosed in 25 (42%) of subjects and resolved in 12 (48%) of the diagnosed children postoperatively. There were no significant differences noted in the preoperative obstructive apnea index, apnea/hypopnea index, RDI or minimum oxygen saturation (t tests, all P > 0.05) in children whose DBD resolved as compared to those whose DBD did not. There were, however, significant correlations between high scores on the preoperative SDB subscale and postoperative improvement in apnea/hypopnea index (Pearson correlation coefficient r = .28, P < 0.03), obstructive apnea index (r = 0.32, P < 0.02), and RDI (r = 0.28, P < 0.04). There was also a strong correlation seen between high preoperative questionnaire scores and resolution of DBD (r = 0.28, P < 0.02). Conclusion: Questionnaires about preoperative symptoms of SDB are predictive of improvement in polysomnographic abnormalities and DBD after adenotonsillectomy. The use of a Pediatric Sleep Questionnaire may be useful in determining which patients have behavioral disorders potentially treatable with surgical intervention. Significance: Questionnaires may provide a simple, inexpensive method of predicting clinical improvement after adenotonsillectomy in children with SDB and DBDs. Support: None reported.