Robert G. Berkowitz

Acute Mastoiditis in Children: A 12-Year Retrospective Study

We undertook a retrospective study to examine our experience with acute mastoiditis over a 12-year period. Fifty-eight cases were identified in children aged 3 months to 15 years. Acute mastoiditis was the first evidence of otitis media in 54% of our patients. Pain and fever lasting for more than a median period of 4 days were most likely to be the harbingers of incipient acute mastoiditis. Streptococcus pneumoniae was the most common organism recovered from the cultures. All children were treated with intravenous antibiotics; 41 children were managed with an adjunctive drainage procedure. No statistically significant differences were observed between the cure rates and failure rates for children treated surgically with myringotomies with or without tubes and children managed more aggressively with mastoidectomies. One infant had bacterial meningitis. Cholesteatoma was diagnosed in two children. We conclude from our study that acute mastoiditis occurs mainly in young children and may be the first evidence of ear disease. Pain and fever that persist despite appropriate treatment for acute otitis media are the two most important symptoms. Intravenous antibiotics combined with myringotomy with or without tube insertion are as appropriate as intravenous antibiotics with mastoidectomy for initial management of acute mastoiditis in the absence of a subperiosteal abscess or central nervous system extension.

Vallecular cysts in newborns and young infants

Vallecular cyst is a rare cause of stridor and respiratory distress in infancy and has been associated with sudden airway obstruction resulting in death. In a retrospective review of eight cases over a 20‐year period all infants developed symptoms during the first week of life. All had stridor and feeding difficulties and two required endotracheal intubation. Other common findings included signs of increased work of breathing and episodes of cyanosis. Failure to thrive was present in five patients diagnosed later than the first week of life. An abnormal or a hoarse cry was present in only two patients. Diagnosis in all cases was made by endoscopy. Where a VC is clinically suspected, it is important to stress the need to visualize the base of the tongue during any diagnostic endoscopic procedure. At endoscopy, a smooth localized mass arising from and distorting the lingual surface of the epiglottis was identified. Histologically, the cysts contained respiratory epithelium with mucous glands with an external lining of squamous epithelium. Treatment by cyst marsupialization is safe and definitive, in particular when performed by CO2 laser. Pediatr Pulmonol. 1999; 27:282–285.

Unilateral tonsillar enlargement and tonsillar lymphoma in children.

The clinical presentation and surgical and pathological findings of 46 children with unilateral tonsillar enlargement (UTE; age range 2 to 13 years, mean age 6.5) who underwent tonsillectomy for biopsy purposes between 1975 and 1995 were compared with those of 7 children who received treatment for tonsillar lymphoma (TL; age range 2 to 9 years, mean age 4.8) during the same period. There was no history of rapid tonsillar enlargement in children in the UTE group, and only 20 (43%) were symptomatic. Symptoms included recurrent sore throats in 10 patients (22%), snoring in 5 (11%), nasal obstruction in 4 (9%), and dysphagia in 1 (2%). No children had systemic symptoms or significant cervical lymphadenopathy. In contrast, tonsillar enlargement was observed to occur within a 6-week period in all children with TL, and 6 (86%) children had symptoms at presentation that included dysphagia in 5 (71%), snoring in 3 (43%), night sweats in 2 (29%), and fever and rigors in 2 (29%). Cervical lymphadenopathy greater than 3 cm was present in 6 (86%) children, while 1 child (14%) had hepatosplenomegaly. There was no histopathologic evidence of neoplasia in the UTE group, and a true discrepancy in size between the two tonsils was confirmed in only 21 of 44 (48%) cases. All 7 patients in the TL group had non-Hodgkins lymphoma. All received chemotherapy, with 5 of the 7 cured and 2 dying of disease. The data suggest that tonsillectomy should be performed for biopsy purposes in UTE where there is a history of progressive enlargement, significant upper aerodigestive tract symptoms, systemic symptoms, suspicious appearance of the tonsil, cervical lymphadenopathy, or hepatosplenomegaly. The diagnosis of TL should also be considered when UTE is present in an immunocompromised child or one with a previous malignancy, when acute tonsillitis is asymmetric and unresponsive to medical treatment, or when rapid bilateral tonsil enlargement occurs. Observation is appropriate management for other cases of UTE.

Laryngeal Electromyography Findings in Idiopathic Congenital Bilateral Vocal Cord Paralysis

Children with idiopathic congenital bilateral vocal cord paralysis (BVCP) were investigated by electromyography (EMG) of the posterior cricoarytenoid and thyroarytenoid muscles to determine whether laryngeal EMG findings had diagnostic or prognostic significance. Four children between 3 weeks and 33 months of age were studied. Three had abductor paralysis and were tracheostomy-dependent, while the fourth had adductor paralysis requiring a feeding gastrostomy. Two of these patients also had other anomalies. Motor unit potentials showing phasic bursts with respiration were found in all four cases, while three children developed a full interference pattern on lightening of the anesthetic. Follow-up for between 37 and 52 months showed no significant clinical improvement in any of the patients. While the diagnosis of idiopathic congenital BVCP can represent a heterogeneous group of conditions, the findings suggest that normal laryngeal EMG findings may be a feature of idiopathic congenital BVCP but do not imply a favorable prognosis for early recovery. They may, however, have implications to explain the likely site of lesion in idiopathic congenital BVCP.

The Relationship Between Acute Mastoiditis and Antibiotic Use for Acute Otitis Media in Children

OBJECTIVE To determine the relationship between prior antibiotic use and the development of acute mastoiditis (AM) in children. DESIGN Retrospective review. SETTING Tertiary pediatric center. PATIENTS We identified 129 patients with AM who were admitted to our center between 1996 and 2005. MAIN OUTCOME MEASURE Proportion of children who developed AM. RESULTS A total of only 67 patients (51.9%) had undergone any antimicrobial treatment prior to hospital admission. In 1996, 64% of patients with AM had received antibiotics for acute otitis media (AOM) prior to admission (n = 7 of 11), but this percentage had steadily decreased to 27% by 2005 (n = 4 of 15). The yearly number of cases of AM treated in our institution has remained stable over this period. A subperiosteal abscess was identified in 45 patients (34.9%), while the remainder (n = 84) had postauricular inflammation only (65.1%). Nineteen patients with a subperiosteal abscess (42%) and 48 patients without a subperiosteal abscess (57%) had undergone prehospitalization antimicrobial therapy for suppurative AOM. There was no significant difference in antibiotic use between the numbers of patients with or without a subperiosteal abscess. Regarding the sensitivity of bacteria isolated from patients with a subperiosteal abscess, only 1 patient was infected with an organism that was not sensitive to the prehospitalization antibiotic prescribed. CONCLUSION Use of antibiotics to treat suppurative AOM in children might not influence the subsequent development of AM.

Serotonin inputs to inspiratory laryngeal motoneurons in the rat

Serotonergic neurons are distributed widely throughout the central nervous system and exert a tonic influence on a range of activities in relation to the sleep–wake cycle. Previous morphologic and functional studies have indicated a role for serotonin in control of laryngeal motoneurons. In the present study, we used a combination of intracellular recording, dye‐filling, and immunocytochemistry in rats to demonstrate close appositions between serotonin immunoreactive boutons and posterior cricoarytenoid (PCA) and cricothyroid (CT) motoneurons, both of which are located in the nucleus ambiguus and exhibit phasic inspiratory activity. PCA motoneurons received 29 ± 5 close appositions/neuron (mean ± SD, n = 6), with the close appositions distributed more frequently on the distal dendrites, less frequently on the proximal dendrites, and sparsely on the axons and somata. CT motoneurons received 56 ± 15 (n = 6), with close appositions found on both the somata and dendrites, especially proximal dendrites. Close appositions on the axons were only seen on one CT motoneuron. These results demonstrate a significant serotonin input to inspiratory laryngeal motoneurons, which is more prominent on CT compared with PCA motoneurons, and may reflect the different functional role of the muscles that they innervate during the sleep–wake cycle. J. Comp. Neurol. 451:91–98, 2002.

Acute epiglottitis in adults: the Royal Melbourne Hospital experience

Background:   To examine the common presentations and management of acute epiglottitis in adults.

Indications for Mastoidectomy in Acute Mastoiditis in Children

The objective of this study was to identify clinical features of acute mastoiditis in children that are indicative of the need for mastoidectomy. We performed a retrospective chart review of 40 children (20 male, 20 female) between 2 months and 12 years 9 months of age with a diagnosis of acute mastoiditis who were managed in our institution between July 1998 and June 2002. All patients received intravenous antibiotics; this was the only treatment in 14 patients (35%). Tympanostomy tubes were inserted in 22 patients, together with postauricular needle aspiration in 12 (30%), and incision and drainage of subperiosteal abscess in 10 (25%). Mastoidectomy was performed in 4 cases (10%), and cholesteatoma was found in 3. One other child was subsequently found to have cholesteatoma. We conclude that children who present with acute mastoiditis should undergo mastoidectomy if cholesteatoma is clinically suspected, or if extratemporal suppurative complications have occurred.

Neonatal upper airway assessment by awake flexible laryngoscopy

Awake flexible laryngoscopy (AFL) provides simple and quick assessment of both the structure and function of the upper airway. To determine its value in neonates, a prospective study was carried out over 2 years of 110 neonates (80 term, 30 premature) under 6 weeks of age (corrected for prematurity) presenting with symptoms suggestive of upper airway disease who underwent AFL performed by the author. A diagnosis was made in 79 cases, while no cause was found for the symptoms in 31. The commonest diagnoses were vocal cord paralysis (29; bilateral 16, unilateral 13), nasal stenosis (9), laryngomalacia (9), glossoptosis (7), subglottic stenosis (6), and choanal atresia (5; bilateral 2, unilateral 3). The AFL was repeated in 31 neonates and the condition was found to be stable in 16, improved in 8, resolved in 2, and progressed in 1, and an additional diagnosis was made in 4. Endoscopy under general anesthesia with or without corrective surgery was performed in 15 neonates (7 also having repeat AFL). The diagnosis was confirmed in 14 and an additional tracheal abnormality was found in 1. The AFL was complicated by cyanosis in 2 neonates and epistaxis in 1, but all complications resolved with minimal intervention. These data suggest that the neonatal upper airway can be relatively safely and reliably assessed by AFL performed by an experienced clinician.

Decannulation and Survival following Tracheostomy in an Intensive Care Unit

We investigated the long-term outcome of patients requiring tracheostomy in an intensive care unit (ICU) in an attempt to identify risk factors that would indicate a low probability of early decannulation. A retrospective study was conducted of a consecutive series of 106 patients who underwent tracheostomy in the period between January 1, 2001, and December 31, 2001, during their admission to the ICU at the Royal Melbourne Hospital, Melbourne, Australia. There were 61 male and 39 female patients with a median age of 65 years. The indications for tracheostomy were prolonged mechanical ventilation (47), tracheobronchial toilet or risk of aspiration (45), and an unstable or obstructed airway (8). Thirty-seven patients died during the study period. All surviving patients were successfully decannulated (median cannulation time, 25 days). Patients with tracheostomies inserted for an unstable or obstructed airway had a significantly shorter cannulation time (median time of 13 days) as compared to the other two indications (mechanical ventilation, 25 days; risk of aspiration, 33 days; log-rank test, χ2(2) = 14.62 and p = .0007). Multivariate analysis showed that the effect of an unstable or obstructed airway was independent of the remaining group variables. We conclude that ICU patients who need a tracheostomy have a high mortality rate. Only the indication for tracheostomy insertion predicts early decannulation, and other patient variables are not significant predictors.