Romaine F. Johnson

An Evidence-Based Review of the Treatment of Peritonsillar Abscess:

OBJECTIVE: Peritonsillar abscess (PTA) is commonly seen but still controversial. We performed an evidence-based review to answer 3 questions: Are steroids beneficial? Which is the best technique for acute surgical management? When is tonsillectomy indicated? STUDY DESIGN: We performed a MEDLINE search of the published literature using appropriate search terms to identify pertinent articles, which were reviewed and graded according to the evidence quality. RESULTS: Forty-two articles were analyzed. There are no published studies on steroids in PTA. There were 5 level I clinical studies on surgical technique, which indicated that needle aspiration, incision and drainage, and quinsy tonsillectomy are all effective for initial management. The overall PTA recurrence rate is 10% to 15%. CONCLUSIONS: Overall, grade C evidence indicates that several methods of initial surgical drainage are equally effective, and the recurrence rate is low. The literature does not specifically address different treatments for children and adults.

Evaluation of Pediatric Sensorineural Hearing Loss With Magnetic Resonance Imaging

OBJECTIVE To evaluate the incidence and type of intracranial and inner ear abnormalities in children with sensorineural hearing loss (SNHL) identified with magnetic resonance imaging (MRI) and stratified by the degree and type of SNHL. DESIGN Retrospective review of medical records and MRIs. SETTING Tertiary care childrens hospital. PATIENTS A total of 227 children aged 1 month to 17 years (mean age, 5.3 years; male to female ratio, 1:1) with a diagnosis of SNHL underwent MRI from June 1,1996, to June 1, 2002. Of these children, 170 had clinical information available and technically adequate MRIs and were included in the study. INTERVENTION Magnetic resonance imaging. MAIN OUTCOME MEASURE Identification of an abnormality of the intracranial contents, inner ear, and cochlear nerve. RESULTS Of the 170 children, 101 (59%) had bilateral SNHL and 69 (41%) had unilateral SNHL, comprising 271 ears with SNHL. Abnormalities of the inner ear were found in 108 ears (40%) with 87 (32%) having abnormalities of the cochlea, which were considered mild in 63 (23%) and moderate to severe in 24 (9%). Forty-nine of 271 ears (18%) with SNHL demonstrated an either absent (26/49 [53%]) or deficient (23/49 [47%]) cochlear nerve. Ears with severe and profound SNHL had more abnormalities than ears with mild and moderate SNHL (66/138 [48%] vs 23/80 [29%]; P = .006), and children having ears with unilateral moderate, severe, or profound SNHL had more inner ear abnormalities than children with bilateral moderate, severe, or profound SNHL (28/45 [62%] vs 54/144 [38%]; P = .004). CONCLUSIONS The overall incidence of inner ear abnormalities in ears of children with SNHL evaluated by MRI is 40%. The most common abnormalities seen were an abnormal cochlea and abnormal cochlear nerve. Children with severe and profound SNHL have a greater percentage of inner ear anomalies than children with mild or moderate SNHL. Children with unilateral hearing loss have a greater percentage of inner ear anomalies than children with bilateral SNHL.

The contemporary approach to diagnosis and management of peritonsillar abscess

Purpose of reviewPeritonsillar abscess is a common problem, but some aspects of diagnosis and management remain controversial. We review the recent literature on peritonsillar abscess. Recent findingsIntraoral ultrasound can be a helpful diagnostic tool for peritonsillar abscess. For management, needle aspiration, incision and drainage, and quinsy tonsillectomy all yield successful results. Recent reviews have still not established that one treatment is consistently preferred. A randomized, placebo-controlled trail found that the use of intravenous steroids seems to reduce many symptoms, when used along with abscess drainage. SummaryThe use of steroids may be beneficial in the treatment of peritonsillar abscess, and different techniques for abscess drainage are still used around the world, with consistently good results.

Chronic sinusitis: Symptoms versus CT scan findings

Purpose of reviewThe association between symptoms of chronic rhinosinusitis and findings on a sinus CT scan remains controversial. Although the 1997 Task Force on Rhinosinusitis definition of chronic rhinosinusitis includes only symptoms and signs, many clinicians use CT scans for diagnosis and assessment of disease severity. Recent findingsTwo prospective studies evaluated associations between symptoms and CT scan findings. One study compared the diagnosis of chronic sinusitis with findings using a validated CT staging system; the CT findings were poorly predictive of the presence or absence of chronic sinusitis. The other study used a nonvalidated assessment of symptoms and several measurements from CT scans and identified a few significant associations. SummaryThere are few recent studies explicitly addressing symptom severity and CT scan findings in chronic sinusitis. Most studies conclude that there is little correlation between CT findings and symptoms but that both are important in the evaluation of sinusitis.

Genetic mutations and aminoglycoside-induced ototoxicity in neonates.

Objective: Mutations in the 12S rRNA gene have been associated with aminoglycoside-induced ototoxicity. Our objective was to study the relationship of these mutations in neonates, duration of aminoglycoside exposure, and other known risk factors to the presence of hearing loss. Study Design: Prospective case-cohort study. Setting: Three neonatal intensive care units (NICUs) in Cincinnati, OH. Subjects and Methods: We studied a population of premature, low-birth-weight (< 2500 g) infants admitted to one of three ICUs. Demographic, genetic, clinical, and audiometric data were collected, and the prevalence of 12S rRNA mutations was calculated. Results: Of the 436 patients enrolled in the study, 378 were exposed to gentamicin during their ICU stay. Mutations in the 12S rRNA gene were identified in four patients (0.9%), all of whom received gentamicin. Of the cohort, 256 patients (60%) received a complete audiometric assessment; 39 failed their initial hearing assessment. Only one of these patients had a 12S rRNA mutation. Of these 39 patients, the mean birth weight (1645 g vs 1306 g) was significantly less than the birth weight of those infants who passed their initial hearing screening. Definitive hearing assessment for those who failed showed no significant differences, however. Conclusion: The prevalence of 12S rRNA mutations related to aminoglycoside ototoxicity in our study population was approximately one percent. Most patients with this mutation and aminoglycoside exposure showed no evidence of hearing loss. Low birth weight was one risk factor related to the presence of failing a hearing assessment.

Screening to the converted: an educational intervention in African American churches.

BACKGROUND African American women have higher incidences of breast and cervical cancers and African American men present with more advanced stages of colon and prostate cancers than do their non-African American counterparts. Since the church is central to the organization of the African American community, the authors set out to determine whether a church-directed educational project could influence parishioners to obtain cancer screening. METHODS Three African American churches having memberships of 250, 500, and 1,500, respectively, were selected for their different socioeconomic strata: one congregation was composed mostly of working poor, the second was more affluent, and the third consisted primarily of retirees. During a five-week summer period, appropriate literature, health fairs, testimonials by cancer survivors, and visits by representatives of the medical community were used to increase awareness of cancer screening. Surveys regarding cancer-screening behaviors were distributed at the end of church services. Using the guidelines established by the American Cancer Society, individual recommendations for screening examinations were developed and sent to parishioners based on their survey responses. RESULTS Of 437 parishioners surveyed (73% female, 27% male), 75% were 40 years old or older. Many reported up-to-date screening for breast (84%), cervical (78%), colon (62%), and prostate (89%) cancers. The results were remarkably similar in all three churches. Telephone follow-up seven months after the survey directed at the 120 parishioners identified as noncompliant for at least one cancer screening revealed that 49% had obtained the appropriate screenings. CONCLUSIONS These African American churchgoers were well screened compared with estimated national averages, possibly due to previous efforts of the activist ministers in the churches selected. The message for cancer screening is heeded when delivered through the African American church.

Cricotracheal Resection in Children 2 Years of Age and Younger

Objectives We examine the surgical outcomes of cricotracheal resection in children 2 years of age and younger. Methods We performed a retrospective case study involving a single tertiary care childrens hospital. All patients who underwent cricotracheal resection from 1993 through January 2006 were included. Patients 2 years old and younger were compared to patients more than 2 years of age (range, 2 to 44 years). The primary outcomes measured were decannulation and complication rates. We used X2 analyses for categorical variables to detect differences in proportions, Students t-tests for continuous data, and logistical regression to explore for confounding. Significance was set at α = .05, 2-tailed. Results Fifteen children 2 years of age or younger were identified. Most patients underwent a single-stage operation (n = 12). The overall decannulation rate was 87% (2 failures). Two patients younger than 2 years had postoperative complications, including 1 patient who developed anastomosis dehiscence. When compared to the patients over 2 years of age, patients younger than 2 were more likely to undergo a single-stage procedure (p < .01). Additionally, the cricotracheal resection was more likely to be their first attempt at airway reconstruction (p = .002). Complication and decannulation rates were similar in both groups. Conclusions Cricotracheal resection can be performed safely and effectively in children less than 2 years old.

Predictors of obstructive sleep apnea severity in adolescents

Importance Untreated obstructive sleep apnea has severe health consequences, yet little is known about predictors of sleep apnea severity in the adolescent population. Objective To evaluate clinical and demographic factors associated with obstructive sleep apnea severity in adolescents. Design, Setting, and Participants A retrospective case series of 224 children (53% male), ages 12 to 17 years who underwent polysomnography from January 1, 2013, to June 4, 2015. The study was carried out in a large tertiary referral children’s hospital associated with an academic medical center in Dallas, Texas. Children were excluded if they were missing clinical data (eg, tonsil size), had major comorbidities (eg, chromosomal abnormalities), or had previously undergone tonsillectomy and adenoidectomy. The mean (SD) age was 14.6 (1.7) years (range, 12.0-17.9 years), and the patients were 55% Hispanic, 30% African American, 13% white, and 2% other. Exposures Electronic medical records were reviewed for demographic, clinical, and polysomnographic parameters. Main Outcomes and Measures Correlation between demographic and clinical characteristics and the apnea hypopnea index. Results In 224 adolescents (53% male) aged 12 to 17 years, the mean (SD) apnea hypopnea index was 14.9 (28.7) (range, 0.0-187.7) and was positively correlated with CDC-defined weight categories (P = .04) and tonsillar hypertrophy (P < .001). Sex, ethnicity, and age were not associated with the apnea hypopnea index. Severe obstructive sleep apnea (apnea hypopnea index >10) was more common in males (OR, 1.8; 95% CI, 1.0-3.2), patients with tonsillar hypertrophy (OR, 3.2; 95% CI, 1.8-5.8), and patients in a heavier CDC weight class (OR, 2.0; 95% CI, 1.3-3.2). Age and ethnicity did not predict severe obstructive sleep apnea. Conclusions and Relevance Obstructive sleep apnea in adolescents is associated with obesity and tonsillar hypertrophy in this study. Severe obstructive sleep apnea is more likely in adolescents who are male or obese, or who have tonsillar hypertrophy. This study supports routine polysomnography in obese male adolescents with tonsillar hypertrophy and symptoms of sleep-disordered breathing to screen for and treat severe obstructive sleep apnea.

Thermally processed polymeric microparticles for year-long delivery of dexamethasone

Dexamethasone-releasing poly(lactic-co-glycolic acid) (PLGA) microparticles were formulated using a solvent displacement technique with the addition of distillation aiming to increase drug delivery lifetime. Two PLGA copolymer ratios (50:50 and 75:25) were used to determine the influence of lactic acid and glycolic acid ratio on microparticle characteristics. The addition of distillation significantly slows the release of dexamethasone compared to traditional solvent removal via evaporation while still maintaining a therapeutic dosage. Microparticles formulated with PLGA 50:50 controllably release dexamethasone up to one year and 75:25 release up to two years in-vitro. The ratio of lactic acid to glycolic acid plays a significant role in microparticle stability, drug loading efficiency, and thermal properties. In all, this formulation technique offers new prospects for inflammation suppression in pediatric vascular and airway diseases.

Nationwide readmissions after tonsillectomy among pediatric patients - United States

OBJECTIVES 1) Investigate incidence and predictors of readmissions after tonsillectomy with or without adenoidectomy (T&A) in children. 2) Identify factors that may predict readmission. SETTINGS Nationwide cross-sectional survey of US hospital admissions. SUBJECTS and Methods: The 2013 Nationwide Readmission Database (NRD) was used to examine all-cause readmissions within 30 days of T&A in children (age <18 years). Logistic regression was used to analyze the associations of demographics, diagnosis, insurance status, length of index stay, and median household income with readmission. RESULTS 9079 children undergoing T&A resulted in 327 (3.6%) patients requiring readmission. The average age of children readmitted were 5.0 years and they were 51% female. The most common readmission diagnoses were dehydration (47%), hemorrhage (26%), and pain (16%). The average time to readmission was 7.3 days. The average times to readmission for hemorrhage, pain and dehydration were 6.3, 4.5 and 4.1 days, respectively. Children who needed respiratory intubation (OR = 4.0), had a medical or surgical complication (OR = 3.3), or prolonged hospital stay (OR = 1.03) during the index admission were more likely to be readmitted. Age, gender, payer and socioeconomic status and diagnosis of obstructive sleep apnea (OSA) did not increase the odds of readmission. CONCLUSIONS Readmissions in children after T&A were primarily due to dehydration, hemorrhage, and pain. Adequate symptom control in children has the greatest potential to reduce readmission rates following T&A.