S. Thomas Westerman

Paper patching for chronic tympanic membrane perforations.

OBJECTIVE This study was designed to evaluate the results of paper-patch myringoplasty in patients with chronic perforations of the tympanic membrane of different sizes. STUDY DESIGN AND SETTING A retrospective survey of paper-patch myringoplasties performed in a tertiary referral academic medical center on 77 patients with chronic perforations of the eardrum was carried out. Data consisted of the causes of the perforations, time the perforations had been present, their size, number of patch applications, duration of application, and number of successfully closed perforations. RESULTS Closure rate was 63.2%, 43.5%, and 12.5% for small, medium, and large perforations, respectively. Small perforations needed the least number of repeated applications and the least time for closure. CONCLUSIONS AND SIGNIFICANCE Paper patching is technically simple, time saving, safe to perform, cost effective, and suitable as an outpatient procedure and has a good success rate, It should be tried in perforations smaller than 5 mm before a patient is referred for surgery.

EFFECTS OF MIDDLE EAR EFFUSION ON THE VESTIBULAR SYSTEM IN CHILDREN

Vertigo and dizziness are not common in childhood, but are probably present more often than was formerly thought. These symptoms caused mainly by otitis media and middle ear effusion, two of the most common diseases in children, have been neglected for a long time, both in the literature and in practice, until recently. The purpose of this study was to determine objectively the incidence of balance-related symptoms in children with long-lasting middle ear effusion and to discover whether these symptoms resolve after the insertion of ventilation tubes. One hundred thirty-six children, ages 4 to 9 years, were given electronystagmographic tests and the Bruininks-Oseretsky tests for motor proficiency before and after tube ventilation of the middle ear. The results were compared with those in 74 healthy children with no history of middle ear diseases. Pathologic findings were found in 58% of the children with chronic middle ear effusion, as compared with only 4% of the control group. The symptoms and signs of balance disturbances resolved in 96% of the children after ventilation tube insertion. The results of this study indicate that balance-related symptoms often encountered in young children may result from chronic middle ear effusion and that these symptoms will resolve after evacuation of the effusion and ventilation of the middle ear.

Laser Partial Epiglottidectomy as a Treatment for Obstructive Sleep Apnea and Laryngomalacia

Obstructive sleep apnea (OSA) and laryngomalacia are two different entities. Occasionally, they may have a common etiology: an elongated, flaccid, and lax epiglottis that is displaced posteriorly during inspiration causing airway obstruction. Twenty-seven adults with a diagnosis of airway obstruction or OSA of various degrees, and 12 infants with severe stridor associated with frequent apneas due to laryngomalacia, who on fiberoptic examination were found to have a posteriorly displaced epiglottis, underwent partial epiglottidectomy with a CO2 laser. Their postoperative recovery was uneventful. Polysomnographic studies performed after operation in the adult patients demonstrated statistically significant improvement in 85% of the patients. In all the cases of laryngomalacia, stridor ceased permanently after surgery, together with complete cessation of the apneic episodes. This study demonstrates that similar pathophysiological mechanisms may be involved in both laryngomalacia and in OSA. Effective and relatively safe treatment can be achieved by partial resection of the epiglottis with a microlaryngoscopic CO2 laser.

Effect of middle ear effusion on the vestibular labyrinth

Although middle ear effusion was once described as the most common cause of vestibular disturbance in children, the association between glue ear and symptoms of dysequilibrium has never been quantified objectively. In this study the effect of middle ear effusion on the vestibular system of the inner ear was studied in a select group of children suffering from long lasting effusion in the middle ear with no evidence of infection at least one year prior to the study. The results were compared with results obtained from otitis free children, as well as from examinations of children after the insertion of ventilating tubes. The results of this study confirm the assumption that middle ear effusion has an adverse effect on the vestibular system, which can be resolved following the insertion of ventilation tubes. This effect may also contribute to the adverse effect that otitis media has on a childs development.

Reading performance in children with otitis media

OBJECTIVE: To examine whether middle ear diseases and the associated hearing loss in early childhood affect reading performance later at school. STUDY DESIGN AND SETTING: One hundred and sixty children, 6.5 to 8 years of age, were enrolled in this study: 80 children with a history of recurrent infections and/or prolonged periods of effusions of the middle ear before the age of 5 years, and 80 healthy children without any history of middle ear disease. Data were collected from the medical records of the children. Every child underwent a complete otological and audiological evaluation, followed by special reading tests. RESULTS: The study group performed more poorly, in all reading tests, as compared to the controls (P < 0.001). CONCLUSION: Children with recurrent or prolonged middle ear diseases during the first five years of life tend to be at greater risk for delayed reading than aged-matched controls with no previous middle ear diseases.

PROPHYLACTIC TREATMENT AFTER VENTILATION TUBE INSERTION : COMPARISON OF VARIOUS METHODS

Otitis media is recognized as one of the most common diseases of childhood. Insertion of tympanostomy tubes for the treatment of otitis media is the most frequently performed otologic operation, and postoperative otorrhea is its most common complication. Many authors have suggested various reasons for posttympanostomy otorrhea, and many different prophylactic treatments were proposed in recent years to prevent this bothersome and frustrating complication. This retrospective study was designed to investigate and compare the efficacy of various prophylactic treatments and to define the most effective method of reducing the rate of postoperative otorrhea. (Otolaryngol Head Neck Surg 1998;119:117–20.)

Extraction of a large tracheal foreign body through a tracheotomy

Foreign body aspiration is not uncommon in children and is a significant cause of childhood morbidity and mortality. Laryngotracheal foreign bodies, although less common than bronchial foreign bodies, are potentially more dangerous and require urgent recognition and treatment. Most of the aspirated foreign bodies are removed with the use of classic instruments like rigid bronchoscope and foreign body forceps, or more rarely with flexible fiberoptic bronchoscope, but sometimes we fail to remove them. We present a large nonasphyxiating, aspirated foreign body lodged in the subglottis of a a-year-old child, which was removed through a tracheotomy under bronchoscopic control, followed by primary suture and closure of the tracheotomy site. Under general anesthesia, bronchoscopy demonstrated a hollow conic-shaped plastic piece of a toy (Fig 2). Repeated attempts to extract the foreign body through the larynx failed because of the size of the foreign body, the fact that its larger diameter was upward, and the anatomic shape of the subglottic region. An attempt at rotation of the foreign body failed too, because of its length. The foreign body was therefore pushed to the right mainstem bronchus, and a tracheotomy was performed over the ventilating Stotz-Hopkins bronchoscope, using a superiorly based tracheal flap (Fig 3). The foreign body was then manipulated endoscopically to the stoma and removed without difficulty. The bronchoscope was replaced by an endotracheal tube, and the flap was returned to its original position and sutured to the tracheal wall.

Qualitative measurement of drugs.

It has been noted for several years that certain drugs produce abnormal test results in patients who are administered the elcctronystagmograph (ENG) test. Drug specific waveforms, termed drug evoked potentials (DEP), have been identified by using the ENG for alcohol, marijuana, cocaine, tranquilizers, amphetamines, barbiturates, opiates, hallucinogens, caffeine, aminophylline, dopamine, several gases and approximately 75 combinations of drugs (N=821). Tests for double blind diagnosis of drug intake as well as tests for repeatability within the same subject were conducted. Subjects included surgical candidates, healthy volunteers, and neonates (N=248). Drugs tested were ketamine hydrochloride, fentanyl, sodium pentothal, cocaine, dextroamphetamine, sodium seconal, morphine sulfate, phenobarbital, and meperidine. Placebos of dextrose in water and sucrose tablets were also used (N=25).

P150: An Open Safety Pin in the Esophagus: Challenging Treatment

OBJECTIVES: To characterize the phenotype of neonatal variant of Bartter’s syndrome with deafness (BSND). METHODS: A 20-year period follow-up of 17 patients with BSND, from a Bedouin Arab tribe from the south of Israel. The disease was due to a single mutation (G28A mutation in exon 1). Relevant clinical data from neonatal intensive care unit, renal and blood chemistry at birth and during childhood were included. All patients underwent an audiological work-up in the first year of life. Two patients underwent high-resolution CT scan of the temporal bone (TBHRCT). RESULTS: All pregnancies were complicated by polyhydramnion and premature birth. Nine infants developed serious bacterial infections (urinary tract infection, 3; bacterial sepsis, 6). The average length of hospital stay after birth was 9.3 3.1 weeks. Two infants died of respiratory failure and sepsis. Hypokalemia was common during follow-up visits (as low as 1.8 mmol/L), in spite of potassium chloride supplementation. All children had been treated with indomethacin (2 mg/kg/day) and potassium supplementation (1.5-3 meq/kg/day). The current average serum creatinine and calculated creatinine clearance from the older group (n 8; mean age: 8.8 1.4 years) is 60.8 16.5 mmol/L and 95 20 ml/min/1.73m2, respectively. CONCLUSIONS: Profound SNHL was diagnosed in all but one case. The latter exhibited flat audiogram with thresholds of around 70dB and developed normal speech. TBHRCTs were completely normal. Profound SNHL is evident in almost all patients with BSND. This finding is mostly attributed to the genetic effects on cochlear development and possibly also to additional postnatal insults to the cochlea.

Ventilation tubes and cholesteatoma: What is the association?

Objectives: Myringotomy and ventilation tube (VT) placement is the most common otological procedure performed today in children. The incidence of posttympanostomy cholesteatoma related to the VT is relatively low, but this complication is associated with a high morbidity rate. This study was designed to examine the incidence of this complication in relation to different variants. Methods: The study consists of a retrospective analysis of VT placements performed in 2829 children (5575 ears) during the years 1978 through 1997. The following information was obtained: sex, age at which the tube was placed, indications for tube insertion, type of tube used, number of previous tube insertions, incidence of postoperative otorrhea, length of time the tube maintained its position, and the presence of cholesteatoma at or near the site of the tube insertion. Follow-up was from 1 to 20 years. Results: Sixty-two cholesteatomas related to the VT were diagnosed (1.1%). The incidence of posttympanostomy cholesteatoma was higher when the tubes were inserted in children younger than 5 years, with the use of Goode T tubes (as compared with polyethylene tubes), in cases of multiple tubes placements, when the intubation period exceeded 12 months and when there were 3 or more episodes of otorrhea while the tubes were in place. Conclusion: In light of the large number of ears studied, the many criteria used, and the prolonged follow-up period, this study provides important data regarding the risk of a cholesteatoma related to a VT and underlines the need for close and adequate follow-up of children after VT placement.