Ted L. Tewfik

Orbital complications of sinusitis in children.

BACKGROUNDnOrbital complications of sinusitis are uncommon but can result in significant morbidity if not appropriately managed.nnnOBJECTIVEnThis study was conducted to evaluate the clinical presentation, diagnosis, management, and outcome of orbital complications of sinusitis in children treated at our institution over a 10-year period.nnnMETHODSnThe study retrospectively reviewed cases of 139 children with evidence of orbital complications of sinusitis admitted to the Montreal Childrens Hospital between January 1990 and March 2000. Factors assessed included the clinical presentation, radiologic findings, management, and outcome (length of admission, complications). Complications were classified as preseptal if they did not penetrate the periorbita. Postseptal complications were defined as those penetrating the periorbita and were further subdivided into cellulitis and abscess categories.nnnRESULTSnSeventy-two percent of patients presented with preseptal cellulitis, 19% with orbital cellulitis, and 9% with subperiosteal abscess. Ophthalmoplegia and proptosis at presentation were found to be predictors of postseptal disease, although computed tomography (CT) was necessary to differentiate between cellulitis and abscess. Preseptal disease resolved with antibiotics in all cases. Postseptal disease was treated medically and in some cases surgically, although surgery did not affect outcome.nnnCONCLUSIONnPreseptal complications of sinusitis can be diagnosed clinically without a CT scan and should be treated with an appropriate course of intravenous antibiotics. Postseptal complications of sinusitis can be diagnosed by the presence of ophthalmoplegia or proptosis and mandate a CT scan to differentiate abscess from orbital cellulitis. Management of these patients should include intravenous antibiotics, reserving surgery for selected cases.

Outpatient tonsillectomy and adenoidectomy: complications and recommendations.

An example of cost-effective alternatives in medical care is the increasing use of out-patient surgery for those children requiring tonsillectomy, or tonsillectomy with adenoidectomy rather than an in-patient procedure. Two studies were carried out to answer questions about the complications, in addition to post-operative hemorrhage, and also the questions about the parental views and concerns relating to providing at-home care for their children following surgery. A triad, including recent history of upper airway infection, knife dissection technique, and increased intra-operative blood loss of 100 ml or more should be used to help identify the risk of post-operative hemorrhage.

Keutel syndrome: Further characterization and review

Keutel syndrome is a rare autosomal recessive disorder characterized by diffuse cartilage calcification, characteristic physiognomy, brachytelephalangism, peripheral pulmonary stenosis, hearing loss, and borderline to mild mental retardation. We report on an Arab boy with Keutel syndrome and cerebral calcifications identified at 15 years while investigating a seizure disorder. The parents are phenotypically normal first cousins. Thirteen cases in 9 families (including this case) have been published. Six families were consanguineous, two had multiple affected sibs (males and females) and 4 families originated from the Middle East.

Lateral neck radiography versus direct video rhinoscopy in assessing adenoid size.

OBJECTIVEnTo evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhinoscopy in assessing adenoid size and the relationship of these methods to associated symptoms and thus the severity of the disease.nnnMETHODSnChildren with suspected adenoid hypertrophy underwent standard lateral neck soft tissue radiographs: the percentage of airway occlusion, adenoid to nasopharynx (AN) ratio, airway to soft palate ratio, and adenoid thickness were assessed by a radiologist. The percentage of airway closure was assessed by direct fibre-optic rhinoscopy in an ear, nose, and throat clinic. Associated clinical symptoms were assessed by parents using a standardized questionnaire, evaluating the severity of symptoms (snoring, sleep apnea, mouth breathing, and otitis media) to give a total symptom score out of 16.nnnRESULTSnNonparametric statistical analysis using Spearmans correlation coefficients was performed on 32 patients. There was a weak correlation, which approaches significance, between the percentage of airway occlusion assessed by fibre-optic rhinoscopy and the total symptom score (r = .344, p = .054). However, this correlation becomes significant when the frequency of otitis media is omitted (r = .367, p = .039). There was also a significant correlation between airway occlusion assessed by rhinoscopy and the percentage of airway occlusion as determined by lateral neck radiography (r = .431, p = .014). There was no correlation between any of the measurements taken by lateral soft tissue neck radiography and total symptom score.nnnCONCLUSIONnDynamic video rhinoscopy is more accurate at assessing adenoid hypertrophy, and the percentage of airway occlusion, as estimated by video rhinoscopy, is better correlated to the severity of symptoms than are values obtained by lateral neck radiography.

The links between allergy and otitis media with effusion.

Purpose of reviewIn this review we will examine evidence indicating that allergic inflammation is present in middle ear effusion. We will also discuss several of the problems relating to the diagnosis of allergy and allergic sensitization, and why anti-allergy treatments have been unsuccessful. This will provide a rationale for future studies in the field linking allergic inflammation with otitis media with effusion. Recent findingsRecent findings in atopic children demonstrated higher levels of eosinophils, T lymphocytes, and interleukin-4+ and interleukin-5+ cells compared with nonatopic patients. T-helper 2 cells and cytokines were found not only in middle ear effusions in atopic children but also in specimens from adenoid tissue. This demonstrates a strong correlation between allergic reaction in the middle ear and the upper airway. SummaryIn summary, as our knowledge of the allergic and nonallergic influences on inflammation broadens, the paradigms of treatment may be altered. The accumulating experimental and clinical data suggest that it may be wiser to screen every child with otitis media with effusion for allergic rhinitis and ultimately to manage those with allergic inflammation differently to nonatopic individuals with otitis media with effusion.

Multidimensional voice program analysis (MDVP) and the diagnosis of pediatric vocal cord dysfunction

BACKGROUNDnVocal cord dysfunction (VCD) can present with signs and symptoms that mimic asthma. This may lead to unnecessary pharmacologic treatment or more invasive measures including intubation. Presently, the diagnosis of VCD can only be confirmed when a patient is symptomatic, via pulmonary function testing (PFT) or visualization of adduction of the vocal cords during inspiration by direct laryngoscopy.nnnOBJECTIVEnMultidimensional Voice Program (MDVP) analysis. a computer program which analyzes various aspects of voice, can detect abnormal voice patterns of patients with upper airway pathology. We determined whether MDVP analysis was useful in the diagnosis of VCD.nnnMETHODSnWe conducted chart reviews of patients referred to our department from 1995 to 1998 with the presumed diagnosis of VCD who had undergone MDVP analysis. The diagnosis of VCD was based on the presenting history, PFT results, laryngoscopy results, as well as voice evaluation conducted by a speech-language pathologist. We analyzed six consecutive patients referred for this investigation. We delineated common trends in the variables measured on MDVP analysis in VCD patients. and compared these with controls and other vocal cord pathology.nnnRESULTSnFive cases of possible VCD had abnormalities in the MDVP variable of soft phonation index (SPI). All five also had abnormalities in the variation in fundamental frequency (vFo). In one case, MDVP analysis was conducted pre- and posttreatment for VCD, and SPI and vFo both normalized. In a sixth case of possible VCD. the diagnosis was not confirmed as the patient had normal PFTs and laryngoscopy. MDVP analysis was normal in this individual. The pattern of abnormal SPI and vFo was not seen in a group of normal controls or in patients with vocal cord nodules.nnnCONCLUSIONSnMDVP analysis may be a useful tool when diagnosingVCD, as well as in evaluating response to treatment.

Head and neck manifestations of Kawasaki disease

Kawasaki disease, also known as acute infantile febrile mucocutaneous lymph node syndrome, is a self-limited vasculitic disease of infants and young children. The cause of the disease remains uncertain. Within the constellation of signs and symptoms, there are numerous otolaryngologic manifestations. The following represents the largest series of patients in the otolaryngology literature, involving 155 confirmed cases of Kawasaki disease as treated at our institution during the last 10 years. The demographic data, clinical pictures of the typical and atypical forms of the illness, as well as the laboratory values, therapy and complications are discussed.

Congenital mid-line cervical cleft: case report and review of literature

Congenital Mid-line Cervical Cleft (CMCC) is a rare but interesting congenital anomaly of the neck that is frequently misdiagnosed. Much controversy exist regarding its aetiology. Embryologically, the occurrence of CMCC is thought to be due to many hypotheses that include impaired mid-line fusion of the first or second branchial arches, exteriorisation of a thyroglossal duct remnant, and or increased pressure in the cervical area from the pericardial roof in the developing embryo. Histologically, the cleft usually consists of a stratified keratinized squamous epithelium with hyperkeratosis, dermal fibrosis and little or no skin appendages. Associated clinical features could include thyroglossal duct cysts, cleft lip/mandible/sternum, cervical contractures, mandibular spurs, microgenia and or bronchogenic cysts. In this article we present a patient with CMCC. An extensive review of the literature is also included.

Hydrogen Peroxide Mouth Rinse: An Analgesic Post-Tonsillectomy

OBJECTIVEnTo compare the analgesic efficacy of hydrogen peroxide (H2O2) mouth rinse with control for post-tonsillectomy pain management.nnnDESIGNnDouble-blinded, prospective, randomized, controlled clinical trial.nnnPATIENTS AND METHODSnThirty-seven patients from 5 to 14 years old undergoing electrocautery tonsillectomy were randomized to either the H2O2 mouth rinse or the water rinse (control) group. For 14 days, patients recorded pain levels twice daily using a visual analogue scale. Analgesic uses, as well as any complications, were also noted by the patients.nnnRESULTSnThirty-seven patients completed the study, 21 in the treatment group and 16 in the control group. Mean postoperative days of pain were 10.3 and 8.3, respectively, and differed significantly (p = .008). Mean postoperative days of analgesic use were 9.0 and 6.7, respectively, and differed significantly (p = .005). Only one incidence of postoperative hemorrhage occurred in the study group.nnnCONCLUSIONnIn our study, the H2O2 mouth rinse does not provide a better analgesic effect than the water rinse for post-tonsillectomy pain relief.

Connexin mutation testing of children with nonsyndromic, autosomal recessive sensorineural hearing loss.

OBJECTIVEnThe etiology of hearing loss is heterogeneous and falls into the two broad categories of genetic and environmental. In the genetic subgroup, 70% are non syndromic. Fifty percent of nonsyndromic sensorineural deafness is due to a mutation in the connexin 26 gene. This article presents the detection rate of connexin mutations in a multiethnic Canadian population.nnnMETHODSnA study of patients with nonsyndromic hearing loss seen over a period of 2 years who had connexin 26 mutation testing.nnnRESULTSnNine of the 18 patients had connexin 26 mutations.nnnCONCLUSIONnThe majority of our patients with connexin 26 mutations had moderate to profound hearing loss. Testing for connexin mutations should be standard care because it accounts for a large proportion of individuals with nonsyndromic hearing loss. Reasons for testing include ruling out a syndromic cause, predicting moderate to profound hearing loss, and the need for language intervention, cochlear implants, and genetic counselling.