Zsuzsanna Csákányi

Acute bacterial rhinosinusitis and its complications in our pediatric otolaryngological department between 1997 and 2006

OBJECTIVE A retrospective survey of the number, age, gender, month of admission, type of persistent acute bacterial rhinosinusitis and case history of pediatric patients who did not respond to conservative therapy, and of those who suffered from complications of acute sinusitis. METHODS The case charts of all children (<19 years of age) admitted to our department between January 1, 1997 and December 31, 2006 with persistent acute bacterial rhinosinusitis that within 14-26 days against the course of appropriate conservative therapy have not recovered and complications of acute sinusitis were subjected to a retrospective review. RESULTS Of the 339 patients 182 were admitted with persistent acute bacterial rhinosinusitis and did not respond to conservative therapy and 157 children were diagnosed with secondary complications of acute sinusitis. Males predominated overall (54.8%). The most endangered age range was between 3 and 6 years. The highest number of admissions occurred in March. The maxillary sinus was most frequently involved. Orbital complications were observed in 150 patients: 126 cases of preseptal cellulitis, 9 of orbital cellulitis, 4 of subperiosteal abscess, and 11 of orbital abscess. Further two children were diagnosed with intracranial complications, four patients presented with osteomyelitis and the remaining one exhibited mucocele. Streptococcus pneumoniae was the most commonly cultured pathogen. There were no mortalities, and morbidity occurred in only two cases. The topicality and importance of this subject are illustrated by taking into account of two cases. CONCLUSIONS The complications of acute rhinosinusitis are challenging, but the prognosis can be favorable. Early diagnosis and surgical drainage procedures in conjunction with aggressive medical management remain the standard of care for these critically ill patients.

Propranolol for infantile haemangioma: Striking effect in the first weeks

OBJECTIVE Discuss effect and dynamics of propranolol (PR) treatment in infantile haemangioma (IH) of head and neck in children during follow-up. METHODS Between 2010 and 2011, 22 children with head and neck infantile haemangioma (IH) treated by PR were recruited into the study. In a retrospective chart review clinical data were analyzed at 5 consecutive, different check-up time from 1 week to 12-14 months. Effectiveness of PR treatment was assessed by a symptom score method. RESULTS In the whole series a significant regression was observed in 13 patients (59%) in the first week of the therapy. Further five patients showed this time a marked, two mild improvements, and two children did not respond initially to the PR therapy. In one of them (case #8) later on a mild improvement could be seen too. At the second check-up (1 month after initiating PR therapy) 50% of children showed definitive improvement compared to the first visit. Difference between first and second check-ups was significant, and between the 4th and 5th visits the improvement showed the lowest rate. Comparison of IH regression between the 2nd and the 5th check-ups resulted in a p value a little larger than 0.05. There was not significant correlation between the initial IH severity and the treatment effectiveness at the follow-ups (p>0.05). No significant differences were found in treatment effectiveness concerning the IH localizations, too. CONCLUSION PR treatment is highly effective in children with IHs. The most striking effect is seen at the first week of treatment; later improvement is much slower, sometimes with periods of stagnations. The cause of this is probably the spectacular early effect of vasoconstriction, though other impacts of PR to the individual molecular markers of IH seemed to be less impressive clinically. However, treatment should be continued for at least 6 months because early cessation can cause a relapse.

Volume and surface of the mastoid cell system in otitis media with effusion in children: A case-control study by three-dimensional reconstruction of computed tomographic images

Objective: To characterize the pneumatization of the temporal bone in age-matched healthy children and in children with otitis media with effusion (OME). Study Design: Prospective case-control study. Setting: Tertiary hospital center. Patients: This study included 40 healthy children and 56 children with OME, with age ranging from 2 to 18 years. Intervention: Mastoid volume and surface determination by 3-dimensional reconstruction of axial temporal bone computed tomographic images. Main Outcome Measure: Mastoid volume and surface area comparison of healthy children and children with OME. Results: The mastoid cell system (MCS) grows continuously up to the age of 18 years, with different intensities. The mean ± SD MCS volume and surface of children with OME are significantly lower (2.82 ± 1.51 ml and 40.45 ± 18.14 cm2, respectively) than those of healthy children (10.05 ± 5.3 ml and 84.47 ± 37.95 cm2, respectively). The mastoid volume and surface area of the left and right ears correlate well in healthy children. In children with bilateral OME, the ipsilateral and contralateral ears can be largely different. The ratio of surface and volume is constant in age groups. Conclusion: In children with OME, the functional volume of MCS acting as a pressure buffer and the surface area serving for gas exchange are small. In case of OME, 1 ear could be more seriously affected by the disease. Otitis media with effusion presumably has a negative effect on the mastoid pneumatization process. The surface-to-volume ratio is constant through chronological age and is a good indicator of a normal middle ear function.

Middle ear gas pressure regulation: The relevance of mastoid obliteration

Objectives To establish a mathematical model of middle ear gas pressure regulation and to discuss potential implications for pathophysiology-oriented theoretical approach to middle ear surgery, with particular attention to mastoid obliteration. Background Numerous studies support that small mastoid volume is associated with cholesteatoma. Latest studies show that mastoid obliteration is an effective technique to lower the recurrence rate in these ears. Methods A mathematical model was used to predict the development of gas pressure balance in the function of different middle ear volumes (VME), considering normal and dysfunctional Eustachian tube. Published data as gas pressure input values and our 3D CT reconstruction data in healthy and pathologic middle ears of children were applied. Results The model predicted ⩽6.66 daPa pressure fluctuations in VME ≥3 ml, compared to ≥16 daPa of a VME ⩽1 ml at perfect ET function, because of the different pressure change rate and pressure buffer effect of the MEs. Substantially larger fluctuations can be expected in a VME <3 ml with malfunctioning ET. Modeling mastoid obliteration predicts similar pressure fluctuations to a VME ≥3 ml resulting from elimination of gas exchange surface. Conclusion Pressure change is faster in smaller MEs than in larger ones. Healthy MEs between 3 and 6 ml are very sensitive to the duration of a potential ET dysfunction to develop ME pathology. In MEs with poor mastoid pneumatization and dysfunctional ET, typical in cholesteatoma cases, mastoid obliteration as surgical reduction of mucosal surface for gas exchange can improve ME gas pressure balance resulting in better long-term outcome.

Timely recanalization of lateral sinus thrombosis in children: should we consider hypoplasia of contralateral sinuses in treatment planning?

The objective of this study was to evaluate long-term clinical and radiological outcomes in children treated with lateral sinus thrombosis secondary to acute mastoiditis considering also contralateral sinus hypoplasia. This study was a retrospective chart review, conducted in tertiary pediatric hospital. Medical reports of eight children with acute mastoiditis and lateral sinus thrombosis from 1998 to 2011 were examined in terms of therapy, clinical recovery and radiological proof of lateral sinus recanalization. Three children presented hypoplasia of contralateral venous drainage system. Condition of sinuses was regularly monitored with MRI. Otologically and neurologically, all children recovered fully. All received antibiotics; six received additional low molecular weight heparin therapy. Mastoidectomy was performed on six cases. Incision and thrombectomy were applied in the other two, one involving internal jugular vein ligation. This latter case presented also contralateral venous hypoplasia; visual impairment proved permanent. The other two children with contralateral sinus hypoplasia recovered fully after steroid, dehydration and low molecular weight heparin therapy. Recanalization occurred in all children except the one with internal jugular vein ligation, in whom good collateral circulation was observed. There were no bleeding complications. Anatomical variations of cerebral venous drainage system can frequently be observed and should be considered in treatment planning. Mastoidectomy with antibiotics and additional low molecular weight heparin treatment is a safe, promising alternative to thrombectomy and internal jugular vein ligation in children with lateral sinus thrombosis following acute mastoiditis, also having contralateral sinus hypoplasia. Recanalization can be expected within two to five months.

Visual and neurologic deterioration in otogenic lateral sinus thrombosis: 15 year experience

OBJECTIVES Otogenic lateral sinus thrombosis is a rare complication of acute otitis media whose clinical presentation has changed with the early use of antibiotics. The aim of this study was to analyze the changing clinical signs, vaccination status, therapeutic management and outcome of these patients. METHODS Retrospective chart review of 10 children treated with otogenic lateral sinus thrombosis in a tertiary level teaching hospital in Budapest, Hungary, from January 1998 till August 2013. RESULTS Patients were divided into Early and Late presenting groups. In the Early presenting group, sepsis developed within one week after the onset of acute otitis media. At admission otological symptoms were predominant. The Late presenting group experienced acute otitis media several weeks prior to presentation and in this group neurologic symptoms dominated the clinical picture at admission. All patients received antibiotics. Eight of them were also treated with low molecular weight heparin. All children underwent cortical mastoidectomy. After surgery, the clinical signs of elevated intracranial pressure transiently worsened. This manifested as progression of papilledema in seven children, causing severe visual disturbance in two cases. After medical treatment and serial lumbar punctures all patients except one recovered. This child has permanent visual acuity failure of 0.5D unilaterally. At one year follow up complete and partial recanalization were noted in five and two patients, respectively. CONCLUSIONS After mastoidectomy the signs of elevated intracranial pressure can transiently worsen, papilledema can progress. Daily bedside monitoring of visual acuity and regular ophthalmoscopy with neurologic examination is recommended during hospitalization. Close follow up is advised up to one year. When the dominant sinus is occluded, the clinical scenario is more protracted and severe.

Parental Ease in Asking Others Not to Smoke and Respiratory Symptoms and Illness among Children

Objective: Childhood exposure to secondhand tobacco smoke (SHS) increases a child’s burden of respiratory conditions, but parental smoking bans may reduce such morbidity. This study evaluated household smoking bans and their relationship to respiratory illness in an outpatient otolaryngology clinic. Methods: The study was performed at the Heim Pal National Children’s Hospital, Ear, Nose and Throat (ENT) Department (Budapest, Hungary) from July to November, 2010. A consecutive series of children’s caregivers were approached to participate in a survey measuring household smoking bans, upper and lower respiratory tract symptoms and illnesses, and socioeconomic factors. Bivariate and multivariate logistic regression analyses were performed. Results: Of the 215 caregivers recruited for the study, 208 agreed to participate (response rate of 96.7%). More than half of the children were male (54%), and 39% lived in a household with at least one member who smoked. Smoking was frequently banned inside the car (91.3%) and home (85.1%). Respondents felt it easiest to ask friends (97.1%) and family members not living in the household (98.1%) to refrain from smoking inside the home. Respondents also found it easier to ask a stranger (81.7%) or a family member (61.1%) not to smoke around the child. Logistic regression showed that respondents for children with a history of pneumonia found it less difficult to ask visitors in the home not to smoke compared to children without pneumonia (OR = 0.23, 95% CI = 0.06–0.98). Conversely, respondents for children who had had adenoidectomy found it over three times more difficult to ask strangers not to smoke near the child compared to those of children without adenoidectomy (OR = 3.20, 95% CI = 1.43–6.38). Conclusions: In a population of children visiting an outpatient ENT clinic in Budapest, Hungary, we found a high degree of exposure to SHS. The ease with which caregivers felt towards asking others not to smoke predicted specific respiratory conditions. Since the ENT clinic offers a wonderful opportunity for clinicians to counsel parents on tobacco cessation, increased tobacco education of these providers is needed.

The c-MYC Protooncogene Expression in Cholesteatoma

Cholesteatoma is an epidermoid cyst, which is most frequently found in the middle ear. The matrix of cholesteatoma is histologically similar to the matrix of the epidermoid cyst of the skin (atheroma); their epithelium is characterized by hyperproliferation. The c-MYC protooncogene located on chromosome 8q24 encodes a transcription factor involved in the regulation of cell proliferation and differentiation. Previous studies have found aneuploidy of chromosome 8, copy number variation of c-MYC gene, and the presence of elevated level c-MYC protein in cholesteatoma. In this study we have compared the expression of c-MYC gene in samples taken from the matrix of 26 acquired cholesteatomas (15 children and 11 adults), 15 epidermoid cysts of the skin (atheromas; head and neck region) and 5 normal skin samples (retroauricular region) using RT-qPCR, providing the first precise measurement of the expression of c-MYC gene in cholesteatoma. We have found significantly elevated c-MYC gene expression in cholesteatoma compared to atheroma and to normal skin samples. There was no significant difference, however, in c-MYC gene expression between cholesteatoma samples of children and adults. The significant difference in c-MYC gene expression level in cholesteatoma compared to that of atheroma implies a more prominent hyperproliferative phenotype which may explain the clinical behavior typical of cholesteatoma.

Tobacco intervention teachable moments for pediatric otolaryngologists: Atopy and second hand smoke exposure among children

OBJECTIVES Pediatric otolaryngology clinics have tremendous access to children with allergic conditions, yet no research has evaluated in this setting environmental tobacco smoke and the occurrence of atopic diseases. METHODS Caregivers or parents of 201 consecutive patients in a Hungarian pediatric otolaryngology clinic were queried on otolaryngologic conditions; self-reported diagnoses of atopic diseases; and tobacco smoke exposure. RESULTS A history of asthma was reported in 10.3% of children; 38.7% had at least one parent who smoked. Fifteen out of the 20 children with asthma (75.0%) had at least one parent who smoked. Having a diagnosis of hay fever and having a parent who smoked greatly increased the odds of having a diagnosis of asthma. CONCLUSIONS Second hand smoke exposure among children in an otolaryngology clinic was common, and was associated with co-existing atopic conditions. Pediatric otolaryngologists have an important opportunity to address parental smoking as part their care of children.