Congenital hip instability in hospital born neonates in Abha

In a prospective screening of 2222 consecutive live hospital births over a ten-month period in Abha, there was an incidence of 3.6% for congenital hip instability by examination within 48 hours of delivery. This is a higher incidence than that reported from most parts of the world and is comparable to earlier Japanese figures. This suggests a regional variation in the incidence of his instability within the Kingdom of Saudi Arabia. Bilateral instability was found in 32% and there was a left lateral dominance. There was a significantly higher incidence in female babies, in the local Saudi population and in first degree relatives of affected babies. Hip instability was noted in 8% of breech deliveries. No association was demonstrable with maternal age, birth order, size of the baby or gestation. Our findings are compared with other published data from Saudi Arabia and the West. The need for continued appropriate neonatal screening for early diagnosis of congenital hip instability is emphasized.

Laser treatment of pharyngeal pouch

The symptoms of pharyngeal pouch become more troublesome, eventually requiring surgical treatment. Excision of the pouch and cricopharyngeal myotomy through a neck incision was the operation of choice until Dohlman described endoscopic diathermy operative treatment 30 years ago. The diathermy technique has been largely superseded by endoscopic microsurgical division of the cricopharyngeus muscle in the party wall using carbon dioxide laser. This operation is now established as a precise, accurate and safe procedure providing reliable relief of symptoms with minimal risk to the patient. Fifteen patients treated by the microsurgical laser procedure in the past 5 years are reported.

Congenital interarytenoid web

Congenital interarytenoid web is a rare laryngeal anomaly whose distinctive feature is a band of tissue joining the medial surfaces of the arytenoids and restricting abduction of the vocal cords. It appears to arise from persistence of the embryonic membranous interarytenoid layers, which form the epithelial lamina of the fetal laryngeal sagittal cleft. This review of 16 cases seen in a 15-year period describes the clinical features, diagnostic evaluation, and management. In addition to the interarytenoid web, which is present to some degree in all patients, associated anomalous features may include subglottic stenosis, enlarged bulky arytenoids, and difficulty exposing the larynx and maintaining the airway during anesthesia and endoscopy. The association of these four features in this rare laryngeal anomaly has not been previously described. Diagnosis depends on direct laryngoscopy with particular attention to the posterior larynx. Tracheotomy may be required for 3 to 5 years as definitive corrective management has not been established.

Clinical and radiological features of chondroectodermal dysplasia

This report documents the presence of chondroectodermal dysplasia in southwestern Saudi Arabia by describing the clinical and radiological features in three patients from two families. Mesomelic dwarfism, characteristic orodental manifestations, small thorax, nail hypoplasia and polydactyly of the hands were seen in all cases. Two patients had atrial septal defect; the third patient, who died, had an undefined cardiac anomaly with congestive heart failure. In addition to the typical radiological features, variations such as anterior scalloping of dor-solumbar vertebrae, syntarsaly and polydactyly of feet with separate unfused metatarsals were seen in one patient each. The combination of ectodermal and mesodermal anomalies permits early recognition of the sydnrome.

Acute epiglottitis

Acute epiglottitis, a fulminating infection in the supraglottic tissue due to Haemophilus influenzae type B can cause relentlessly progressive airway obstruction in infants, children and sometimes in adults. Rapid infection and swelling of the epiglottis and aryepiglottic folds causes airway obstruction which can be relieved by endotracheal intubation. The systemic infection and septicaemia must be treated by the appropriate intravenous antibiotics. Acute epiglottitis must be differentiated from viral laryngotracheitis or "croup" which is very common and from pseudo-membranous bacterial tracheitis which is rare. A protocol for management of acute inflammatory airway obstruction must involve an orderly sequence of diagnostic and therapeutic measures, instituted without delay.

Giant Teflon granuloma of the larynx

Endolaryngeal injection of Teflon paste to augment and medialize the paralyzed hemilarynx aims to improve dysphonia and relieve aspiration. After an initial short-lived inflammatory reaction in the laryngeal tissues, a foreign body granuloma forms around the Teflon. In most cases the results are good but it may occasionally be necessary to consider removal of the granuloma if too large a volume has been injected, if it is inappropriately placed, or if the paralyzed vocal cord subsequently recovers. Surgical removal is difficult and the results are unpredictable. This case illustrates, for the first time, that evaluation using both a high-resolution computed tomographic (CT) scan and endoscopy with telescopes permits satisfactory assessment before removal of Teflon.

Management of airway obstruction in the Pierre Robin sequence

A 10-year retrospective study of the management of airway obstruction in 26 infants with Pierre Robin sequence was made. It was not possible when the infant was first seen to assess the future severity of the airway obstruction but later 3 distinct groups could be identified according to the airway management which had become necessary. The deaths from respiratory obstruction indicate the prime importance of airway management. Laryngoscopy for intubation or endoscopic evaluation was often difficult and sometimes could not be achieved. 'Awake intubation' without general anesthesia has proved to be safer and less difficult using a special purpose slotted laryngoscope. Airway management should be individualized following the progressive sequence of posturing in the prone position, nasopharyngeal tube, endotracheal intubation and tracheotomy until successful control is achieved as indicated by the clinical features and pulse oximetry.

Review of intubation in severe laryngotracheobronchitis

Of 208 children who required relief of severe airway obstruction due to laryngotracheobronchitis by an artificial airway (nasotracheal intubation or tracheostomy) during a 10-year-period, 181 (87%) were intubated and later extubated. Twenty-seven children (13%) had tracheostomies performed. The tracheostomies were for severe subglottic narrowing precluding the passage of an adequate size endotracheal tube in 10 children, and for severe endotracheal tube trauma in 17 children. Five children developed acquired subglottic stenosis (2.4% of 208) and 1 of these has a retained tracheostomy. One child died of cardiac disease. The remaining 202 children had no long-term complications of laryngotracheobronchitis, intubation, or tracheostomy. It is concluded that nasotracheal intubation is a satisfactory artificial airway for laryngotracheobronchitis. Endoscopic evaluation in a selected group of these children will identify those with significant intubation trauma or severe subglottic narrowing in whom continued intubation may cause permanent subglottic damage. The low incidence of acquired subglottic stenosis in this series supports the practice of selective endoscopy and tracheostomy.

Diagnosis of H-type tracheoesophageal fistula

A study was made of the diagnostic aspects of 11 cases of congenital tracheoesophageal fistula without atresia (H-fistula) seen in the 17 years 1971 through 1988. The features of aspiration with feeding were present from birth in all cases, and yet the diagnosis was often delayed. The results emphasise the complimentary diagnostic roles of contrast esophagogram and rigid open-tube endoscopy. The latter not only yields a high diagnostic rate but is necessary for evaluation of associated congenital anomalies of the aerodigestive tract.

Lipoid pneumonia in children following aspiration of animal fat (ghee)

Exogenous lipoid pneumonia induced by modified animal fat (ghee) in 10 children is described. The initial presentation was of an acute or chronic pneumonia which proved refractory to anti-microbial chemotherapy. The radiological presentation varied from mild perihilar consolidation to diffuse and extensive bilateral involvement, particularly of the posterior lung segments. A history of administration of ghee provided the initial clue to the diagnosis, which was confirmed by demonstration of fat by bronchoalveolar lavage or by open lung biopsy. Eight of the 10 patients improved with either steroid therapy alone or steroids with resection of the most involved lung segments. One patient, who had extensive superinfection with Mycobacterium fortuitum, died. Lipoid pneumonia should be considered in the differential diagnosis of 'non-resolving' pneumonias in communities where the cultural practice of infant feeding with ghee is prevalent. Public awareness through health education about the potential hazards of this practice to infants and children can contribute to reduce the incidence of the problem.

Infant tracheotomy--endoscopy and decannulation

The records of 73 infants aged 24 months or less who underwent tracheotomy in a 10-year period were reviewed. Two common problems before decannulation were granulations and suprastomal collapse of the anterior tracheal wall above the internal stoma. There were no decannulation failures which could not be accounted for by the primary airway problem. There was no evidence of unexplained "dependence" on the tracheotomy. The results confirm that tracheotomy in the infant patient can be safe both short-term and long-term. There has been no similar long-term review of tracheotomy in small infants indicating the place of endoscopy and the technique of decannulation.

Patient, provider and hospital characteristics associated with inappropriate hospitalization

To determine the relation between patient and provider characteristics and inappropriate hospital use, we examined adult nonpregnancy hospitalizations from a randomized trial of health insurance conducted in six sites in the United States. Appropriateness of inpatient treatment was based on medical record review; patient characteristics on sociodemographic, economic, and health status; and provider characteristics on descriptors of physician practice and hospital facilities. Twenty-seven percent of admissions attended by physicians licensed for more than 15 years were judged inappropriate, compared to 20 percent for younger physicians. Admissions were more likely to be inappropriate if the patient was female (27 percent compared with 18 percent). Controlling for patient and provider characteristics reduces but does not eliminate the differences in the appropriateness of inpatient care across the study's six sites. Differences in available provider and patient characteristics do not account for geographic differences in inappropriate hospitalization in this study.

Alcohol use and limitations in physical functioning in a sample of the Los Angeles general population

The authors examined the relationships between drinking and perceived current health and physical functioning for a general household sample of Mexican Americans and non-Hispanic whites. These relationships differed by sex and by the presence or absence of medical and psychiatric comorbidity, but not by ethnicity. Among men with a chronic medical illness, current abstinence was uniquely associated with poor current health and physical functioning, especially when current abstinence was combined with a past history of alcohol disorder. Among men without a chronic medical illness, a history of alcohol disorder (irrespective of current drinking) was uniquely associated with poorer functioning. For women, among the medically or psychiatrically ill, drinking was not strongly associated with physical functioning; while among women without chronic medical or psychiatric illness, a history of drinking was uniquely associated with poor physical functioning. The authors interpret the findings in terms of adverse effects of drinking and chronic medical conditions on functioning and the tendency of physically limited and chronically medically ill persons to stop drinking.

T-cell abnormalities in antibody deficiency syndromes

We studied two patients with hypogammaglobulinaemia, three with selective IgA deficiency, and four with selective extreme IgM deficiency for T-cell abnormalities in the circulating blood. Most patients had altered CD4+ helper/inducer and CD8+ suppressor/cytotoxic T-cell subsets, and an elevated percentage of HLA-DR+ and interleukin 2 (IL-2) receptor+ antigens on lymphocytes. One patient with the selective IgA deficiency had an absence of CD4+ T cells in blood. The lymphocytes of eight patients showed a diminished proliferative response and deficient IL-2 production in response to stimulation with phytohaemagglutinin or concanavalin A. The three patients with selective IgM deficiency were found to have a defective T-cell abnormality in IgM synthesis by B cells. It is interesting that CD8+ T cells of the two patients with IgM deficiency demonstrated suppressor cell function for IgM synthesis by the normal B and T cells.

Gastric heterotopia causing airway obstruction

Two infants are reported each with a mass of heterotopic gastric tissue in the hypopharynx causing airway obstruction. Endoscopic laser removal of the tumours proved a satisfactory method of treatment. Gastric heterotopia in the head and neck region is rare but should be considered as a cause of stridor in infants.

Minor congenital laryngeal clefts: diagnosis and classification

Cleft larynx is a rare congenital anomaly. Detection of an unsuspected minor cleft may be difficult, but the pediatric laryngologist should suspect the possibility of cleft larynx from the clinical features. Four minor clefts are reported, three cases of supraglottic interarytenoid cleft and one of partial cricoid cleft. The technique for endoscopic diagnosis and the distinctive features are described and a classification into four types is proposed.

Demographic aspects of ageing

The first part of this paper examines future changes in the age structure of the population of England and Wales which are likely to occur as a result of past and future changes in fertility and mortality. These changes in fertility and mortality are examined in some detail. Different methods of projecting future changes in mortality are discussed. On the basis of conservative estimates of these changes, estimates are made of the future economic strain of dependency and there is some discussion of the way in which this might be best handled to the advantage of both the active and the elderly populations. The second part of the paper looks at different ways of examining improvements in longevity and also discusses some of the biological and environmental factors involved. Reference is made to the limited morbidity data available and the tentative conclusion is reached that improvement in longevity, so far, owes less to the reduction of disease incidence than to medical maintenance. This review paper, which relates to England and Wales, is in two main parts: (1) a general discussion of the population factors and changes which have led to a focusing of attention upon the ageing of the population and associated economic problems; and (2) a consideration of the implications of current health advances for individual survival.

Recurrent respiratory papillomatosis: a 10 year study

Sixty cases of recurrent respiratory papillomatosis in both children and adults treated over a 10 year period were reviewed. An unexpected finding was that nine of the 60 patients (15 per cent) had symptoms by two months of age; an earlier onset than previously described. The control rate was 66 per cent for paediatric onset patients and 44 per cent with adult onset; the former required more operations. No anaesthetic deaths or complications were encountered. Glottic webs were the only surgical complication. The findings confirm that there is no relationship between puberty and the rate of control or recurrence. The necessity for precise and comprehensive endoscopic examination of the upper aerodigestive tract using a range of endoscopes and rigid telescopes under general anaesthetic is emphasized.

Primary retroperitoneal mucinous cystadenocarcinoma

A case of primary retroperitoneal cystadenocarcinoma is presented as the fourth reported case in the world literature to date. The cyst was removed intact and demonstrated an infiltrating malignant process with nuclear pleomorphism and mitotic activity. No ovarian tissue was identified and a cancer antigen 125 (CA 125) test was normal. The patient underwent a staging procedure subsequently that included peritoneal washings, hysterectomy, bilateral salpingoophorectomy, and iliac node dissection. No metastases were found and the patient is without recurrence 22 months postoperative. The literature is reviewed to better define the origin and prognosis of these tumors.

Transient T-cell abnormality in a selective IgM-immunodeficient patient with Brucella infection

We describe here one 9-year-old female patient with an unusual form of selective IgM and CD4+ (OKT4+) helper/inducer T-cell immunodeficiency associated with Brucella infection. During the acute phase of Brucella infection, the percentage of infection. During the acute phase of Brucella infection, the percentage of peripheral blood lymphocytes (PBL) displaying OKT3+, OKT11+, and OKT4A+ phenotypes was decreased, and that of the OKT8+ cell was increased. These phenotypic T-cell abnormalities disappeared after antibiotic therapy in a 5-week period. However, the marked deficiency of CD4+ T cells and the IgM deficiency present during the acute phase of illness remained after recovery from illness. In vitro immunoglobulin production experiments during the acute phase of illness demonstrated that the patient's T cells lacked the capacity to provide helper/inducer function for normal B-cell differentiation to secrete IgM. The patient's T cells were also shown to possess IgM-specific suppressor cell activity on normal B- and T-cell differentiations. Thus impaired T-cell function was shown to be responsible for IgM-deficient antibody production. Defective interleukin 2 receptor expression and production by the patient's PBL in response to mitogenic stimulation also were present, indicating a severe defect in the patient's T-cell function.

A case study of two tunnels driven in the Singapore ‘Boulder Bed’ and in grouted coral sands

As part of the construction of the Singapore Mass Rapid Transit, two tunnels had to be driven from a shaft to Raffles Place Station. Each drive was approximately 170 m long and was mostly in the Singapore ‘Boulder Bed’. This formation underlies much of the Central Business District of Singapore, and is thought to be a colluvial deposit comprising sandstone boulders in a stiff clay matrix

The first 60 m of the upper tunnel had a mixed face with an old coral reef above axis and the Boulder Bed below it. The corals and sands of the reef were highly permeable and had to be injected with chemical grout before tunnelling commenced.

The Raffles Place area is in the commercial heart of Singapore and the tunnels passed close to two high-rise buildings. One of these buildings had an underground car park within 5 m of the upper tunnel. Shield drives in the Boulder Bed had recorded high surface settlements, and there was concern about the underground car park which was known to be sensitive to settlement. It was proposed to drive the tunnels using the New Austrian Tunnelling Method, and one of the justifications for choosing the technique was that the resulting soil movements could be minimized. In order to check this claim surface settlement arrays, inclinometers and extensometers were installed to monitor movements caused by the tunnelling.

Records of ground movements measured are presented, and compared with the movements recorded above shield driven tunnels in the same deposit. Methods of grouting and testing used in the coral and sands are also reported.

New endoscope for (laser) endoscopic diverticulotomy

In the United States, traditional treatment of the hypopharyngeal (Zenker's) diverticulum has been single stage transcutaneous diverticulectomy. Complications following this procedure include mediastinitis, vocal cord paralysis, esophageal stenosis, fistula, and recurrent or persistent diverticulum. Endoscopic diverticulotomy, widely used throughout Europe, is relatively straightforward and efficacious. Transoral management of these diverticulae has allowed symptomatic relief with a low incidence of complications. A new endoscope has been developed to facilitate use of the carbon dioxide laser for endoscopic diverticulotomy. The instrument combines the characteristics of the Dohlman endoscope (bilateral distal slots) with a wider proximal end for microscopic endoscopy, a smoke evacuator channel, a fiberoptic light carrier, and a handle adaptable for suspension microendoscopy.