Demographics of Pediatric Head and Neck Infections in a Tertiary Care Hospital

EDUCATIONAL OBJECTIVE

Discuss potential patterns in the epidemiology of infectious disease of the head and neck.

STUDY OBJECTIVES

To investigate patterns in the epidemiology of severe head and neck infections that may reflect the impact of host factors.

STUDY DESIGN

Population-based, historic cohort study.

METHODS

Information on 1,010, incident head and neck infections occurring over a 5-year period was reviewed for demographics, location, and time of year. A nonparametric Kruskal-Wallis test was used to identify significant differences in the age distributions among the diagnosis groups. A Bonferroni, pair-wise comparison procedure was used for comparison of the average age of first onset of severe head and neck infections. Chi-square test was used to identify any significant association between season of the year and disease.

RESULTS

Significant differences were identified in the age distributions among the diagnosis groups (P < .001). The average age of first onset of cellulitis of the neck and retropharyngeal abscess is earlier than peritonsillar abscess, at 2 to 3 years and 13 years, respectively. Parapharyngeal and periapical abscesses and cellulitis of the face occur at approximately age 6. The incidence of parapharyngeal abscess and diseases of the pharynx is decreased during Spring, whereas peritonsillar abscesses and acute periodontitis occurs more often in Spring and Summer. Age does not appear to be related to season of first occurrence.

CONCLUSIONS

Head and neck infections are not random occurrences based on exposure alone; host factors are clearly important. Given the lack of correlation with school age, the results cannot be explained on the basis of exposure alone. Developmental patterns of the host immune response may be related to the age differential identified in the current study and are cause for further investigation.

Complications in Head and Neck Surgery

OBJECTIVE

To summarize the potential risk factors for postlaryngectomy pharyngocutaneous fistula.

DATA SOURCES

Observational studies in the English-language literature about postlaryngectomy pharyngocutaneous fistula from January 1, 1970, to March 31, 2003. Studies were identified through a MEDLINE search with relevant key words; additional studies were identified through references.

STUDY SELECTION

We included studies about the site of primary malignancy, type of procedure, and type of closure; studies had to have been based on individual-level data, with a comparison group for each risk factor evaluated.

DATA EXTRACTION

Data required to calculate the relative risk of fistula associated with commonly reported risk factors were abstracted from the studies, and a meta-analysis using a random-effects approach was performed to estimate a summary relative risk of fistula for each risk factor. The statistical significance of heterogeneity of effects among studies was assessed.

DATA SYNTHESIS

Of 65 studies identified, 26 met the inclusion criteria. Significant risk factors identified in the pooled analysis included postoperative hemoglobin level less than 12.5 g/dL, prior tracheotomy, preoperative radiotherapy, and preoperative radiotherapy and concurrent neck dissection. The degree of heterogeneity of effects among studies was significant for postoperative hemoglobin level, preoperative radiotherapy, concurrent neck dissection, and comorbid illness. The severity of fistula was greater in patients with a history of radiotherapy.

CONCLUSIONS

This meta-analysis identified several significant risk factors for postlaryngectomy pharyngocutaneous fistula. The clinical implications of these findings and the potential sources of heterogeneity of effects among studies are discussed.

The throat: an important site for MRSA colonization

In order to evaluate the value of bacterial cultures taken from the throat, 266 patients with MRSA were retrospectively assessed. At the time when MRSA was first detected in the patient, the most frequent sites positive for MRSA were a skin lesion (110 patients, 41%), the anterior nares (109 patients, 41%), and the throat (102 patients, 38%). In 26%, 17%, and 17% of the patients, a skin lesion, the anterior nares, and the throat, respectively, were the only site where MRSA was seen. In 123 patients cultured for MRSA because of a close contact with an already known MRSA patient, 65 patients (53%) were positive for MRSA in their throat and in 40 patients (33%), throat was the only sample site with MRSA at the time when the patient was found to be MRSA positive. 146 of the 266 patients (55%) were colonized with MRSA in the throat any time throughout the period they were MRSA positive. We conclude that throat is an important reservoir for MRSA and that samples taken from the throat should be included in screening patients for MRSA.

Gaseous distention of the hypopharynx and cervical esophagus with nasal CPAP: a mimicker of pharyngeal perforation and esophageal atresia

BACKGROUND

Nasal continuous positive airway pressure (CPAP) has been used since 1975 as the initial treatment for respiratory distress syndrome (RDS) in very premature infants. Gaseous distention of the abdomen (CPAP belly) is a common secondary effect of CPAP. Gaseous distention of the hypopharynx is also common.

OBJECTIVE

To determine the incidence of hypopharyngeal distention in infants on CPAP.

MATERIALS AND METHODS

We performed a retrospective review of the chest radiographs of 57 premature infants treated with CPAP during a 4-week period to find the presence and degree of hypopharyngeal distention.

RESULTS

Of the 57 radiographs, 14 (25%) revealed gaseous distention of the hypopharynx and/or cervical esophagus. On occasion, this raised concern for pharyngeal perforation or esophageal atresia.

CONCLUSION

Awareness that CPAP-related hypopharyngeal distention is common should help radiologists avoid erroneous consideration of esophageal atresia or hypopharyngeal perforation.

Laryngopharyngeal dysfunction after the Norwood procedure

OBJECTIVE

We sought to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction after a Norwood procedure compared with that after biventricular aortic arch reconstruction.

METHODS

From April 2003 through December 2004, 36 neonates underwent a Norwood procedure; 33 of 36 had postoperative fiberoptic laryngoscopy and modified barium swallow. Study results were used to guide the transition from nasogastric tube to oral feeding and placement of gastrostomy tubes. During the same time period, 18 neonates underwent aortic arch reconstruction as part of a biventricular repair.

RESULTS

After a Norwood procedure, laryngoscopy showed left true vocal fold (cord) paralysis in 3 (9%) of 33 patients. The results of a modified barium swallow were abnormal in 16 (48%) of 33 patients, with aspiration in 8 (24%) of 33 patients. Of the 3 patients with vocal fold paralysis, 2 had a normal modified barium swallow result, and 1 had aspiration. Gastrostomy tubes were placed in 6 (18%) of 33 patients, all with an abnormal modified barium swallow result. Hospital stay was longer in patients with an abnormal modified barium swallow result: 34 +/- 13 versus 22 +/- 7 days (P < .01). After biventricular repair with aortic arch reconstruction, left true vocal fold paralysis occurred in 4 (25%) of 16 patients; results of a modified barium swallow were abnormal in 10 (59%) of 17 patients, with aspiration in 6 (35%) of 17 patients (all nonsignificant vs patients undergoing the Norwood procedure). Follow-up laryngoscopy in 4 patients with vocal fold paralysis showed no change in 3 of 4 patients and improvement in 1 patient. Follow-up modified barium swallow showed resolution of aspiration in 11 (85%) of 13 patients. Hospital survival was 32 (89%) of 36 patients for the Norwood procedure and 18 (100%) of 18 patients for biventricular repair. There has been 1 sudden death before second-stage palliation.

CONCLUSIONS

After a Norwood procedure, swallowing dysfunction occurs in 48% of patients, with aspiration in 24%, and results in increased length of hospital stay. Left recurrent laryngeal nerve injury, seen in 9% of patients, is an uncommon cause of swallowing dysfunction. Postoperative aspiration generally resolves over time, whereas vocal fold paralysis does not. Systematic evaluation of swallowing function allows appropriate tailoring of feeding regimens and might contribute to decreased hospital and interstage mortality.

Is laryngopharyngeal reflux an important risk factor in the development of laryngeal carcinoma?

Laryngopharyngeal reflux (LPR) as a causative irritating factor in the development of laryngeal carcinoma has been suggested. However, the association between LPR and laryngeal carcinoma remains unclear. The aim of this study was to compare the prevalence and severity of reflux between patients with laryngeal carcinoma and clinical LPR. The intention was to find out if a correlation exists between the laryngeal findings and the level of acid reflux. The study population consisted of 29 patients with laryngeal cancer (group I), 33 LPR patients with normal laryngeal findings (group II) and 70 LPR patients with related laryngeal pathology (group III). The results of 24-h, double-channel ambulatory esophageal pH monitoring were analyzed comparing the three groups. The occurrence and severity of abnormal acid reflux at the upper and lower esophageal segments were evaluated. The incidence of LPR or gastroesophageal reflux (GER) did not vary in any of the three groups (LPR was present in 62, 42 and 56% of the patients, while GER was present in 45, 24 and 37% of the patients, respectively). Patients with LPR or GER from the three groups did not differ significantly in terms of the number of acid reflux episodes and percentage of times when the pH was <4. Our data do not support the hypothesis that LPR can be an independent risk factor in the development of larynx cancers. However, the data also do not thoroughly exclude the possibility. The reason why LPR leads to variable pathologies in the larynx may be uncovered by studies probing the differences between patients via detailed examinations of the local anti-reflux barriers such as epithelial morphology and functions.

Endoscopic findings in children with obstructive sleep apnea: effects of age and hypotonia

Obstructive sleep apnea (OSA) syndrome is a common disorder among children and is often associated with significant morbidity. The causes of OSA are related to either fixed upper airway abnormalities such as adenotonsillar hypertrophy, or dynamic airway abnormalities such as laryngomalacia and pharyngeal wall collapse. The aim of the present study was to determine the prevalence of dynamic upper airway abnormalities, based on endoscopic findings, in normotonic and hypotonic children with polysomnographically documented OSA. The records of 39 consecutive children with OSA who underwent bronchoscopy (22 with normal tone, and 17 with hypotonia) were reviewed. The prevalence of dynamic defects among children with normal tone decreased with age. All 7 patients less than 1 year old had dynamic abnormalities (isolated or combined fixed/dynamic), compared to only 66% (6/9) of patients between 1-2 years old, and 17% (1/6) of children more than 2 years old. In contrast, dynamic abnormalities were very common among hypotonic children, independent of age. Since children with dynamic defects are less likely to respond to surgical treatments, it would be appropriate to identify these children prior to any intervention. Due to the higher frequency of dynamic defects in both infants (< 1 year) and hypotonic children, it may be appropriate to include endoscopy as part of the diagnostic evaluation of OSA in these subgroups.

Frequency of pharyngeal reflux in children with adenoid hyperplasia

OBJECTIVES

The purpose of the study is to investigate whether there is any association between pharyngeal reflux and adenoid hyperplasia by using 24-h esophageal pH monitoring with a dual probe in children.

METHODS

The study group consisted of 30 children with adenoid hyperplasia, and the control group consisted of 12 healthy children, studied prospectively. All children underwent 24-h esophageal pH monitoring with a dual probe (distal and proximal esophageal pH monitoring). The results were evaluated by the Measurement and Analysis Software of Medical Measurement System program (Version: 7.2a).

RESULTS

In the study group, the frequency of pharyngeal reflux was 46.7% and the gastroesophageal reflux (GER) was 64.5%, while, in the control group, they were 8.3% and 25%, respectively. There was a significant difference between study and control groups for frequencies of pharyngeal reflux and GER. Mean adenoid nasopharyngeal ratio (ANR) was 0.78+/-0.11 in children with adenoid hyperplasia. There was not a significant difference between positive pharyngeal reflux, positive GER and mean ANR (p>0.05).

CONCLUSIONS

Children with adenoid hyperplasia had higher frequency of pharyngeal reflux than children at the same age healthy group. These results supported that pharyngeal reflux may play an important role in the etiology of adenoid hyperplasia.

Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003

BACKGROUND

The Centers for Disease Control and Prevention developed screening and diagnostic testing guidelines for chlamydia and gonorrhea at urethral, rectal, and pharyngeal sites for men who have sex with men (MSM). However, in most clinical settings, rectal chlamydial testing is not performed for MSM, and primarily sexually transmitted disease (STD) clinics alone perform routine rectal and pharyngeal gonorrhea screening for asymptomatic men.

METHODS

We evaluated the prevalence of rectal, urethral, and pharyngeal chlamydial and gonococcal infections among MSM seen at the municipal STD clinic and the gay men's community health center. We also determined the proportion of asymptomatic rectal infections, described the patterns of single and multiple anatomic sites of infection, and evaluated the proportion of chlamydial infections that would be missed and not treated if MSM were not routinely tested for chlamydia. We tested specimens using previously validated nucleic acid amplification tests (NAATs).

RESULTS

The prevalence of infection varied by anatomic site (chlamydia: rectal, 7.9%; urethral, 5.2%; and pharyngeal, 1.4%; for gonorrhea, rectal, 6.9%; urethral, 6.0%; and pharyngeal, 9.2%). Approximately 85% of rectal infections were asymptomatic supporting the need for routine screening. Because 53% of chlamydial infections and 64% of gonococcal infections were at nonurethral sites, these infections would be missed and not treated if only urethral screening was performed. In addition, >70% of chlamydial infections would be missed and not treated if MSM were tested only for gonorrhea.

CONCLUSIONS

Because these infections enhance both HIV transmission and susceptibility, clinical settings serving MSM should evaluate the prevalence of chlamydial and gonococcal infections by anatomic site using validated NAATs.

Oral histoplasmosis associated with HIV infection: a comparative study

OBJECTIVE

Histoplasmosis is a granulomatous fungal disease caused by Histoplasma capsulatum. The objective of the present paper was to describe the prevalence of oral histoplasmosis (OH) in two services from an endemic area in Argentina between 1991 and 2002 and to compare the clinicopathological profile of OH between HIV-positive and HIV-negative patients.

METHODS

About 733 HIV+ (group A) and 14 260 patients (group B) were examined. Clinical diagnosis was confirmed by cytology, biopsy or culture.

RESULTS

About 21 (3%) and 10 (0.07%) cases of OH were diagnosed in group A and B respectively. Most patients were male. A total of 90% of patients in group A were <45 years old whereas 70% of group B were more than 45 years old. Palate, gingiva and oropharynx were the most frequent locations. The importance of including histoplasmosis in the differential diagnosis of ulcerated oral lesions in immunocompromised patients was discussed.

Long-term effects of condom promotion programmes for vaginal and oral sex on sexually transmitted infections among sex workers in Singapore

OBJECTIVES

To evaluate the long-term impact of condom promotion programmes for vaginal and oral sex among female brothel-based sex workers in Singapore.

DESIGN

A pre-test/post-test comparison group followed by a time series design was used to compare trends in condom use for vaginal sex and cervical gonorrhoea incidence from 1990 to 2002 across cross-sectional samples of sex workers before and after programme implementation in 1995. The subsequent condom promotion programme for oral sex was evaluated using the interrupted time series with a retrospective pre-test to post-test matched control group design.

METHODS

Sex workers completed a questionnaire before and 6 months after participation in educational sessions. Cervical and pharyngeal swabs were taken monthly for cultures for Neisseria gonorrhoeae.

RESULTS

Consistent condom use for vaginal sex increased significantly from < 45.0% before 1995 (pre-intervention period) to 95.1% in 2002, with a corresponding decline in cervical gonorrhoea incidence from > 30 to 2/1000 person-months. Adjustment for temporal changes in sociodemographic characteristics did not materially alter the trends. Consistent oral condom use increased significantly from < 50% before 1996 to 97.2% in 2002, with a corresponding decline in pharyngeal gonorrhoea from > 12 to 4.7/1000 person-months.

CONCLUSION

The interventions produced sustained high levels of condom use for vaginal and oral sex with corresponding declines in cervical and pharyngeal gonorrhoea incidence.

[The relationship between oral habits, oronasopharyngeal alterations, and malocclusion in preschool children in Vitória, Espírito Santo, Brazil]

The objective of this study was to estimate the prevalence of malocclusion and associated variables such as deleterious habits (DH) and oronasopharyngeal alterations (OA), mouth breathing, atypical phonation, and atypical swallowing in three-year-old children in Vitória, Espírito Santo State, Brazil. The sample included 291 children of both sexes enrolled in a Children's Educational Center and selected through probability sampling by conglomerates. Logistic regression indicated a high relative risk (RR) in children with altered overjet, open bite, and cross-bite to present mouth breathing (RR = 1.89; CI: 1.56-2.03), (RR = 2.46; CI: 2.00-3.02), (RR = 1.45; CI: 1.23-1.72); atypical swallowing (RR = 2.57; CI: 1.87-3.52), (RR = 3.49; CI: 2.53-4.81), (RR = 1.86; CI: 1.46-2.39); and atypical phonation (RR = 2.25; CI: 1.66-3.05), (RR = 3.18; CI: 2.38-4.25), (RR = 1.71; CI: 1.32-2.22), respectively. An association was shown between finger or pacifier sucking and altered overjet (p < 0.001), and between pacifier sucking and open bite (p < 0.001). Such results indicate that the prevalence of malocclusions is associated with DH and OA.

[Epidemiology of tonsillectomy and/or adenoidectomy in Italy]

OBJECTIVES AND METHODS

Aim of the study was to describe frequency, causes, regional variations, setting and risk of mortality of tonsillectomy and adenoidectomy in Italy. The study is based on hospital discharge data for the years 1998-2000 provided by the Ministry of Health.

RESULTS

During the year 2000, 61.280 tonsillectomy with or without adenoidectomy and 32.655 adenoidectomy alone were performed in Italy. ICD-9-CM codes reported on discharge abstracts indicated that the most frequent causes of tonsillectomy were chronic tonsillitis (45%) and hypertrophy of tonsils and adenoids (43%). The total tonsillectomy rate was 10.6 x 10.000 (CI 10.5-10.7) in 2000, and it was stable throughout the study period. We observed a wide geographical variability of regional tonsillectomy rates, standardised by age and sex. They ranged from 3.5 x 10.000 (CI 3.1-4.0) in Basilicata to 19.0 (CI 18.6-19.5) in Piemonte. We found an inverse correlation (r = -0.50) between regional tonsillectomy rates for tonsillitis and minimum temperatures recorded in capitals of the regions. Most operations were performed in the acute setting with a hospital stay longer than one day. The mortality risk associated to surgery was estimated to be at least of one case over 95.000 operations.

CONCLUSIONS

The observed variability of regional tonsillectomy rates, only partly explained by weather differences, may be ascribed to disagreement among physicians. Inappropriate variations and setting were the two main reasons conducive to the development of the guidelines "Clinical and organisational appropriateness of tonsillectomy and/or adenoidectomy in Italy", in the frame of LINCO project and of the Italian National Program for Guidelines.

Retrospective analysis of 50 cases of guttural pouch tmpany in foals

Between 1994 and 2001, guttural pouch tympany was diagnosed in 51 foals; there were approximately three times as many fillies as colts, of Arabian, different German warmblood breeds and Western horse breeds. There were significantly more Arabian and paint horse foals than expected in comparison with the breed distribution of the foals hospitalised at the Clinic for Horses. The foals' breed and sex did not influence the age of onset, the type and severity of the clinical signs or the recurrence rate. A surgical laser technique was used on 50 of the foals; in 35 cases only one surgical treatment was necessary, in seven cases a second operation was required during the foal's initial period of hospitalisation, and in eight cases a second operation was performed during a second period of hospitalisation. Long-term follow-up information was obtained for 44 of the 50 treated horses; 24 of them were under two years of age and 20 were over two years of age. In six horses, no follow-up information was available. Four horses were euthanased for reasons unrelated to the condition or its treatment. The horses over two years of age were in training or were being used for competitions in dressage or jumping or for breeding purposes, and in only one of them was an adventitious respiratory noise reported. All the horses up to two years of age were reported to be healthy.

Incidence and predisposing factors of pharyngocutaneous fistula formation after total laryngectomy. Is there a relationship with tumor recurrence?

Pharyngocutaneous fistula is the most common complication (8.7 to 22%) in the immediate postoperative period following total laryngectomy. The study's objective was to determine the incidence of post-laryngectomy fistulas in patients operated on in our department to establish whether specific factors predispose to fistula formation and to determine whether fistulas and tumor recurrence are related. Between 1992 and 2001, 377 cases of laryngeal carcinoma were diagnosed, and the patients underwent total laryngectomy in our department. Of these patients, 291 had total laryngectomy as the primary management of their disease, while in 86 patients the operation treated recurrence of the disease. In 92 patients, total laryngectomy was combined with radical or eclectic neck dissection. The presence of early postoperative fistula was established in 49 of the 377 patients (13%) studied. The cancerous stage, exact localization of the tumor, degree of differentiation, previous irradiation, patient's age, performance or not of neck dissection or emergency tracheostomy and fitting of voice prostheses were all factors that, after statistical analysis, did not appear to significantly influence the incidence of postoperative fistulas. Factors that did show statistical significance were the histological infiltration of the tumor's surgical margins (11% negative vs. 38% with positive margins) and coexisting early complications. Fistula management was conservative in the majority of cases. The necessary closure period for a fistula varied between 5 and 81 days (mean: 29 days). Postoperative follow-up of all patients revealed that fistulas did not influence the incidence of tumor recurrence. The incidence of postoperative fistulas in our study was 13%. Incomplete excision of the tumor and coexisting complications were related, among other things, to a higher rate of fistula formation. The rate of tumor recurrence after total laryngectomy was not related to the presence of a fistula during the postoperative period.

[Pharyngoesophageal stenosis following surgery and radiotherapy in patients with advanced laryngeal cancer]

OBJECTIVE

Our objectives were to 1) know the frequency of pharyngoesophageal stenosis in patients with clinical stage III transglottic laryngeal cancer (LCa Stage III) post-surgery and radiotherapy, and to 2) describe clinical, radiologic, and endoscopic characteristics of pharyngeal-esophageal stenoses and response to dilations.

MATERIALS AND METHODS

We conducted a series of consecutive cases from 1997-2000 at the National Cancer Institute (INCan) in Mexico City and included patients with transglottic (LCa Stage III) post-surgery and -radiotherapy. We evaluated dysphagia and stenosis (length, diameter, and localization) by radiology and endoscopy before and after surgery and radiotherapy. Statistical method was descriptive.

RESULTS

Sixty five of 197 cases (33%) with laryngeal cancer were transglottic and 52 (26.3%) were clinical stage III. Patients were treated with total laryngectomy and pharyngo-esophageal "Y" stent and post-operative radiotherapy with average 7,000 cGy total dose. Thirteen patients (25%) presented pharyngo-esophageal stenosis. There was no pre-operative dysphagia; dysphagia was present in five patients post-surgery and in all after radiotherapy. In all cases, stenoses were simple and were treated with Savary Guillard-guided endoscopic dilation with an average of five sessions. Five of 13 patients (38.5%) had persistent dysphagia: two due to fibrosis, two due to loco-regional recurrences, and one due to recurrence in pharyngo-esophageal closure.

CONCLUSIONS

A total of 197 cases of laryngeal cancer were present during this period; 33% were transglottic, the majority in clinical stage III. Global frequency of stenosis was 25%; all cases were simple. Endoscopic dilations were useful in absence of fibrosis, extrinsic compression, and tumor recurrence.

The relationship between factors that impair wound healing and the severity of acute radiation skin and mucosal toxicities in head and neck cancer

PURPOSE

To determine which wound-healing factors impact on the severity of radiation skin and oral mucosal reactions in head and neck cancer and to test modifications to the Radiation Therapy Oncology Group (RTOG) acute toxicity scoring system.

METHODS

A consecutive sample of 53 head and neck cancer patients who were scheduled for curative or palliative radiation therapy. Therapy was planned using traditional computerized techniques. A new RTOG subscale for tongue reactions was developed. Information on potential predictors was collected during the first week of treatment. Reactions were observed and documented each week throughout treatment using the RTOG Acute Reaction Scoring System scores of acute oropharyngeal reactions and various personal factors.

RESULTS

Significant relationships were found between severe skin and oral reactions and age, commencing radiation within 2 months of surgery and smoking. Significant relationships for severe oral mucosal reactions were found with weight at the commencement of treatment, inadequate or poor diet, having had mucositis with previous chemotherapy, and the use of a custom-made Perspex tongue immobilizer.

CONCLUSIONS

Three conclusions can be derived from this study: (1) structures within the oral cavity should be considered separately for toxicity scoring, (2) the newly developed tongue RTOG subscale adds accuracy and specificity to the RTOG acute toxicity scoring system, and (3) wound healing factors are an important component of understanding risk for side effects in head and neck cancer treatment.

[Descriptive study of 21,804 ENT emergencies in a third level hospital]

We present a descriptive study about 21.804 emergency patients (ENT Department) treated in our hospital between 1994 and 2000. We have seen about 260 patients every month being the otologic pathology (35.63%) the most frequent one, followed by the nasosinusal (26.65%). Individually, the epistaxis where the 13% of all cases attended. The nasal traumas (contusions and fractures) where about a 10% of the total and in a third place, the external otitis (6.84%). We estimate in more than a 60% of the patients with a simple pathology (not urgent) and in a 3% of the patients without ENT pathology when they came to emergency. We believe, like other consulted authors, that there is a high patients index coming to the Hospital, for other reasons, without a justifiable ENT emergency. That contributes to different levels, with other specialities, to the collapse of the emergencies services.

Annual report of the Australian Gonococcal Surveillance Programme, 2002

The Australian Gonococcal Surveillance Programme (AGSP) monitors the antibiotic susceptibility of Neisseria gonorrhoeae isolated in all states and territories. In 2002 the in vitro susceptibility of 3,861 isolates of gonococci from public and private sector sources was determined by standardised methods. Antibiotic susceptibility patterns again varied considerably between jurisdictions and regions. Resistance to the penicillins nationally was at 18 per cent but ranged up to 22 per cent in larger urban centres. Quinolone resistance in gonococci (QRNG) remained widespread. Nationally 10 per cent of all isolates were QRNG, and most of this resistance was at high MIC levels. All isolates remained sensitive to spectinomycin. A small number of isolates demonstrated some decreased susceptibility to ceftriaxone (MIC 0.06 mg/L or more) and were concentrated in New South Wales. Patterns of infection were unaltered from previous years. A high proportion of gonococci examined in larger urban centres were from male patients and rectal and pharyngeal isolates were common. In other centres and in rural Australia the male to female ratio of cases was lower, and most isolates were from the genital tract.

[Population genetic analysis of the heritability of gutteral pouch tympany in Arabian purebred foals]

The objective of the present study was to analyse the importance of the influences of the sex, inbreeding coefficient and the additive genetic contribution to the occurrence of guttural pouch tympany in Arabian foals. Horses affected by guttural pouch tympany were ascertained in the Clinic for Horses, School of Veterinary Medicine Hannover. The data comprised 27 Arabian purebred foals with guttural pouch tympany. Of these 27 animals 22 were patients of the Clinic for Horses between 1994 and 2001 and 5 Arabian foals were sampled on the studs. Information on the pedigrees of these patients allowed us to sort in the affected foals into four families with a total of 276 animals. Female foals were more often affected by guttural pouch tympany. The difference was 11.9% in favour of female foals. The size of the inbreeding coefficient was not important for the occurrence of guttural pouch tympany. The heritability estimate for the frequency of guttural pouch tympany using a threshold model was 0.49 +/- 0.28. This is the first report that could show a genetic component responsible for guttural pouch tympany in foals.

[The management of pharyngocutaneous fistulas after total laryngectomy and the factors affecting their incidence]

OBJECTIVES

This study sought to determine the incidence and etiologic factors of pharyngocutaneous fistulas occurring after total laryngectomy.

PATIENTS AND METHODS

A total of 138 patients (136 males, 2 females; mean age 59.5 years; range 36 to 83 years) underwent total laryngectomy for squamous cell carcinoma. Risk factors and the management of pharyngocutaneous fistulas were assessed together with durations in relation to fistula occurrence, oral feeding, hospitalization, and healing.

RESULTS

Pharyngocutaneous fistulas were seen in 37 patients (26.8%). Significantly high rates of fistula occurrence were detected in patients with alcohol consumption (p=0.032), and in those who underwent partial pharyngectomy (p=0.058) or bilateral neck dissection (p=0.049) along with total laryngectomy. The occurrence of fistulas was significantly associated with prolonged lengths of time for oral feeding and hospital stay (p<0.001). Fistulas were repaired surgically in 24.3% of patients, in whom the time to oral feeding was significantly shorter than that of patients who received local wound care (p=0.03).

CONCLUSION

Our data show that early surgical intervention is more beneficial in preventing further morbidity associated with pharyngocutaneous fistulas.