Posttraumatic stress disorder comorbidity in patients undergoing ECT for major depressive disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is not recognized as an indication for electroconvulsive therapy (ECT). However, research indicates promise for this treatment modality. To elucidate the effects of ECT for treating PTSD, prospective research is needed. The first step in assessing the feasibility of such research is to determine if many patients being treated with ECT have comorbid PTSD. This study examined the PTSD comorbidity rates and compared demographic data among patients with major depressive disorder (MDD) who were treated with ECT vs patients with MDD who were not treated with ECT.

METHODS

Data from patients with MDD were obtained from the Nationwide Inpatient Sample.

RESULTS

Approximately 10% of patients undergoing ECT for MDD also had PTSD. The difference in comorbidity of PTSD in those treated with ECT vs those not treated with ECT was approximately 1%.

CONCLUSIONS

Prospective naturalistic studies that examine the response of PTSD to ECT are feasible because a sizable number of patients with PTSD are receiving ECT.

Years of life lost due to deaths of despair and COVID-19 in the United States in 2020: patterns of excess mortality by gender, race and ethnicity

BACKGROUND

In 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen-which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020.

METHODS

This cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation.

RESULTS

In 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes.

CONCLUSIONS

This study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.

Genome-wide analysis of DNA turnover and gene expression in stationary-phase Saccharomyces cerevisiae

Exponential-phase yeast cells readily enter stationary phase when transferred to fresh, carbon-deficient medium, and can remain fully viable for up to several months. It is known that stationary-phase prokaryotic cells may still synthesize substantial amounts of DNA. Although the basis of this phenomenon remains unclear, this DNA synthesis may be the result of DNA maintenance and repair, recombination, and stress-induced transposition of mobile elements, which may occur in the absence of DNA replication. To the best of our knowledge, the existence of DNA turnover in stationary-phase unicellular eukaryotes remains largely unstudied. By performing cDNA-spotted (i.e. ORF) microarray analysis of stationary cultures of a haploid Saccharomyces cerevisiae strain, we demonstrated on a genomic scale the localization of a DNA-turnover marker [5-bromo-2'-deoxyuridine (BrdU); an analogue of thymidine], indicative of DNA synthesis in discrete, multiple sites across the genome. Exponential-phase cells on the other hand, exhibited a uniform, total genomic DNA synthesis pattern, possibly the result of DNA replication. Interestingly, BrdU-labelled sites exhibited a significant overlap with highly expressed features. We also found that the distribution among chromosomes of BrdU-labelled and expressed features deviates from random distribution; this was also observed for the overlapping set. Ty1 retrotransposon genes were also found to be labelled with BrdU, evidence for transposition during stationary phase; however, they were not significantly expressed. We discuss the relevance and possible connection of these results to DNA repair, mutation and related phenomena in higher eukaryotes.

Multidisciplinary approach to management of hemangiomas and vascular malformations

Hemangiomas and VMs are potentially complicated lesions that are often misdiagnosed and treated under the presumption that if left untreated, they will go away on their own. A well thought out multidisciplinary team put together to determine the most appropriate diagnosis of a lesion and to formulate and insititute a treatment plan can prove invaluable to the patient and community as a whole. Team members must be chosen to maximize input and use time to best diagnose and treat these lesions. It is imperative that the presence of such a team be brought to the attention of primary care providers who most often are the first to see these patients and that correct information about diagnosis, potential treatment options, and projected results be conveyed.

Optimizing effectiveness of laser tympanic membrane fenestration in chronic otitis media with effusion. Clinical and technical considerations

OBJECTIVE

To describe the patient, disease and clinical characteristics that optimize the effectiveness of laser tympanic membrane fenestration (LTMF) to treat chronic otitis media with effusion (OME).

SETTING

Four pediatric otolaryngology tertiary referral centers. IRB approved; participation by informed consent.

METHODS

An observational clinical effectiveness trial was conducted in 164 ears (94 children), who had chronic OME. All patients were candidates for insertion of pressure equalization tubes (PETs) but agreed to undergo LTMF instead. Clinical and audiologic follow-up are reported at 90 days after LTMF.

OUTCOME MEASURES

Clinical effectiveness was defined as an effusion free middle ear at otoscopy with A or C1 tympanogram and normal hearing.

RESULTS

At 90 days, 66% of the 95 evaluable ears were effusion free, all with normal hearing. Children younger than 4 years (P<0.04), who had shorter durations of effusion (P<0.009), and who experienced longer duration of fenestration patency (FP) (P<0.009) correlated to improved outcomes.

CONCLUSIONS

The use of LTMF to create 2--3 weeks of middle ear ventilation in patients with chronic OME (middle ear effusion (MEE) for 3 months or greater) is effective in 66% of 95 (58%) of ears evaluable at 90 days follow-up. This study provides basic information needed to optimize the use of LTMF today and enhance research efforts in the future.

Comparison of the microanatomical distributions of macrophages and dendritic cells in normal and diseased tonsils

The palatine tonsils play an important role in immunologic surveillance and resistance to infection in the upper aerodigestive tract. Dendritic cells and macrophages function to capture and process antigen and present it to T lymphocytes, a critical step in the early immune response. Few studies have characterized the distribution and phenotype of those antigen-presenting cells in the normal palatine tonsil, or determined how those parameters change with disease. Immunohistochemical analysis was performed to determine the microanatomical distribution, quantity, morphology, and phenotype of macrophages and dendritic cells in both normal and diseased tonsils. Differences were observed in macrophage and dendritic cell distribution, quantity, and phenotype in the surface and crypt epithelium. The number of macrophages was significantly increased in all compartments in all disease groups (p < .05), although the number of macrophages that expressed phenotypes of maturity and/or activation was not concomitantly increased. In the surface epithelium, Langerhans and interdigitating cells decreased significantly with disease (p < .05). Chronic infection may impose an immunosuppressive effect on responses within tonsil tissue, affecting the immunologic factors responsible for macrophage maturation and activation.

Effectiveness of adenoidectomy and laser tympanic membrane fenestration

OBJECTIVE

Adenoidectomy alone or with tonsillectomy (A+/-T) is an effective surgical intervention in the management of otitis media in children, especially when it is performed in conjunction with insertion of pressure equalization tubes (PETs). Otorrhea and persistent tympanic membrane (TM) perforation are frequent complications. This study evaluates the effectiveness of intermediate duration middle ear ventilation using laser tympanic membrane fenestration (LTMF) without tube insertion and as an adjunct to adenoidectomy in resolving middle ear disease within the first 90 days after surgery.

STUDY DESIGN

This pilot study was a multicenter, prospective clinical cohort trial. Institutional review board approval and informed consent were obtained. The study involved four tertiary care pediatric otolaryngology departments. Fifty children (96 ears) were treated with LTMF in conjunction with A+/-T from June 1, 1998, through March 30, 1999. Ages ranged from 9 months to 12 years. Patients undergoing A+/-T who would have been recommended for PET insertion instead underwent middle ear ventilation with LTMF using the Oto-LAM device (ESC/Sharplan, Yokneam, Israel). Patients were seen at 30, 60, and 90 days postoperatively. Resolution of otitis media with effusion was determined by clinical examination, which included pneumatic otoscopy, audiometry, and tympanometry.

RESULTS

Of the treated ears, 88%, 86%, and 83% had clinical resolution of middle ear disease at 30, 60, and 90 days, respectively. Preoperatively, 45% (n = 85) of ears had normal hearing; 92% (n = 49) had normal hearing at 90 days. Eighty-nine percent (n = 92) had type C2 or B tympanograms preoperatively, and 12% (n = 60) had type C2 or B at 90 days.

CONCLUSION

Laser tympanic membrane fenestration in conjunction with adenoidectomy was effective in restoring normal middle ear function at 90 days post-treatment in greater than 80% of children who otherwise may have had placement of PETs.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease

OBJECTIVE

To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

STUDY DESIGN

Retrospective chart review

METHODS

Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy).

RESULTS

A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality.

CONCLUSION

Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis.

Clinical presentation as a guide to the identification of GERD in children

OBJECTIVE

to determine if there is a correlation between common otolaryngologic symptoms and presence of gastroesophageal reflux disease (GERD) in children.

METHODS

charts of 295 children presenting with suspicion of GERD were reviewed for presenting symptoms including: (1) airway symptoms: stertor, stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, blue spells, hoarseness, throat clearing; (2) feeding symptoms: wet burps, globus sensation, frequent emesis, dysphagia, choking/gagging, sore throat, halitosis, food refusal, stomach aches, arching, drooling, chest pain, irritability, and failure to thrive. At least one positive test of barium esophagram, gastric scintiscan, pH probe or esophageal biopsy resulted in inclusion in the GERD positive group.

RESULTS

214 children had GERD diagnosed while 81 had no positive tests for GERD. Between the GERD positive and GERD negative groups, the significantly different symptoms were stertor (P=0.040), cyanotic spells (P=0.043), frequent emesis (P=0.007), failure to thrive (P=0.006), and choking/gagging (P=0.044). Three pooled variables were created: airway flow (stertor, stridor, cyanotic spells), airway irritation (frequent cough, recurrent croup, throat clearing), and feeding (dysphagia, failure to thrive, frequent emesis). GERD patients who were 2 years or less were compared to those older than 2 years and all three of these pooled variables were significantly different between these groups (P<0. 001).

CONCLUSION

children who present with a certain constellation of airway or feeding symptoms are more likely to have a positive GERD test. Children 2 years old or less are more likely to present with airway symptoms or feeding difficulties while children older than 2 years are more likely to present with airway irritation.

Office-based laser assisted tympanic membrane fenestration in adults and children: pilot data to support an alternative to traditional approaches to otitis media

OBJECTIVES

To determine the role of intermediate duration ( approximately 3 weeks) middle ear ventilation using office-based laser assisted tympanic membrane fenestration in resolving an episode of otitis media with effusion in adults and children who otherwise would have been treated with insertion of pressure equalization tubes.

METHODS

A retrospective chart review of 92 patients (162 ears) was conducted to identify the utility and technical challenges associated with laser assisted tympanic membrane fenestration in an office setting. Clinical characteristics reviewed included: age, gender, duration of effusion, season performed, and hearing and health status of middle ear upon healing of the fenestration.

RESULTS

69% of all patients were effusion free upon closure of the fenestration; 68% of those <3 years; 70% of those 3-7 years; and 70% of those 25-80 years. Some episodes recurred and at final follow-up 64% had normal middle ear structure and function (range of follow-up =1-18 months, mean 2.5 months, median 2.0). Shorter duration of effusion pre-fenestration was more often associated with return to normal middle ear structure and function (P<0.01). Season performed, number of previous episodes of otitis media and pre-treatment tympanometry were not predictive of result. No significant complications were observed.

CONCLUSIONS

The use of office-based laser assisted tympanic membrane fenestration is a reasonably safe and effective procedure for the treatment of otitis media in most adults and children. As a minimally invasive otologic procedure, laser assisted tympanic membrane fenestration has great potential to decrease the rates of both antibiotic usage and insertion of ear tubes.

A comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy

BACKGROUND

Morbidity following tonsillectomy continues to be a major concern to parents, children, and physicians alike. Reduction in post-operative complications, optimal control of pain, and satisfactory return to a normal lifestyle are all important to both family and society. This study compares both the complication and recovery rates after microbipolar dissection (MBPD) technique of tonsillectomy to two well established tonsillectomy techniques: hot knife (HK) and cold knife/cautery (CK/C).

METHODS

A total of 200 consecutive patients presenting for tonsillectomy by the first author (MP) were randomized to either undergo MBPD or HK tonsillectomy. Concurrently, an additional two hundred patients were randomized to undergo MBPD or CK/C tonsillectomy by the second author (LB). Patients were prospectively followed for complications including bleeding and dehydration and multiple indicators of recovery rate.

RESULTS

Postoperative bleeding of any kind was significantly less in the MBPD group than in the CK/C and HK groups (5 vs 12.4 vs 12.5% (P<0.001). The need for post-operative intervention for bleeding, i.e. local control or return to the operating room, was also significantly less in the MBPD group. Return to normal activity occurred 2 days earlier in the MBPD group versus either CK/C or HK (P<0.001). Additionally, earlier recovery was reflected in fewer total doses of pain medication in the MBPD group. Operative time was 3-5 min longer for MBPD (24.2 min) than for CK/C or HK (21.1 and 16.5 min, respectively); blood loss was similar (within 15 cc) among all treatment groups.

CONCLUSION

MBPD tonsillectomy compared most favorably to conventional techniques (CK/C and to HK tonsillectomy). Important clinical outcome differences included a lower bleed rate, earlier recovery and fewer days lost from work and school. The financial impact is estimated to be quite favorable. MBPD tonsillectomy is now our preferred method in children.

Severe non-obstructive sleep disturbance as an initial presentation of gastroesophageal reflux disease

A 2.5-year-old child presented with a sleep disturbance initially diagnosed as a behavioral problem. The child had several atypical symptoms of gastroesophageal reflux disease (GERD). The sleep disturbance resolved quickly after treatment of GERD. GERD is a disease with protean manifestations which is becoming of greater interest to the pediatric otolaryngologist. We discuss diagnosis of this entity.

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration

OBJECTIVE

To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting.

STUDY DESIGN

Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals.

METHODS

Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described.

RESULTS

All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements.

CONCLUSIONS

The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.

Cellular immune response of adenoidal and tonsillar lymphocytes to the P6 outer membrane protein of non-typeable Haemophilus influenzae and its relation to otitis media

Cellular immune responses to the P6 outer membrane protein of non-typeable Haemophilus influenzae (NTHi) were determined in vitro by measuring immunoglobulin (Ig) secreting cells and lymphocyte proliferation in adenoidal and tonsillar lymphocytes from 19 children. Preliminary tests showed that P6 did not stimulate naive cells such as cord blood lymphocytes, but did stimulate sensitized cells in adenoids and tonsils. Cellular proliferation was significantly higher in adenoidal lymphocytes than in tonsillar lymphocytes (median: quadratile of stimulation index = 3.7:2.3-5.5 vs. 1.2:1.0-2.1, p < 0.02). A comparison between children with or without otitis media revealed that proliferative responses to P6 of adenoidal lymphocytes from children with otitis media were significantly decreased (2.0:1.8-3.6 vs. 3.7:2.3-5.5, p < 0.04). P6-specific antibody secreting cells were identified in a total of 14 adenoids and the number of cells secreting IgA was decreased in the otitis media group compared to controls (median: quadratile/10(6) cells = 435:359-499 vs. 755:593-1870, p < 0.05). Cultivation with P6 stimulated IgA secretion in children without otitis media, while no response was seen in children with otitis media (median: quadratile/10(6) cells = 1323:915-2410 vs. 2240:1900-2830, p < 0.02). These preliminary data demonstrate that lymphocytes from adenoids and tonsils recognize P6 as a specific antigen and that the adenoid is the more reactive of the two organs. Impaired P6-specific cellular immune responses of adenoids in children with otitis media may explain the recurrent nature of otitis media due to NTHi in the otitis prone population.

Quantitative study of germinal center area in normal and diseased tonsils using image analysis

The aim of this study was to measure the germinal center area of secondary follicles in a consistent and unbiased manner using image analysis. Tonsil specimens were obtained from children with clinical evidence of recurrent tonsillitis and/or idiopathic tonsillar hypertrophy. Normal control biopsy specimens were obtained from children with no history of ear, nose, or throat infections. The results show a significant increase in the germinal center area in tonsils exhibiting hypertrophy when compared to normal controls (p < .002). Image analysis is an important tool for making quantitative size comparisons in lymphoid tissues.

A role for genetic predisposition in subglottic stenosis

We present the development of ASGS in two of three premature male triplets; the affected infants were monozygotic, while the unaffected triplet was dizygotic. All three shared remarkably similar risk factor profiles. There is suggested the existence of a genetic factor or factors which may predispose certain infants to the development of ASGS. The expression of such genetic influence may be expressed through the a priori presence of CSGS or other genetically based mechanisms including abnormal cartilage growth or development, specific patterns of chondral or mucosal injury, the action of specific growth factors, or the effects of autoimmune or inflammatory mediators. We propose that genetic predisposition be considered a possible risk factor in the development of subglottic stenosis.

Supernumerary nostril: a rare congenital deformity

Duplication anomalies of the nose include polyhinia (double nose) and supernumerary nostril (assessory nostril). These are rare congenital nasal deformities resulting from aberrant embryological development. Differential diagnoses include glioma, encephalocele, nasal dermoid, nasolacrimal duct duplication, mid facial cleft and proboscis lateralis (K. Nakamura, T. Onizuka. Plast. Reconstr. Surg. 80 (3) (1987) 436-441). Our review of the English language literature revealed eight reported cases of duplication anomalies of the nose. Four of these were cases of polyrhinia (double nose). Of the cases remaining, one patient had a supernumerary nostril in association with a cleft lip, leaving only three reported cases of an isolated supernumerary nostril. We present a newborn infant with an isolated right supernumerary nostril. MRI, CT and photographic documentation are provided. Pertinent embryology, anatomy and a thorough review of the literature are included.

Deep neck infections in children: a new approach to diagnosis and treatment

Forty-seven children presented with the diagnosis of a deep neck infection--either cellulitis or abscess--between January 1991 and July 1996. Forty-four (94%) had contrast-enhanced computed tomography (CT) imaging consistent with this diagnosis. Three patients with no CT scan had confirmation of an abscess at surgical drainage. Parenteral antibiotics alone were effective in the treatment of 24 of 47 infections (51%): seven parapharyngeal, one retropharyngeal, and 16 combined. By CT scan these infections represented cellulitis in 17 of 24 (71%), an abscess in three of 24 (13%), and incomplete abscess in four of 24 (17%). The average duration of hospitalization for this group was 4.8 days, with symptomatic improvement usually seen within 24 hours. Surgical drainage was performed on 23 of 47 infections (49%): three parapharyngeal, 17 combined, and three of unknown specific location. In 22 of these 23 children (96%), transoral drainage of the abscess was used as the primary surgical approach. In 21 of these 22 (95%) there was complete resolution without complications or recurrence; one abscess required a subsequent external approach. CT scanning with contrast revealed that all deep neck infections were located medial (usually anteromedial) to the great vessels. Abscesses with volumes estimated to be greater than 2000 mm3 were more likely to undergo surgery, but these differences were not statistically significant. The use of contrast-enhanced CT scanning provides information regarding abscess size, location, and relative position of the great vessels for safe and successful transoral drainage. Thus we recommend CT-assisted transoral drainage for combined retropharyngeal/parapharyngeal abscesses and selected isolated parapharyngeal abscesses that do not respond to parenteral antibiotics.

Open trial of intravenous immune serum globulin for chronic sinusitis in children

BACKGROUND

Chronic sinusitis in children is a complex clinical problem. Some patients do not improve with medical therapy and some fail surgery as well.

OBJECTIVE

A therapeutic trial of intravenous immune serum globulin (IVIG) was given to children whose sinus disease was recalcitrant to the usual therapeutic modalities. The objective of IVIG administration was to modulate the inflammatory process contributing to the chronicity of the sinusitis.

METHODS

Six patients were given a 12-month trial of monthly (400 mg/kg) IVIG infusions. Entry criteria included persistence of sinusitis after 3 months of full course antibiotics, or two episodes of sinusitis within a 3-month period while on prophylactic antibiotics. All patients had abnormal sinus CT (computerized tomography) scans at entry. Three of the six patients remained symptomatic despite prior sinus surgery. Patients with primary immune deficiencies were excluded. Each patient served as his own control based on their previous 12-month history and clinical course. Four of the 6 patients were atopic as demonstrated by prick skin testing; however, all patients had nasal eosinophilia.

RESULTS

Full course antibiotic use decreased in five of the six patients (183 to 84 days); correspondingly, the episodes of sinusitis decreased (average 9 to 4 per year). In addition, sinus CT scans showed significant improvement.

CONCLUSION

This preliminary open-trial of IVIG suggests its usefulness as adjunct therapy to medical management in selected patients with chronic sinus disease. The mechanism(s) by which IVIG may be helpful is probably not based on the concept of replacement therapy, but more likely as an immune or inflammatory modulating agent.

Retinoic acid-induced modulation of IL-2 mRNA production and IL-2 receptor expression on T cells

BACKGROUND

Retinoic acid (RA) has important immune-modulating effects on both T and B cell function. Our laboratory has shown that RA can enhance in vitro polyclonal B cell immunoglobulin (Ig) response. Investigating cytokines known to affect B cell differentiation, we have recently shown that IL-6 production is augmented by RA. In the present study we have examined the immune modulating effects of RA on IL-2 mRNA, another important cytokine for B cell immunoglobulin production, the expression of IL-2 receptors on T cells, and the RA nuclear receptors.

METHODS

Purified T cells were obtained from adenoidal tissues, and incubated with RA (10(-7) M) or DMSO solvent/media control for 0, 6-8, and 24 h. Total mRNA was extracted from T cells, and using RT-PCR, changes in the production of IL-2 and RA receptors (RAR)-alpha,beta,gamma mRNA were determined. The effects of RA on IL-2-alpha receptor expression was determined by flow cytometry on T cells.

CONCLUSION

These studies suggest that RA can augment IL-2 mRNA production by T cells with a possible paracrine effect on IL-2R-alpha expression. These changes appear to be mediated by RAR-alpha. Thus, IL-2 may be another important cytokine modulated by RA in the immune response.

Clinical classification as a guide to treatment of sinusitis in children

Evaluation of all 153 children undergoing CT scan of the paranasal sinuses for recalcitrant sinusitis symptoms between January 1988 and July 1992 was performed. Clinical categorization into groups of patients presenting with chronic sinusitis (CS) and recurrent acute sinusitis (RAS) was based upon pattern of disease and presentation. Clinical symptoms and signs, radiological examination, treatment, and outcome were compared between these distinct clinical groups. Eighty-two (55%) children were categorized as RAS and 68 (45%) as CS. Children with CS presented more frequently with a persistent cough, purulent nasal discharge, immune deficiency, and more severe mucosal disease on CT than children with RAS. Medical therapy successfully controlled the symptoms of sinusitis in 79 (96%) with RAS versus 27 (40%) with CS. Surgery was performed in 44 children: 3 (3.6%) with RAS versus 41 (60%) with CS, p < 0.01. At a mean follow-up of 2.0 years, >80% of all the children were either asymptomatic or improved regardless of treatment modality. These data support the use of clinical classification as a guide to medical versus surgical therapy in children with sinusitis.

Dysphagia with respiratory/pulmonary presentation: assessment and management

Breathing and swallowing are two of the most important basic functions that must be established at or soon after birth. Although each function serves a different purpose, they are intimately related by virtue of their sharing the same anatomic conduit for air and food. Thus, problems associated with swallowing and feeding can present with airway symptoms, and conversely, an airway problem may be made worse by feeding. This article discusses functional anatomy in relation to the clinical manifestations of airway problems in children with feeding problems. Evaluation and treatment of the most common problems by anatomic location is described, and the special complications of tracheotomy, chronic aspiration, and chronic sialorrhea (drooling) are considered in detail.

Optimizing albunex in the left ventricle: an analysis of the technical parameters of four ultrasound systems in canines and humans

Albunex, an intravascular ultrasound contrast agent, has been used clinically to enhance echocardiographic images. The purpose of this study if (1) to determine whether varying the settings on commercially available ultrasound machines has an effect on left ventricular opacification after intravenously administered Albunex and if there is an effect on left ventricular opacification and (2) to determine the ideal settings for each ultrasound scanner. Six canine hearts were imaged with 1 ml injections of intravenously administered Albunex while varying the transducer frequency, preprocessing curves, postprocessing curves, and dynamic range on a variety of ultrasound units. Subsequently 50 human subjects underwent imaging with the various machines while the dynamic range and transducer frequencies were altered. All subjects received two or three intravenous injections of 10 ml Albunex. The opacification of the left ventricular cavitary images in both parts of the study were interpreted visually on a scale of 0 to 4 (0 = none, 1 = trace, 2 = moderate, 3 = dense, and 4 = ideal) by four observers. The maximum compression and transducer frequency of 3.5 MHz showed significant improvement of left ventricular opacification in both canines and humans. These studies have shown that (1) varying the ultrasound unit's parameters affects the quality of left ventricular imaging when Albunex is used to enhance the image, and (2) higher compression and a transducer frequency of 3.5 MHz tend to enhance Albunex images of canine and human hearts.

Congenital stridor

Congenital stridor is a common problem that has many very different etiologies. A complete history and physical examination will allow the astute clinician to direct the laboratory evaluation efficiently. Establishing a relationship with a specialist will be useful for consultation when considering a referral in questionable situa.

Neonatal septoplasty: case report and review of the literature

Treatment of nasal septal deformity in childhood has received growing acceptance in recent years. Traditionally, concern about the role of the septum in the overall growth of the midface has led otolaryngologists to take a very cautious approach to correction of septal deformities in children. However, a great deal of evidence now suggests that severe traumatic septal deviation can and should be corrected early in childhood to prevent future nasal and systemic complications. Closed manipulation of the septum in the first 1-2 days of an infant's life has been performed by many otolaryngologists with good results. The use of this technique, however, is usually limited to those subluxations of anterior cartilage which are diagnosed immediately or very shortly after birth. We present a case of severe traumatic nasal deformity presenting with obstructive asleep and awake apnea and cyanosis at the age of 8 days. The child underwent limited septoplasty using endoscopic techniques at age 14 days with resolution of both the apneic and cyanotic episodes immediately post-operatively. This unusual presentation and the literature surrounding infant nasal/septal surgery are discussed.

The effects of retinoic acid on immunoglobulin synthesis: role of interleukin 6

Retinoic acid (RA) and its parent compound, retinol (ROH, vitamin A), have been recognized as important immunopotentiating agents. Previous studies from our laboratory have demonstrated that RA can augment formalin-treated Staphylococcus aureus (SAC)-stimulated immunoglobulin (Ig) synthesis of cord blood mononuclear cells (CBMC). To determine the mechanism(s) by which RA modulates Ig synthesis, we studied the effects of RA on B cells and cytokine production. The addition of RA (10(-5) to 10(-10) M) to Epstein-Barr virus (EBV)-transformed B-cell clones derived from either adult or cord blood B cells augmented Ig secretion twofold. In contrast, cell proliferation was inhibited as measured by 3H-thymidine incorporation. We evaluated two cytokines known to be constitutively produced by EBV cell lines, IL-1 and IL-6. While RA had no effect on IL-1 production, IL-6 synthesis was greatly enhanced (20- to 45-fold), which was also reflected by an increase in steady-state mRNA levels for IL-6 but not TNF-alpha or TGF-beta on Northern blot analysis. Polyclonal rabbit anti-IL-6 antibodies were used to block the augmenting effects of RA on Ig synthesis of adenoidal B cells. RA-induced augmentation in IgG and IgA synthesis was blocked 58 and 29%, respectively, by anti-IL-6 antibodies. These studies suggest that the enhancing effects of RA on Ig synthesis are mediated, at least in part, by the autocrine or paracrine effects of IL-6 on B-cell differentiation.

The role of dendritic cells in the development of chronic tonsillar disease in children

Thirty-one children, 2.6-12.2 years (mean = 7.9 +/- 5.0) were divided into four clinical categories: normal controls (n = 7), recurrent tonsillitis (n = 8), idiopathic tonsillar hyperplasia (n = 9) and recurrent tonsillitis with hyperplasia (n = 7). Immunohistopathologic studies were performed to determine the presence and location of HLA-DR, S-100 positive antigen presenting dendritic cells (DCs) in six microanatomic compartments: surface and crypt epithelium and submucosae, extrafollicular areas and lymphoid follicles. The results were analyzed in the context of the clinical history, bacteriology, and routine histopathology. The distribution of DCs was altered significantly with disease fewer numbers of DCs were found in the surface epithelium and greater numbers in the crypts and extrafollicular areas, than in normals, p <0.01. The surface : crypt ratio of DCs was 1:1 for normal tonsils, but dropped to 1:3 in disease. Chronic cryptitis was more common in disease and correlated strongly to the presence of beta-lactamase producing microorganisms (R = 1.0). An increased total bacterial concentration was correlated with increased numbers of DCs in the surface epithelium (R = 0.5, p <0.009). In summary, the microanatomical distribution of DCs within the tonsil is significantly altered in disease. These alterations appear to be influenced by potentially pathogenic bacteria more often found in the crypts of abnormal tonsils.

Microanatomical distribution of dendritic cells in normal tonsils

Lymphoid dendritic cells play an essential role in antigen presentation in primary immune responses and are believed to be important in normal healthy responses of the mucosal immune system. The microanatomical distribution of HLA-DR-positive/S100 antigen-positive dendritic cells was analyzed in 10 normal palatine tonsils. Tonsil biopsies were obtained from 8 normal children undergoing otolaryngological surgery for reasons completely unrelated to tonsil disease. Two samples of normal adult tonsil were also obtained. Standard immunohistochemical methods, with antigen retrieval, were used to detect cell surface markers in formalin-fixed and/or frozen tissue specimens. The clinical identification of these tonsils as normal was confirmed by their microscopic appearance. HLA-DR antigen expression was restricted to lymphocytes, macrophages and dendritic cells; all normal epithelia were negative. S100-positive dendritic cells were readily detected in surface and crypt epithelium and were rare in submucosal sites or follicles. T cells were observed as frequently as dendritic cells in epithelial sites. Dendritic cell density was highest in extrafollicular T cell areas, where CD4-positive lymphocytes were especially abundant. A significant correlation was observed between the total number of different bacterial species isolated from individual normal tonsils and the frequency of dendritic cells in both the crypt epithelium and extrafollicular T cell areas. The number of dendritic cells at the tonsil surface was not similarly related to the bacterial flora.

Adenoid lymphocyte responses to outer membrane protein P6 of nontypable Haemophilus influenzae in children with and without otitis media

The cellular immune responses to nontypable Haemophilus influenzae in adenoids were determined in children by measuring lymphocyte blast transformation and antibody secretion in response to the P6 outer membrane protein. In the lymphocyte transformation assay, stimulation index of adenoid lymphocytes stimulated by P6 in otitis children (2.34 +/- 0.25) was significantly lower than that in non-otitis children (3.91 +/- 0.64, p <0.05). The number of IgM as well as IgA secreting cells after 8 days' culture with P6 were significantly smaller in otitis children (IgM: 7,534 +/- 2,843/10(6) lymphocyte; IgA: 1,573 +/- 620/10(6) lymphocyte) than those in non-otitis children (IgM: 12,994 +/- 2,533, p <0.05; IgA: 2,828 +/- 528, p <0.05). These data suggest that P6 protein is a target for the cellular immune response of the adenoid, and failure of adenoid lymphocytes to recognize it as a specific immunogen may be one of the causes of recurrent otitis media.

Microbipolar dissection vs. cold knife/suction cautery tonsillectomy in children: preliminary results of a prospective study

Tonsillectomy and adenoidectomy (T&A) is a common surgical procedure for which many different surgical techniques have been described. However, detailed information is lacking regarding complications or recovery rates for any particular procedure. A newly described technique for T&A, microbipolar dissection (MBPD) is being compared with cold knife dissection with suction cautery of bleeding vessels (CKC) in a prospective study of 200 children aged 2-16 years. Patients are randomly assigned and stratified by age-group into one of two treatment arms. Intraoperative and post-operative measures of T&A effectiveness relative to complications and patient recovery rate are being studied. The preliminary data presented here focus on the reliability of the measures and potential clinical relevance of the findings in 129 of these children, with anticipated confirmation of these tentative results after completion of the larger cohort. Thus far it appears that post-operative bleeding rates are significantly reduced, recovery rate is improved, and return to normal activities are all better in the MBPD patients. Although these data reflect small numbers of children and must be interpreted with caution, it appears that MBPD T&A holds great promise in reducing the morbidity associated with the CKC technique of T&A.

Development and assessment of a home care tracheotomy manual

As home care tracheotomy has become a viable option for children with long-term canulation, medical personnel are challenged to provide as safe an environment as possible out of the hospital for these children. The tools used in the training of the families and other caregivers have received little attention in the literature. This study describes the development of a home-care tracheotomy manual for parents. The use of appropriate content presented in an organized, informative and pleasing fashion at the appropriate reading level is stressed. The evaluation of the manual by parents with children who have a child with a tracheotomy is also described.

The effect of post-operative diet on recovery in the first twelve hours after tonsillectomy and adenoidectomy

The effect of post-operative diet selection on the recovery rate of 100 children ages 3-17 years undergoing tonsillectomy and adenoidectomy (T & A) was studied. In the first 12 h after T & A children were allowed either a 'restricted' diet of only soft foods and liquids or a 'non-restricted' diet of foods preselected and usually eaten by the child. Parental evaluation of the child's general well being, pain level and nausea were evaluated. The number of episodes of emesis, doses of acetominophen and the list of foods and drinks consumed were also recorded. No significant differences in any aspect of recovery were noted between groups. However, a trend towards decreased nausea and parental perception of a more successful general recovery was noted at 12 h in the 'non-restricted' group. Children in the 'non-restricted' group were able to eat foods more often associated with their regular diet. No child from either group experienced any immediate or delayed complications. Implications for children and their families undergoing T & A are discussed.

Airway obstruction in the Crouzon syndrome: case report and review of the literature

Craniofacial dysostosis (Crouzon syndrome) is a syndrome characterized by premature closing of calvarial and cranial base sutures as well as those of the orbit and maxillary complex. Orofacial manifestations of this disease include maxillary hypoplasia, external nasal deformity, and prognathism. Airway distress is a well described feature of this syndrome, and both upper and lower airway obstruction may be present in the Crouzon syndrome. Obstructions in the upper airway have been reported secondary to septal deviation, midnasal and choanal abnormalities, and nasopharyngeal narrowing. This study presents a child with the Crouzon syndrome who required tracheotomy during the first 2 years of life for airway obstruction caused in the newborn period (first 6 months) by midnasal stenosis and laser (6 months to 2 years) compounded by soft palate obstruction at the level of the oro/hypopharynx. A review of the English language literature revealed one similar patient presentation but no comprehensive review of this subject. Previously reported airway anomalies are reviewed and airway management is discussed in patients with Crouzon syndrome.

Qualitative and quantitative immunoglobulin production by specific bacteria in chronic tonsillar disease

Tonsillar tissue lymphocyte (TTL) function as measured by immunoglobulin production was assessed in vitro in 60 tonsils, 51 diseased and 9 normal controls. The diseased specimens were from children (aged 3 to 10 years) clinically classified as having recurrent tonsillitis (RT), idiopathic tonsillar hyperplasia (ITH), or recurrent tonsillitis with hyperplasia (RT/H). TTLs were challenged with intact, heat-inactivated bacteria found in the core of diseased tonsils--Streptococcus pyogenes (SP) and Haemophilus influenzae type B (HIB) as well as the dominant bacterium (DB) grown from that particular tonsillar core. The phytomitogen, leukoagglutinin (LA), was used as a nonspecific activator. Qualitative immunoglobulin production was assessed for the immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) classes. Immunoglobulin-specific production was quantified at the basal level, and at 2, 4, and 6 days following stimulation. Stimulation with HIB produced the greatest amount of IgG and IgM in TTLs from control tonsils. The DB was a relatively weak stimulator of normal (control) TTLs, yet produced relatively brisk IgG responses in the RT and ITH categories. It did, however, yield only marginal IgM secretion in these groups. IgA was consistently produced after stimulation in diseased TTLs, yet was not elicited from normal TTLs. The aforementioned findings suggest a differential qualitative and quantitative immunoglobulin response for healthy, recurrently infected, and hyperplastic tonsils. Lymphocyte hypofunction along with structural changes associated with hyperplasia may be central to the etiology of chronic tonsillar disease. The tonsillar immunologic response in disease and health is discussed.

OmniMed II: a new system for use with the emphasis erodible mask

Clinical experience has shown the emphasis erodible mask to be an effective method for performing photorefractive keratectomy (PRK) using an eyecup placed in contact with the corneal surface. A new system (OmniMed II) which incorporates the erodible mask as an element in the optical delivery system has been developed for performing photorefractive keratectomy. With this new configuration the eyecup is no longer used. We describe in detail the advantages of the erodible mask, the associated hardware of the optical delivery system, and the mask shape transfer process.

Coagulation profile as a predictor for post-tonsillectomy and adenoidectomy (T + A) hemorrhage

The risk of hemorrhage after tonsillectomy and adenoidectomy (T + A) was studied in 1061 children. Twenty-seven (2.5%) had at least one abnormality on a preoperative coagulation profile consisting of a prothrombin time (PT), partial thromboplastin time (PTT), bleeding time (BT) and platelet count (PC). Of these 27 who had an initially abnormal test (PTT or bleeding times only), 8 had diagnosed coagulopathies by hematology evaluation (Group A), and 17 had repeat tests which returned to normal (Group B). Two borderline tests (PTT) were not repeated (Group C). Sixty-four patients (6.0%) bled after T + A. Six of these (9.3%) had an initially abnormal coagulation profile--one in Group A (12.5%), four in Group B (23.5%) and 1 in Group C (50%). This is in contrast to the bleed rate of 5.7% for the 1034 children with normal coagulation profiles. Although it is not surprising that 6 (22.2%) children with an initially abnormal coagulation profile bled, of note is that 4 of them had an initially abnormal coagulation profile which upon repeat testing returned to normal. However, none of these four bleeders required active intervention for control. Coagulopathies were newly diagnosed in 7 (0.57% of total group; 25.9% of 27 with abnormal laboratory values). One additional child had a known intrinsic platelet dysfunction prior to surgery. Only one child was newly identified by a positive family history for abnormal bleeding. These results suggest that new hematologic disorders were diagnosed infrequently. An initially abnormal coagulation profile may identify those more likely to bleed after surgery (22.6% vs. 5.5%). A coagulation profile which includes a PTT and BT may be a valuable screening tool for children undergoing T + A.

The effects of preoperative steroids on tonsillectomy patients

A prospective, randomized, double-blind study to determine the postoperative efficacy of steroids in tonsillectomy was performed in 49 children. A single dose of intravenous dexamethasone or placebo was administered after each child was anesthetized. Postoperatively each child was examined for objective signs of trismus (measured by interincisor distance), temperature elevation, and weight loss, as well as for subjective signs of mouth odor, oral intake, pain, level of activity, and analgesic usage. There were no statistical differences noted in any of the variables compared in the two groups and the complication rates were also similar.

Effect of specific bacteria on lymphocyte proliferation in diseased and nondiseased tonsils

Tonsillar tissue lymphocyte (TTL) function as measured by lymphocyte proliferation was assessed in vitro in 38 tonsils--30 diseased and 8 normal controls. TTLs from diseased and control tonsils were challenged with intact, heat-inactivated bacteria which may be found in the core of diseased tonsils; these bacteria were Streptococcus pyogenes and Hemophilus influenzae type B (HIB), as well as the dominant bacterium (DB) grown from that particular tonsillar core. The phytomitogen leukoagglutinin (LA) was used as a nonspecific activator. Lymphocyte proliferation was quantified and reported using a stimulation index (SI) which was based upon viable cell counts at 2, 4, and 6 days following inoculation. Overall, the greatest degree of lymphocyte proliferation in diseased TTLs (SI = .91) was produced by HIB. However, both SP and HIB produced more lymphocyte proliferation in the nondiseased TTLs than in the diseased TTLs (P < .01). H influenzae (non-B) and group A beta-hemolytic streptococci were the pathogens most frequently cultured as the dominant bacteria from the core of diseased tonsils; Streptococcus viridans was most frequently cultured in nondiseased tonsils. The DB caused greater TTL proliferation in diseased (SI = .89) versus control (SI = .63) TTLs (P < .001). These findings suggest a differential proliferative response in vitro for diseased and nondiseased TTLs in response to specific bacteria. The role of possibly pathogenic bacteria and commensals, as well as the implications for clinical disease, are discussed.

Bacteriology and immunology of normal and diseased adenoids in children

Adenoid physiology as reflected in the qualitative and quantitative bacteriology and immune cell distribution was correlated with clinical presentation in 69 children (16 to 130 months of age) undergoing adenoidectomy for obstructive adenoid hyperplasia (n = 38) or chronic adenoid infection (n = 31) and in 16 adenoid core biopsy specimens from 16 nondiseased controls. In the control adenoids, few potentially pathogenic bacteria were found as the dominant bacteria in the adenoid core (25%), and significantly greater concentrations of nonpathogens (commensals) were isolated (P < .01). Potential pathogens as the dominant bacteria were found twice as often in obstructive adenoid hyperplasia (62%) and in chronic adenoid infection (55%) (P < .05). Haemophilus influenzae was most common in the diseased adenoids, 53% in obstructive adenoid hyperplasia and 48% in chronic adenoid infection, compared with only 19% in the controls (P < .05). No significant differences in lymphocyte density, B and T cells, as well as T-helper subsets, were found between clinical classifications. However, T-suppressor cells, monocytes-macrophages, and natural killer cells were significantly increased in chronic adenoid infection only (P < .05). The findings in this study support roles for both alterations in bacterial homeostasis and an altered immune profile in the etiology of chronic adenoid disease in children.

Needle aspiration of peritonsillar abscess in children

Needle aspiration for the treatment of peritonsillar abscess was assessed in 43 consecutive children aged 7 to 18 years (mean age, 13.9 +/- 2.5 years) during the 3-year period from 1988 through 1991. A positive aspirate was obtained in 31 (76%) of the 41 patients who cooperated for needle aspiration; a mean of 2.9 +/- 1.9 mL of pus was withdrawn. Of the 31 children with a positive aspirate, in 27 (87%) the abscess resolved, two (6%) required a second aspiration for resolution, and two (6%) underwent immediate tonsillectomy for persistent abscess. Of the 10 children (24%) with negative aspirations, in six (60%) the abscess resolved with antibiotic treatment alone, three (30%) underwent immediate (quinsy) tonsillectomy, and in one (10%) the abscess spontaneously drained. No bleeding, airway obstruction, or anesthetic complications occurred. Needle aspiration of peritonsillar abscess in children, with tonsillectomy reserved for nonresponders, appears to be an efficacious and safe method of treatment.

Benefits of antibiotic prophylaxis in children with chronic sinusitis: assessment of outcome predictors

Eighty-six children with chronic sinusitis, documented by x-ray with symptoms and signs for more than 12 weeks, were evaluated for atopy and B-cell immune abnormalities. Twenty-nine percent (25/86) of the patients had some B-cell abnormality of immunoglobulin isotype, IgG subclass, and/or hyporesponsiveness to pneumococcal polysaccharide (PPS) vaccine (Pneumovax). Eleven of 17 patients who were hyporesponsive to PPS vaccine had normal immunoglobulin isotypes and IgG subclasses. Twenty-six of these 86 children were followed prospectively for > or = 1 year on prophylactic antibiotics. The 12-month period before the use of prophylactic antibiotics was taken as the control period for each child for comparison. Nineteen of 26 (74%) children had a good outcome (greater than a 50% reduction in the number of exacerbations of sinusitis during a 12-month period compared with the previous year) on prophylactic antibiotics with a reduction in exacerbations of sinusitis from 9.8 per year to 2.7 episodes per year. In contrast, 7/26 had a poor outcome (p < .0001) on prophylactic antibiotics (from 12.6 per year to 8.7 per year on prophylactic antibiotics). There were no significant differences in age, gender, atopy, or presence of a B-cell immune abnormality in the good versus the poor outcome groups to prophylactic antibiotic therapy. Treatment outcome correlated inversely with the number of sinus infections before prophylactic antibiotics, p = .036. Underlying B-cell immune abnormalities could not be correlated with intervention outcome on prophylactic antibiotics. The use of prophylactic antibiotics was an effective treatment modality in children with chronic sinusitis, even in patients with selective immune abnormalities.

The effect of post-operative instructions on recovery after tonsillectomy and adenoidectomy

The effect of postoperative diet and activity instructions on the recovery rate after tonsillectomy and adenoidectomy (T & A) was assessed in 92 children ages 3 to 14 years. Two types of postoperative instruction were randomly assigned: 'Restricted', which advised limited, stay at home activities and a soft food liquid diet for 7-10 days, and 'nonrestricted', which advised return to activity and diet as tolerated by the child. Parental evaluation of the levels of pain, activity, and diet using an equal intervals scale was obtained. The number of doses of pain medication, the types of food eaten and postoperative complications were also recorded. No significant differences were found between the two groups in pain level, activity tolerance, return to normal diet, and numbers of doses of pain medication at day 3 and day 7 after surgery. More 'junk' food and spicy foods were eaten in the 'nonrestricted' group. Postoperative hemorrhage requiring intervention occurred in one child in each group. Implications for the children and their families undergoing T & A are discussed with attention to a review of the literature.

Anatomic correlates of normal and diseased adenoids in children

In order to better understand the pathogenesis and sequelae of obstructive adenoid hyperplasia in children, the anatomic relationships of the adenoids to the hard and soft palates, oropharynx, and nasopharynx were studied in vivo in 94 children. Direct, intraoperative palatal, nasopharyngeal, and oropharyngeal measurements were performed in 19 children with normal, nondiseased adenoids (controls [C]) and compared to 75 children undergoing adenoidectomy for obstructive adenoid hyperplasia (OAH) (n = 44) or chronic adenoid infection (CAI) (n = 31). As expected, the weight and volume of the adenoids removed were significantly greater in the OAH vs. CAI group (P < .001). Before adenoidectomy, the volume of the nasopharynx was significantly smaller in the OAH group; however, nasopharyngeal volumes after adenoidectomy were quite similar in all three groups and ranged from 5.4 to 6.2 cc. Only the change in the volume of the nasopharynx after adenoidectomy for obstruction was significant (2.5 +/- 1.2 cc, P < .01). Differences in oropharyngeal and palatal dimensions were not associated with longstanding obstruction from adenoid hyperplasia. These data indicate that the nasal obstruction from adenoid hyperplasia is due to an absolute increase in adenoid size rather than a relatively smaller nasopharynx. Differences in palatal and oropharyngeal dimensions usually described and attributed to longstanding nasal obstruction could not be demonstrated in this study.

Pediatric tracheotomy referrals to speech-language pathology in a children's hospital

The pattern of referral of infants and children with tracheotomy to speech-language pathology (SLP) was studied through a retrospective review. Less than half (29/62) were referred to SLP with no difference by surgical service (otolaryngology vs pediatric surgery) or length of time with tracheotomy. Younger children were referred far less frequently than older children. Furthermore, more than half of all children referred to SLP showed moderate to severe communication deficits. Central nervous system abnormalities were documented in 66% of the subjects. In the majority tracheotomies were in place longer than 12 months. On the basis of the findings, a protocol was established for early routine involvement of SLP with infants and children with tracheotomy.

Needle aspiration of neck abscesses in children

Needle aspiration of neck abscesses with CT-scan guidance was studied in 17 children with 18 abscesses from 1986 to 1991. Clinical and radiologic findings were analyzed according to treatment outcome. A majority of abscesses (55.6%) resolved after treatment with one to two attempts at needle aspiration and parenteral antibiotics. Unilocular abscesses were more likely than multilocular abscesses to resolve with needle aspiration. In general, abscesses in younger children who presented with smaller neck masses on physical examination and smaller abscess cavities on CT scan resolved with needle aspiration. The data support the use of needle aspiration as an effective initial treatment for pediatric neck abscesses. CT scan was found beneficial in documenting the abscesses and in guiding treatment. A treatment protocol is suggested for the use of needle aspiration in the management of neck abscesses in children.

Effect of prior antibiotic treatment on middle ear disease in children

The effect of prior antibiotic treatment on the course of otitis media was assessed in a group of 62 children who experienced 83 episodes of ear infection during 3 years of observation. Bacterial quantitation in middle ear fluids demonstrated a significantly higher colony count in symptomatic children (3.9 x 10(4) +/- 12 bacteria per milliliter) compared to asymptomatic children (6.3 x 10(3) +/- 10 bacteria per milliliter; p = .05). Bacterial counts similarly tended to be higher in children with Streptococcus pneumoniae (4.0 x 10(6) +/- 16 bacteria per milliliter) and Hemophilus influenzae (2.0 x 10(6) +/- 16 bacteria per milliliter), who were more often symptomatic (73% and 55%, respectively, versus 38%) than children with Moraxella catarrhalis (7.9 x 10(3) +/- 2). Antibiotic therapy between 3 and 30 days prior to bacterial diagnosis was associated with a reduction in symptoms from 70% to 38% (p less than .025). However, prior treatment did not statistically reduce bacterial colony counts, although S pneumoniae decreased 90% in the previously treated group. Resistance to ampicillin occurred in 0% of S pneumoniae, 39% of nontypeable H influenzae, and 80% of M catarrhalis subjects without prior treatment and in 0%, 46%, and 100%, respectively, of subjects previously treated (p less than .025). These data suggest that prior treatment has a significant impact on the subsequent course of otitis media in children.

Tissue distribution of mucosal antibody-producing cells specific for respiratory syncytial virus in severe combined immune deficiency (SCID) mice engrafted with human tonsils

Groups of C.B-17 SCID mice were reconstituted intraperitoneally with human tonsillar mononuclear cells (hu-TMC) from children seropositive for antibody to respiratory syncytial virus (RSV) and subsequently challenged intraperitoneally with inactivated RSV or sham-immunized. The synthesis and the distribution characteristics of human antibody to RSV in various murine tissues were studied using an enzyme-linked immunospot assay (ELISPOT). No specific antibody was observed in sham-immunized animals. In contrast, mice engrafted with hu-TMC exhibited the appearance of specific human antibody secreting cells (hu-ASC) after i.p. immunization with inactivated RSV. RSV-specific hu-ASC were detected only in animals engrafted with cells from donors seropositive for antibodies to Epstein-Barr virus. Hu-TMC engrafted mice showed RSV-specific IgM and, in lower numbers, IgG hu-ASC in several tissues including the lungs. Numbers of RSV-specific IgA hu-ASC were low, however, and detected only in the lung. No RSV-specific hu-ASC were detected in the intestine. These data demonstrate for the first time that hu-TMC-SCID chimeras respond to immunization with viral antigen. Furthermore, the results suggest that hu-TMC engraft in lungs but not in the intestinal tissue.