Childhood pseudohypacusis in patients with high risk for actual hearing loss

OBJECTIVE

While pseudohypacusis or nonorganic hearing loss is a well-recognized phenomenon in adults, it is the aim of this report to heighten the physician's awareness of the occurrence of nonorganic hearing loss in pediatric patients. The medical and otologic histories of 18 cases identified consecutively between 1983 and 1991 at The Children's Hospital, Boston, Massachusetts, were retrospectively reviewed. In these selected cases an analysis of the audiometric configuration, age range, and sex distribution is undertaken. This review highlights the need to rule out pseudohypacusis even in pediatric cases where suspicion is low. A precedent trauma was the presenting complaint in a high percentage of our patient population. This association has not been previously reported in the pediatric literature. While the severity of the traumatic incident was often minor, extensive medical and surgical investigations had been considered before the identification of nonorganic hearing loss.

STUDY DESIGN

A retrospective chart analysis of patients identified with pseudohypacusis over a 7-year period.

METHODS

A tertiary care children's hospital in an urban community. Eighteen consecutively identified patients examined by a staff audiologists at a tertiary care children's hospital. A specific battery of standard audiologic testing with the goal of detecting pseudohypacusis in children.

RESULTS

Successful if additional interventions such as exploratory tympanotomy were avoided.

CONCLUSIONS

Pseudohypacusis was identified in 18 patients with a majority having an antecedent history of trauma. Additional interventions were canceled upon the detection of true threshold values. A high index of suspicion of pseudohypacusis in children and an organized standardized battery of audiologic testing will facilitate early identification of these patients and will avert inappropriate interventions.

Angiofibroma. Changes in staging and treatment

OBJECTIVE

To identify specific preoperative tumor characteristics and potential surgical decisions that ultimately place a patient at a greater risk for tumor recurrence.

DESIGN

The clinical presentation, management, and prognosis of 23 consecutive cases of juvenile nasopharyngeal angiofibroma were reviewed retrospectively from January 1, 1977, to June 30, 1993. A minimum follow-up of 12 months was necessary for study inclusion.

SETTING

A single, tertiary care pediatric facility.

INTERVENTIONS

All available preoperative imaging studies were reevaluated to ensure consistency in reporting. Preoperative computed tomography was performed in 21 patients, but only 18 scans were available for review. Preoperative angiography with embolization was performed in 21 of 23 patients. Surgical excision was the primary mode of treatment in 22 of 23 patients, and complete surgical excision was possible in 21 of 23 patients.

MAIN OUTCOME MEASURES

The rate of recurrence was examined with respect to time of presentations, initial tumor stage, intraoperative blood loss, and surgical approach.

RESULTS

When compared with patients without a recurrent tumor, there was no difference in age at presentation, primary symptom, or duration of symptoms before diagnosis. Preoperative tumor stage was found to be the primary factor affecting tumor recurrence. A recurrence rate of 21.7% (five of 23 patients) was identified after an average 6-year follow-up. A trend toward use of the midfacial degloving approach for surgical exposure was identified and was not associated with an increased risk of recurrence. All patients were ultimately cured of their tumor without the need for open craniotomy despite a 32% incidence of stage IIIA and IIIB tumors. No deaths were reported during the study.

CONCLUSIONS

Juvenile nasopharyngeal angiofibromas are benign tumors occurring almost exclusively in adolescent males. Recent advances in radiographic imaging techniques allow for more accurate preoperative staging, especially in regard to skull base involvement. Recognition of the extent of the tumor before surgical extirpation reduces the risk of recurrence.

Changing patterns in pediatric supraglottitis: a multi-institutional review, 1980 to 1992

Supraglottitis is a rapidly progressive, life-threatening airway emergency in pediatric patients typically caused by Haemophilus influenzae type B (HIB). With distribution of the first efficacious vaccine for HIB in April 1985, changing disease patterns have begun to emerge; however, certain characteristics have remarkably persisted. The authors reviewed 252 pediatric patients with acute supraglottitis spanning the prevaccination and postvaccination years 1980 to 1992 at three major regional pediatric hospitals in Massachusetts, Ohio, and California, as well as at two community hospitals in Massachusetts. Findings include a decline in disease prevalence in all geographic areas with demographic, etiologic, and management evolution all seen. Children who had been immunized yet developed supraglottitis have been examined as predictive of future trends.

Penetrating trauma of the oropharynx in children

Penetrating trauma of the oropharynx is not an uncommon problem in the pediatric population. Innocuous injuries with minor soft-tissue trauma have been associated with severe neurologic sequelae. A review of 77 oral trauma cases that occurred from 1981 to 1990 at Boston Children's Hospital was undertaken to see if constant factors could be identified so that a treatment protocol might be outlined for these patients. Twenty-three (30%) patients sustained injury to the soft palate and peritonsillar area. Fifty percent of these cases required surgical debridement and repair. None of the 23 patients developed neurological sequelae. Physical examination may not correlate with the development of symptoms nor the mechanism of injury. Care should be taken during the examination to identify any neurological problems that may not relate to the degree of injury. Conservative management can be entertained if no abnormal neurologic findings are noted.

Thyroglossal duct remnants. Preoperative evaluation and management

Midline cervical cysts arising from the thyroglossal duct are one of the most common causes of anterior neck swelling in children. The potential for confusion between the thyroglossal duct cyst and the ectopic thyroid gland is well documented and may result in serious complications. A retrospective chart analysis was therefore undertaken to determine the relative importance of clinical evaluation, thyroid function testing, and radioisotope scanning in distinguishing these two entities preoperatively. A combined study was carried out by The Children's Hospital, Boston, Mass, and Rainbow Babies Hospital, Cleveland, Ohio. The hospital records, including nuclear scans, were reviewed. A total of 229 patients were taken to the operating room between January 1, 1978, and December 31, 1987. Nuclear scanning was performed in 30% of these patients. This subgroup of patients forms the basis for our guidelines of preoperative assessment. The absolute need for a preoperative scan is reexamined.