Corticosteroids suppress in vitro tonsillar proliferation in children with obstructive sleep apnoea

Intranasal corticosteroids (CS) are potentially useful interventions for children with obstructive sleep apnoea (OSA), and may reduce lymphadenoid tissue size in the upper airway. The present authors hypothesised that CS would reduce cellular proliferation and the production of pro-inflammatory cytokines in a tonsil/adenoid mixed-cell culture system. Dissociated tonsils or adenoids harvested intra-operatively from children with polysomnographically diagnosed OSA were cultured in control medium (CO) or after stimulation with lipopolysaccharide and concanavalin A (STIM), and incubated with dexamethasone (DEX; 10(-5)-10(-7) M), fluticasone (FLU; 10(-5)-10(-14) M) and budesonide (BUD; 10(-4)-10(-14) M). Proliferation and apoptosis were assessed, and supernatants were assayed for the cytokines tumour necrosis factor (TNF)-alpha, interleukin (IL)-6 and IL-8. STIM increased tonsillar and adenoidal proliferation compared with CO (1,976+/-133 versus 404+/-69 counts min(-1); n = 54). DEX, FLU and BUD reduced cellular proliferation rates, and exhibited dose-dependent effects, with the potency being FLU>BUD>DEX (n = 25 per group). Conversely, CS increased cellular apoptosis (n = 20 per group). Furthermore, TNF-alpha, IL-8 and IL-6 concentrations in the supernatant were increased by STIM, and markedly reduced by all CS (n = 48 per group). Whole tissue cell cultures of adenoids and tonsils provide a useful approach for in vitro assessment of therapeutic efficacy of corticosteroids in the management of lymphadenoid hypertrophy that underlies obstructive sleep apnoea in children.

Priorities in the management of penetrating maxillofacial trauma in the pediatric patient

Penetrating facial trauma is uncommon in children; a large series published by Cooper et al revealed that only 1% to 2% of the total population of infants and children admitted for trauma during their study period had a diagnosis of penetrating trauma to the head or neck. Little has been published specifically addressing these injuries in the pediatric population. The records of 20 patients treated for penetrating facial injuries at Kosair-Children's Hospital in Louisville, Kentucky from January 1991 through December 1994 were reviewed. The location, mechanism and extent of injury, as well as the diagnostic and management practices used in patient treatment, were collected. Categorizing the injuries relative to the involvement of one or more facial zones helped guide diagnostic studies and therapeutic intervention and predict associated injuries. This article evaluates the authors' method of management and any differences in management between pediatric and similarly injured adult patients.

Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.

Otolaryngologic clinical patterns in pediatric infectious mononucleosis

PURPOSE

Classic infectious mononucleosis (IM) is uncommon in children; therefore, the incidence of severe pharyngotonsillitis complicating the infection is not well established. This study was undertaken to better define the management of complications with special emphasis on the use of parenteral steroids and the role and timing of surgical management.

MATERIALS AND METHODS

A retrospective review of all cases of IM encountered between January 1989 through December 1993 was undertaken.

RESULTS

There were 109 patients admitted with IM. Sixty patients (55%) were admitted for severe pharyngotonsillitis. Twenty-nine patients in this subgroup were felt to have symptoms of severe upper airway obstruction and were treated with parenteral steroids. Surgical intervention was required in three patients.

CONCLUSION

The study shows a higher incidence of admissions for severe pharyngotonsillitis complicating IM than reported in the adult literature. It suggests that routine use of parenteral steroids is indicated in cases of severe upper airway obstruction and may decrease the need for surgical intervention.

Embolization as the definitive treatment of epistaxis in the pediatric patient

Epistaxis occurs often in children, but these patients are seldom hospitalized. Two cases of intractable epistaxis, which were definitively treated with internal maxillary artery embolization, are presented with an algorithm for management of similar cases.

Eustachian tube dysfunction and its sequelae in patients with cleft palate

The incidence of middle ear disorders in patients with cleft palate deformities was determined in a retrospective review of 110 children with palate or palate and lip involvement. Ages ranged from 2 months to 18 years and included patients with associated abnormalities such as Pierre Robin syndrome and Treacher Collins syndrome. Clinical manifestations of eustachian tube dysfunction were found in 79% in the form of effusions, retraction pockets, adhesions, and ossicular erosion. Only two patients had confirmed cholesteatoma formation. Despite the low incidence of acquired cholesteatoma in these patients, the frequent occurrence of other disorders that affect hearing warrants early and aggressive otologic management to prevent long-term sequelae.

Subglottic tuberculosis: a case report

Granulomatous disorders of the larynx can take on many forms and usually represent the end stage of chronic disease. In the past, laryngeal granulomas were much more prevalent primarily because of the frequency of tuberculosis. Seldom is the larynx the site of origin for granulomatous disease, but it is usually a manifestation of a pulmonary entity such as histoplasmosis, blastomycosis, sarcoidosis, or tuberculosis. The actual diagnosis is frequently arrived at while trying to rule out carcinoma. Laryngeal tuberculosis, although rare in the United States, remains the most common granulomatous disease of the larynx. Its increasing incidence has paralleled the diminished incidence of tuberculosis in the general population. Specific clinical characteristics for diagnosis are few and diagnosis is arrived at through a high index of suspicion and biopsy. When biopsy is carried out, adequate tissue should be obtained for both histological sections, cultures, and sensitivities.

Orbital invasion by an intracranial chordoma

A 26-year-old woman experienced bilateral hearing loss, progressive nasal obstruction, and rhinorrhea. Examination disclosed a retropharyngeal mass. A needle biopsy specimen of the mass showed that it was a chordoma. The patient underwent surgery to remove the mass and received a postoperative course of radioactive cobalt. She did well for 18 months, at which time proptosis gradually developed in her right eye. Although the optic nerve heads and visual fields appeared normal, roentgenograms showed a large lesion involving the anterior and middle cranial fossae and destruction of the right posterior ethmoid sinus and right superior orbital fissure. Shortly after completing a course of methotrexate therapy (total dose, 89 mg), the patient experienced sudden pain and visual loss in her right eye. Surgical decompression of the orbit failed to restore light perception. The following year, her left eye became involved. A transfrontal craniotomy and extradural orbital decompression provided only temporary improvement. Four months later, left lateral rectus muscle palsy developed and her visual acuity decreased to 6/60 (20/200). Radiation therapy (400 rads per week; total dose, 3,200 rads) and treatment with methotrexate, vincristine sulfate, and prednisone did not improve her condition. At the time of her death, six years after the first symptom appeared, the patient was blind in both eyes, almost completely deaf, and suffered from severe dysphagia.

Cyclic pharyngeal lymphoiditis: immunological considerations

This communication presents the concept that recurrent infections of the lingual tonsils, lateral pharyngeal lymphoid bands and lymphoid follicles on the posterior pharyngeal wall, occurring with the same periodicity, is a cyclic clinical and immunological entity. These patients lacked resistance to the normal flora of the nasopharynx and pharynx. They were accordingly treated with a mixed respiratory bacterial vaccine, administered intradermally and according to a formulated program, to improve resistance or immunity of the lymphoid tissue. These patients showed definite improvement by this method of therapy. It is suggested that the effectiveness of therapy was accomplished through the immunological process of cell-mediated immunity. The immunobiologic development of cell-mediated immunity by T thymic-dependent cells and humoral immunity by B cells is briefly discussed.

Indirect laryngoscopy

Indirect laryngoscopy is one of the procedural methods used for achieving a histopathologic diagnosis of cancer of the larynx. A chronologic historical summary of the development of mirror laryngoscopy is presented. The details of the procedure employed for obtaining a biopsy with the aid of topical anesthesia is discussed.