Safety and long-term efficacy of tonsillectomy versus subtotal tonsillectomy in children with sleep disordered breathing

OBJECTIVES

to compare safety and long-term symptoms after TE compared to Subtotal Tonsillectomy (STT).

METHODS

A retrospective review data of 412 patients, one to twelve years old that underwent either TE or STT, as treatment for sleep disorder breathing, at two different medical centers. Symptoms were assessed by a questionnaire 3-5 years post-surgery. Additionally, data regarding immediate post-operative symptoms and complications were also collected.

RESULTS

Long-term symptoms score was significantly lower in the TE group: 1.585 (±1.719) compared to 1.967 (±1.815) in the STT group (p = 0.033); 51.3% of patients in the ST group presented long-term SDB symptoms, compared to 40.6% in the TE group (p = 0.035); The main difference between the groups was snoring as 49% of the STT group suffered from snoring, versus 28.9% in the TE group (p < 0.001).

CONCLUSIONS

TE showed an advantage over STT in resolving snoring in the long term.

Acute mastoiditis in children under 15 years of age in Southern Israel following the introduction of pneumococcal conjugate vaccines: a 4-year retrospective study (2009-2012)

OBJECTIVES

To describe the epidemiologic, microbiologic, clinical and therapeutic aspects of acute mastoiditis (AM) in children <15 years of age during the 4-year period (2009-2012) following the introduction of pneumococcal conjugate vaccines in Israel.

PATIENTS AND METHODS

The medical records of all children with a discharge diagnosis of AM were reviewed.

RESULTS

A total of 66 AM episodes occurred in 61 patients. Forty-four (66.6%) cases occurred among patients <4 years, recent acute otitis media (AOM) history was reported in 27.1% and 28.8% patients received previous antibiotics for AOM. Postauricular swelling, postauricular sensitivity, protrusion of auricle and postauricular edema (93.8%, 90.6%, 85.9% and 95.7%, respectively) were the most common signs of AM. Leukocytosis >15,000 WBC/mm(3) was found in 39 (59.1%) cases. Cultures were performed in 52/66 episodes (positive in 27, 51.92% episodes), with recovery of 32 pathogens. The most frequently isolated pathogens were Streptococcus pneumoniae (15/52, 28.85%), Streptococcus pyogenes (9, 17.3%) and nontypeable Haemophilus influenzae (5, 9.62%). Eight (53.3%) S. pneumoniae isolates were susceptible to penicillin. Mean incidence of overall and pneumococcal AM were 11.1 and 2.58 cases/100000, with no significant changes during the study years. Surgical intervention was required in 19 (28.8%) patients.

CONCLUSIONS

(1) AM occurs frequently in patients without previous AOM history and with no previous antibiotic treatment; (2) S. pneumoniae and S. pyogenes continued to be the main etiologic agents of AM during the postvaccination period; (3) No changes were recorded in overall AM incidence and in pneumococcal AM incidence during the postvaccination period.

Circulating cytokines in patients undergoing tonsillectomy with fibrin glue

OBJECTIVE

Fibrin glue is used as a haemostatic agent or as a sealant. The aim of this study is to objectively evaluate the efficacy of the use of fibrin glue Quixil - a human surgical sealer - in tonsillectomy, for the reduction of post-operative inflammatory response.

STUDY DESIGN

A prospective randomized single-blind study.

METHODS

The study was performed on 40 consecutive patients undergoing adenotonsillectomy (T&A). Patients were randomly assigned to one of two sub-groups: a study group and a control group. The tonsillar beds of patients in the study group were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation; the patients in the control group were treated for hemostasis without the use of fibrin glue. Complete blood counts and circulating pro-inflammatory cytokines (assayed by specific immunoassay - ELISA) were assessed in samples drawn pre- and 16 h post-tonsillectomy.

RESULTS

Forty patients (aged 5.8 ± 2.4 years) were consecutively enrolled; 45% (18) of the patients were treated with fibrin glue, 55% (22) were not. Compared to controls, Quixil-treated patients demonstrated a reduction in post-tonsillectomy circulating leukocytes (29.2% vs. 45.4%, p<0.05), neutrophiles (28.3% vs. 42.1%, p<0.05), IL-6 (+1% vs. +42%, p<0.05), and TNF-alpha (+8% vs. +26%, p<0.05.

CONCLUSIONS

Intra-operative fibrin glue therapy is associated with decreased immediate inflammatory response following T&A. Further studies are warranted to assess long-term outcome.

LEVEL OF EVIDENCE

1B.

Nasal polyps in the pediatric population

OBJECTIVE

Chronic sinusitis with nasal polyps is an uncommon pathology in the pediatric population and may be associated with systemic disease. In this study we aimed to characterize children who underwent nasal surgery at our medical center due to nasal polyps and review the current literature related to pediatric nasal polyps.

STUDY DESIGN

We retrospectively reviewed all medical records of patients younger than 18 years who had sinus surgery from 2000 to 2010. We collected demographic and clinical data including age, sex, laterality, revision operations, and comorbidities including asthma, allergy, and cystic fibrosis (CF).

RESULTS

Thirty-one patients age 8.8 to 18 years (mean 13.7) were treated surgically in our hospital. Thirteen had antrochoanal polyp, 16 had chronic sinusitis with nasal polyps, and 2 had mucocele. Among patients treated for nasal polyps, there were 6 boys and 10 girls, mean age was 14.2 years, and 14 (87.5%) had bilateral disease. Mean Lund McKay score was 15.8. Five (31.2%) had asthma, 15 (93.7%) had sleep breathing disorder, and none had known allergy. Three patients (18.7%) had more than one surgery, including one patient with CF. Nine healthy children were tested for CF; one was positive.

CONCLUSIONS

Nasal polyps in children are more common in teenagers, are usually bilateral, and are commonly associated with bronchial asthma. There was no association with allergy. Meticulous anamnesis and a high index of suspicion are recommended to manage other comorbidities.

Relation between Peritonsillar Infection and Acute Tonsillitis

Objective. To investigate the relationship between tonsillar and peritonsillar infections.

Study Design. Retrospective population-based study and a retrospective case series review.

Settings. Tertiary academic medical facility.

Subjects and Methods. All individuals hospitalized with peritonsillar abscess (PTA) or peritonsillar cellulitis (PTC) during 2004-2008 were reviewed. Patient age, gender, diagnosis of PTA or PTC, recurrence, and date of presentation were recorded. In addition, a database of patients diagnosed in the community with acute tonsillitis (AT) was reviewed for the same time period. The weekly number of patients with AT was recorded, and a comparison between incidence of tonsillar infections and peritonsillar infection was performed.

Results. A total of 685 patients were hospitalized with either PTA (467) or PTC (218). Incidence of both upper respiratory infections and AT peaked in January and February of every year with a nadir in August. In contrast, PTA and PTC showed a consistent rate of infection throughout the year. Likewise, assessment based on weekly intervals showed that peaks of PTA and PTC did not follow those of acute tonsillitis with a 1 to 2 weekly lag as would be expected if peritonsillar infection is a complication of AT. Rather, an association between peritonsillar infection and tonsillitis was found within the same week ( P = .04).

Conclusion. Higher rates of occurrence of PTA or PTC following AT outbreaks were not found. These results lend further support to the theory that peritonsillar infection is associated not only with complications of AT but may occur from infection of Weber glands or other unknown causes.

Beneficial effects of caloric vestibular stimulation on denial of illness and manic delusions in schizoaffective disorder: a case report

INTRODUCTION

Preliminary data suggests that caloric vestibular nerve stimulation (CVS) single session application of cold water to the left ear induces a clinically significant, short-lived beneficial effect on specific types of illness denial (i.e., anosognosia) and delusions (i.e., somatic type).

METHODS

We recently studied the effect of left versus right ear ice water (4°C) CVS on delusions and insight of illness in a patient with manic episode due to schizoaffective disorder. The patient was evaluated at baseline, immediately after the CVS, and then at 20 minutes, 60 minutes, and 24 hours. The method was first applied to one ear and 4 days later to the other. To assess whether the effect is specific to mania we employed the same procedure in two other patients with schizophrenia who also demonstrated delusions and impaired insight.

RESULTS

All three patients showed a difference favoring left versus right ear CVS that was maintained for 20 minutes, and diminished over a 60 minute period. EEG analyses showed a numerically non-significant increase in bilateral frontal and central alpha EEG band activation (more pronounced in the right hemisphere) with left but not right ear CVS 5 minutes after the CVS, and that diminished after 20 minutes.

DISCUSSION

The results suggest that left versus right CVS may have a short lived beneficial effect on manic delusions and insight of illness that seem to appear in other types of psychoses (i.e., schizophrenia).

CONCLUSION

These preliminary results suggest that single session CVS may have short lived beneficial effects in mania and perhaps in other types of psychoses. Further research is mandatory.

[The Hebrew dizziness handicap inventory]

BACKGROUND

The dizziness handicap inventory (DHI) has become a well accepted method for specifically assessing the quality of life among dizzy patients and in evaluating the results of different types of therapy, especially of vestibular rehabilitation programs.

OBJECTIVE

To assess the reliability of a translated Hebrew version of the DHI (HDHI) on a cohort of patients attending a tertiary dizziness clinic.

METHODS

A double translation method was applied on the original DHI. Consecutive patients with symptoms of dizziness lasting at least six months were included. HDHI questionnaires were completed by patients on three occasions: while waiting to be examined, after the examination and one week later. Internal consistency reliability of each questionnaire and test- retest reliability between the questionnaires were analyzed on the total score and for each of the emotional, functional and physical subgroups of the questionnaires.

RESULTS

Thirty-one patients completed all three questionnaires. Internal consistency reliability of the three subgroups of questions: physical, emotional and functional in each of the three questionnaires were all high (Cronbach's Alpha coefficient 0.83-0.96). The test- retest reliability, the correlation between the total DHI scores of the first and second questionnaire (same day) showed a correlation coefficient of 0.96, and between the first and third questionnaire (7 days apart) was 0.94, with P values of < 0.01. The correlation coefficient of the subgroups ranged from 0.93 to 0.97.

CONCLUSION

The HDHI is a reliable test of dizzy patients' symptoms and may be applied in patient care and for reporting on their follow-up.

Pediatric cochlear implants in prelingual deafness: medium and long-term outcomes

Unfortunately, no large-scale, well-designed, comprehensive studies on medium and long-term effect of cochlear implants in prelingual children exist. Furthermore, the few studies listed have addressed different aspects of this issue, in a non-standardized manner. With the question of outcomes becoming so important in modern medicine, standardized reporting methods are essential. This would enable a fair comparison between the different commercial devices and between rehabilitation-education methods. The studies presented above were published between 1999 and 2008. Due to the long follow-up period required for reporting medium and long-term outcomes, they actually represent patients implanted one and two decades ago. At present and in the near future, we may expect better results from patients who were implanted in the last few years for several reasons: a) superior cochlear implants with better coding strategies; b) developments in rehabilitation and higher awareness among parents and staff; c) better health care and universal screening programs, leading to implants being performed in an earlier age; and d) a high rate of performing bilateral cochlear implants (either simultaneously or sequentially) in the last decade, which accomplishes even better results compared to unilateral implants. From the studies reviewed above, mainstreaming the child who has auditory-verbal and oral communication is the preferred educational setting for maximizing the medium and long-term benefit from a cochlear implant. Hearing and speech skills continue to improve many years after the implant. Non-use and failure rates (as reported by the authors from the medical centers and not solely by the cochlear implant manufacturers) are low, ranging from 1% to 2.7% per year. Overall, patients have a high rate of employment, close to that of the general population. However, they may be less satisfied, as the individual and the parents may feel compromised by their communication skills.

Paranasal sinus complications caused by dental implants and complementary procedures

OBJECTIVE

To describe the paranasal complications that may occur after dental implantation.

STUDY DESIGN

A literature search was performed in order to review currently available information about the complications of dental implantations and complementary procedures.

RESULTS

The use of dental implants has gained great popularity due to their convenience, natural look, and better speech and chewing efficiency, as well as their potential to slow and even stop jawbone atrophy. Nevertheless, an increasing number of publications have drawn attention to the possible complications of the procedure for the paranasal sinuses. Both short-term and long-term complications have been described that should be familiar to otolaryngologists.

CONCLUSIONS

Although the procedure is performed by dentists, dental implantations may also have a major impact on the paranasal sinuses. Complications may necessitate the knowledge and cooperation of both dentists and otolaryngologists.

Cleidocranial dysplasia - review with an emphasis on otological and audiological manifestations

Cleidocranial dysplasia is a rare developmental abnormality of bone that affects both the skeleton and the temporal bone. It is genetically characterized and the clinical signs and symptoms can be diverse. Aural pathologies may be the presenting symptoms of the disease. We reviewed the up to date literature on the syndrome with an emphasis on the otological and audiological manifestation.

Bilateral consecutive blindness due to sphenoid sinus mucocele with unilateral partial recovery

BACKGROUND

We present an interventional case report of a rare occurrence of sphenoid sinus mucocele causing bilateral consecutive blindness with unilateral partial recovery after endoscopic surgery.

METHODS

A 64-year-old woman with known sphenoid sinus mucocele and right blindness was referred because of an acute drop of vision to hand motion in her only-seeing left eye over 5 days. Imaging revealed a large mucocele enlarging the sphenoid sinus, eroding the base of the skull, protruding into the cranial cavity, and compressing the left optic nerve.

RESULTS

Urgent endoscopic sphenoidotomy was performed. Several hours after the procedure, visual acuity was partially recovered in the left eye.

INTERPRETATION

Sphenoid sinus mucoceles can cause bilateral blindness. A high index of suspicion and urgent imaging studies are necessary. Because visual recovery depends on prompt diagnosis and surgical intervention, a close collaboration between otolaryngologists and ophthalmologists is crucial.

The silent sinus syndrome

Patients with silent sinus syndrome typically present for investigation of facial asymmetry. Unilateral, spontaneous enophthalmos and hypoglobus are the prominent findings at examination. Imaging of the orbit and sinuses characteristically show unilateral maxillary sinus opacification and collapse with inferior bowing of the orbital floor. It has been suggested that SSS is due to hypoventilation of the maxillary sinus secondary to ostial obstruction and sinus atelectasis with chronic negative pressure within the sinus. Treatment involves functional endoscopic sinus surgery for reestablishing a functional drainage passage, and a reconstructive procedure of the floor of the orbit for repairing the hypoglobus and cosmetic deformity. Ophthalmologists, otorhinolaryngologists, and radiologists must be familiarized with this relatively newly reported disease.

Rhinolithiasis: a very late complication after dacryocystorhinostomy with rubber-gum and polyethylene stenting

PURPOSE

To describe a rare case of rhinolith formation 21 years after dacryocystorhinostomy (DCR) with rubber gum and polyethylene tubing surgery.

DESIGN

Interventional case report.

METHODS

A 23-year-old-woman underwent uneventful left DCR with rubber gum and polyethylene tubing for chronic dacryocystitis. Twenty-one years later, she presented with purulent rhinorrhea, nasal obstruction, and facial pain. Computed tomography revealed a radiopaque density in the left nasal cavity.

RESULTS

A rubber gum foreign body embedded with granulation tissue and a huge rhinolith was removed endoscopically through the anterior nares. After surgery, the patient reported immediate and complete relief of symptoms.

CONCLUSION

Rhinoliths can develop progressively several years after DCR as a result of foreign body reaction to rubber gum or polyethylene tubing. This rare complication should be ruled out in patients complaining of purulent rhinorrhea who underwent DCR with tubing before the early 1980s.

Endoscopic orbital decompression for Graves' ophthalmopathy

BACKGROUND

In patients with Graves' ophthalmopathy, orbital decompression surgery is indicated for compressive optic neuropathy, severe corneal exposure, or for cosmetic deformity due to proptosis. Traditionally this has been performed through a transantral approach, but the associated complication rate is high. More recently, endoscopic orbital decompression has been performed successfully with significantly fewer postoperative complications.

OBJECTIVE

To report our experience of endoscopic orbital decompression in patients with severe Graves' ophthalmopathy.

METHODS

Three patients (five eyes) underwent endoscopic orbital decompression for Graves' ophthalmopathy at Soroka Medical Center between the years 2000 and 2002. The indications for surgery were compressive optic neuropathy in three eyes, severe corneal exposure in one eye, and severe proptosis not cosmetically acceptable for the patient in one case. An intranasal endoscopic approach with the removal of the medial orbital wall and medial part of the floor was performed.

RESULTS

In all five eyes an average reduction of 5 mm in proptosis was achieved. Soon after surgery, visual acuity improved in the three cases with compressive optic neuropathy, and exposure keratopathy and cosmetic appearance also improved. The diplopia remained unchanged. No complications were observed postoperatively.

CONCLUSIONS

Endoscopic orbital decompression with removal of the medial orbital wall and medial part of the floor in the five reported eyes was an effective and safe procedure for treatment of severe Graves' ophthalmopathy. A close collaboration between ophthalmologists and otorhinolaryngologists skilled in endoscopic sinus surgery is crucial for the correct management of these patients.

[Endoscopic management of chronic frontal sinusitis in the Negev population, Israel]

BACKGROUND

Chronic frontal sinusitis is a relatively common condition, yet one with potential for complications. The treatment of chronic frontal sinusitis has always been a challenge for the otolaryngologist, and it remains so even in the age of endoscopic sinus surgery. Successful treatment is evaluated by both subjective (patient history) and objective (radiologic and endoscopic) criteria.

PURPOSE

This article aims to present our experience in endoscopic surgery for chronic frontal sinusitis, with particular focus on the importance of the wide opening of the naso-frontal outflow tract, with maximal preservation of the mucosa in this area.

METHODS

During the period 1999 to 2001, 72 patients at the Soroka University Medical Center underwent endoscopic surgery for chronic frontal sinusitis. We reviewed the cases of fifty four patients of this group with a minimum six months follow-up. Patients who did not return for routine post-operative visits were excluded from this study. We evaluated and quantified subjective measurements including facial pain, nasal respiratory obstruction and hyposmia, and objective measurements, based on radiographic studies and endoscopic examination.

RESULTS

Most patients experienced improvement in all of the subjective categories, and particularly in the categories of facial pain/headache and nasal respiratory obstruction. Most patients who experienced this improvement had suffered from chronic pansinusitis.

CONCLUSIONS

The endoscopic management of chronic frontal sinus disease is an effective treatment, when principles of wide sinus drainage with maximal mucosal preservation are observed. Most patients undergoing this type of procedure experience significant clinical and radiologic improvement in their condition.

[Management of nasal meningoencephaloceles and cerebrospinal rhinorrhea]

CSF rhinorrhea constitutes a diagnostic challenge. If unrecognized or incompletely managed, it can result in devastating complications. The physician must e aware to this entity and it's management. The conventional neurosurgical management of meningoencephaloceles and cerebrospinal rhinorrhea has been by the intracranial approach. Otolaryngologists have undertaken extracranial approaches for repair of these problems with fair results. In recent years, functional endoscopic sinus surgery has gained popularity and was advocated for the repair of nasal meningoencephaloceles and CSF fistulae. Between 1998 and 1999, five patients were operated by the senior author (M.P) by means of endoscopic sinus surgery. His success rate and lower morbidity make this approach the treatment of choice. The perioperative use of fluoroscein allows us to locate precisely the defect and to confirm complete sealing of the leak. We present our experience in managing 5 cases, 3 of which presented with meningoencephaloceles.

Otogenic lateral sinus thrombosis in children

INTRODUCTION

The clinical picture of lateral sinus thrombosis (LST) has changed with the advent of antibiotics, as have the utility of various diagnostic tests. LST may appear in children as a complication of acute otitis media, but nowadays it is more frequently encountered in adults with long-standing chronic ear disease.

METHOD

A retrospective study of all the pediatric patients with LST between 1982 and 1997.

RESULTS

Thirteen cases of LST were diagnosed and treated by our department. In six cases, LST was due to acute otitis media and in the remaining cases it was due to chronic otitis media. Headache, fever, aural discharge and mastoid tenderness were the most frequent findings in these patients and four patients were initially diagnosed with meningitis. In the majority of the patients, LST was accompanied with other intracranial complications, such as perisinus abscess, brain abscess and meningitis. One patient with multiple brain abscesses, unresponsive to several drainage procedures, died. The other patients recovered and have since been followed-up as out-patients.

CONCLUSION

LST may be difficult to diagnose due to previous antibiotic treatment and to the overlap of clinical findings with other entities such as meningitis. Despite the value of modern imaging techniques in the investigation of the disease, a high index of suspicion based on the clinical picture is warranted. Our results are consistent with those of other recent studies, who found that mortality of LST has dropped below 10%.

Comparative biochemistry of gestational and postnatal lung growth and development in the rat and human

We compared the ontogeny of collagen (hydroxyproline), elastin (desmosine), soluble protein, and DNA in the lungs of rate and humans during gestation and postnatal life. In humans, lung weight/body weight ratios declined faster during gestation than postnatally, whereas in rats lung weight/body weight ratio declined little during gestation and then suddenly on the first day of life. Lung weight/body weight ratios may be lower than expected around term in humans, and prediction data are given to assess human pulmonary hypoplasia. Rats and humans differed in water content of their lungs, with rats showing a sharper decline during gestation. In the human lung, collagen and elastin made their appearance at an early stage of gestation; elastin. In particular, increased rapidly during gestation, suggesting a role in intrauterine alveolar formation. In the rat, elastin accumulation is primarily a postnatal event, as is alveolar formation. Hydroxyproline concentrations increased with conceptual age and continued to increase rapidly postnatally between 4 and 7 weeks in the rat, but slowed in the human after 60 weeks of conceptual age. Desmosine concentrations level off at the end of the study period in rats, while these are still increasing, although slowly, in humans. Overall lung growth, as assessed by weight, was linear in humans, but phases of lung growth were apparent in the rat, including one of minimal growth in the immediate postnatal period.

A severe form of Sjogren's syndrome

Sjogren's syndrome is an autoimmune disease characterized by exocrine gland destruction and manifested by parotid, submandibular and lacrimal gland infection. We report a case with recurrent severe parotid gland infections. The sialographic and CT findings are presented.

Early prediction of anthracycline cardiomyopathy using standard M-mode and digitized echocardiography

In this study, we attempted to identify echocardiographic findings that can be used as early predictors of left ventricular dysfunction due to anthracyclines in 26 pediatric oncology patients. Retrospective review identified six patients (group 1 mean anthracycline dose = 337 +/- 123 mg/m2) who developed clinical evidence of cardiomyopathy and 20 consecutive patients followed prospectively (group 2 mean anthracycline dose = 298 +/- 102 mg/m2) who did not. All of the patients had serial m-mode echocardiography before and at approximately every 50 mg/m2 of anthracycline treatment depending on the dosage schedule. The following measurements were recorded: left ventricular dimensions and wall thickness, indices of left ventricular function, including systolic time intervals, shortening fraction, and ejection fraction. Using digitized echocardiography, the following parameters were recorded: peak and normalized systolic and diastolic velocities of the left ventricular chamber, posterior and septal wall velocities, and percent of posterior wall thickening. Variations from established normal longitudinal bounds and actual changes from pre-anthracycline values were compared for the two groups throughout the course of therapy. At 70 mg/m2 of anthracycline, group 1 showed significant deterioration in shortening fraction (mean change = 8.8 versus 2.5, p = .03), left ventricular velocity in diastole (2.9 versus 0.21, p = .04), left ventricular normalized velocity in systole (.65 versus 0.03, p = .02), and left ventricular normalized velocity in diastole (1.15 versus 0.002, p = .04) compared to group 2. These values were mostly compensated by 125 mg/m2, but they slowly deteriorated again at higher doses of anthracycline, leading to the appearance of clinical evidence of cardiomyopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cricopharyngeal myotomy for upper esophageal achalasia]

Cricopharyngeal achalasia (CA) causes inability to swallow liquids or solids without initiating a violent coughing spasm. Etiological factors which may precipitate obstruction by cricopharyngeal spasm include neuromuscular disorders, radical oral surgery, central nervous system disease, and idiopathic disorders. Cricopharyngeal myotomy is a simple procedure which gives considerable improvement in swallowing. 2 cases with complete dysphagia who were able to swallow fluids and solids after excision of the cricopharyngeal sphincter are described.

Increased compliance in response to salbutamol in premature infants with developing bronchopulmonary dysplasia

We compared the effect of salbutamol and placebo in a double-blind study of preterm infants with bronchopulmonary dysplasia, using a randomized, crossover design with several replicates per subject. Sixty-two tests were performed on 20 ventilator-dependent infants weighing less than 1500 gm. Patients were entered as early as the first week of life and studied for at least 4 weeks or until extubation. Each subject was his own control subject and was randomly assigned to a placebo-salbutamol or salbutamol-placebo sequence administered on 2 consecutive days of each week. Static compliance, expiratory resistance of the respiratory system, and changes in transcutaneous oxygen and carbon dioxide tension were measured. Static compliance improved by 0.240 ml/cm H2O/kg (35.3%) after salbutamol and by 0.010 ml/cm H2O/kg (2.8%) after placebo (p less than 0.0001). The presence of a predetermined decrease in carbon dioxide tension correlated with large changes in static compliance per kilogram and with the need for a high level of fractional inspired oxygen. The magnitude of the clinical and physiologic improvement observed, and the early response suggest that long-term bronchodilator therapy starting as early as the second week of life may be beneficial for very low birth weight infants with early bronchopulmonary dysplasia.

Granular cell lesions in head and neck: a clinicopathological study

Twenty-five cases of granular cell lesions in the region of the head and neck are presented. The adult form (18 cases) was more frequent in women, and the most frequent sites were the tongue, the skin, and subcutaneous tissues, followed by the lip and buccal mucosa. One lesion occurred in the larynx. The congenital forms (7 cases) all occurred in female infants and involved the mucosa overlying either the anterior ridge of the maxilla or the mandible. Immunohistochemical studies revealed positive staining for S100 protein in all the granular cell tumors of the adult but in none of the congenital granular cell epulides. Embryonic antigen was present in the cells of all the congenital cases and in three-quarters of the adult cases. The significance of the histological and immunohistochemical findings is discussed. We conclude that the congenital and adult lesions are similar morphologically but are not necessarily of similar histogenesis. The findings with respect to S100 protein favor a neural (Schwann cell) origin of the adult granular cell tumor, but not the congenital form.

Iatrogenic cholesteatoma of the neck

Epidermal cysts of the upper neck may appear years after ipsilateral radical mastoidectomy for cholesteatoma. Three patients are presented, and the etiological factors operating in the development of such tumors in these patients and others cited in the literature are discussed.

Infection and immunity in Down syndrome: a trial of long-term low oral doses of zinc

To determine whether orally administered zinc supplements could correct the abnormal humoral and cell-mediated immunity of Down syndrome, we randomly assigned 64 children with Down syndrome, aged 1 to 19 years and living at home, to receive either zinc gluconate or placebo daily for 6-month periods with crossover from one regimen to another. Control subjects were siblings and age-matched, unrelated children. Serum zinc, copper, and measures of immune system competence were tested at 3- or 6-month intervals. Parents kept daily logs of clinical symptoms such as cough and diarrhea and of physician visits. Mean serum zinc concentrations increased to about 150% of baseline during zinc supplementation, but we found no effect on serum levels of copper, immunoglobulins, or complement; on lymphocyte number or subset distribution; or on in vitro response to mitogens. Children with Down syndrome who were receiving zinc had a trend toward fewer days or episodes of cough and fever but no change in other clinical variables. Long-term, low-dose oral zinc supplementation to improve depressed immune response or to decrease infections in children with Down syndrome cannot be recommended.

Low-grade papillary adenocarcinoma of buccal mucosa salivary gland origin

The clinicopathologic features of a low-grade papillary adenocarcinoma arising in minor salivary gland tissue are presented. This tumor demonstrates a predilection for minor salivary glands of the oral cavity, a slow growth pattern, recurrence in spite of radical excision, and a tendency to produce nodal metastasis. This is the second documented case in the English literature of this recently defined subtype of polymorphous low-grade adenocarcinoma arising in a minor salivary gland of the buccal mucosa.

Benign nasopharyngeal lymphoid tumors, lymphoepithelial lesions, and lymphocytic interstitial pneumonitis

A clinico-pathologic and immunologic case study of a 57-year-old woman who has shown progressive lymphoid proliferations and lymphocyte dysfunction over the course of 10 years is presented. Early in the course of her disease, she presented with recurrent benign nasopharyngeal lymphoid tumors. She subsequently developed benign lymphoepithelial lesions involving both a submandibular and then a parotid salivary gland. She eventually underwent pneumonectomy for lymphocytic interstitial pneumonitis with marked cystic degeneration and lung destruction. Although frank malignancy has not been demonstrated review of her nasopharyngeal biopsies and of her pulmonary pathology shows a tendency toward distinct cellular uniformity with loss of follicles and germinal centers. Concurrently, immunologic studies have demonstrated abnormalities of cell mediated (T cell) function.

Giant cementoblastoma simulating a peridental infection

A case of giant cementoblastoma of the maxilla in a young female is reported. An unusual painful swelling of the gingivolabial area led to an initial misdiagnosis of a peridental infection and consequently to inappropriate treatment.

Vallecular papilloma simulating chronic pulmonary disease

Presented here is a case of chronic persistent cough, in a patient in whom squamous papilloma of the base of tongue was found. The cough disappeared completely after removal of the tumour.

Pedunculated malignant melanoma of the hard palate

We report the case of a primary malignant melanoma arising from the mucosa of the hard palate on a fibrovascular stalk. This is to our knowledge the first report of a pedunculated melanoma in this location. The possibility of a more favorable prognosis, because of the stalk, which shows no signs of invasion by the neoplasm, is considered.

Primary lymph nodal Kaposi's sarcoma of the parotid gland

Two cases of Kaposi's sarcoma arising within intraparotid lymph nodes are presented. The tumor masses, clinically thought to be primary epithelial tumors of the parotid gland, were pathologically defined as Kaposi's sarcoma. No other evidence of this disease has been found elsewhere in either of the two patients studied. Immunologic studies performed in both patients demonstrated a depression of T-lymphocyte function and altered cell-mediated immunity in one. Search of the medical literature shows that these are the first two reported cases of Kaposi's sarcoma arising within lymph nodes of salivary glands.

Tracheobronchial foreign bodies: the impact of a postgraduate educational program on diagnosis, morbidity, and treatment

Aspirated foreign bodies (FBs) may remain undetected and cause serious complications. As part of a postgraduate educational program, results of a local survey were presented to the local medical staff in order to increase its awareness of this diagnostic possibility. The present study was carried out in order to evaluate the management of children with tracheobronchial FBs during two 2-year periods, before and after teaching sessions held in December 1976. In comparison with the previous two years during the 1977-1978 period, the percentage of cases in which a positive history of aspiration was obtained increased from 47.6% to 84.0%; the mean number of hospitalizations due to tracheobronchial FBs decreased from 1.9 to 1.04 per infant, and the mean number of hospital days required for final diagnosis decreased from 17.6 to 5.3. The postgraduate educational program had a positive effect on physician performance and patient care.