Retrospective Review of Management and Outcomes of Pediatric Descending Mediastinitis

Objectives

To review the management and outcomes of pediatric patients treated for descending mediastinitis at a single institution and contribute to an updated mortality rate.

Study Design

Case series with chart review.

Setting

Tertiary care pediatric hospital.

Subjects and Methods

This study is a 19-patient case series of all patients treated for descending mediastinitis at a tertiary pediatric hospital from 1997 to 2015, and it serves as an update to the case series published from this institution in 2008. Review of management included time to diagnosis, time to surgery, surgical procedures performed, and antibiotics administered. The primary outcomes measured were length of hospitalization and mortality.

Results

In addition to 8 previously reported patients, we identified 11 pediatric patients treated for descending mediastinitis in the period of review. All 19 patients were <18 months old, and all survived their hospitalization. Fourteen patients underwent surgical drainage at least twice. The median length of hospital stay was 15 days. Retropharyngeal abscess was the source of infection in 16 of 19 patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the isolated organism in 14 of 15 positive cultures.

Conclusion

This review represents the largest reported series of pediatric patients with descending mediastinitis. With 100% survival, our results suggest that pediatric descending mediastinitis can be safely managed by prompt surgical drainage. Broad-spectrum antibiotics covering MRSA and a low threshold for repeat surgical intervention have been an important part of our successful approach and may decrease length of stay.

Surgical Skills of Applicants to Residency in Otolaryngology

Objective: 1) Measure baseline competence in the performance of a basic surgical task by 4th-year medical students applying to otolaryngology residency. 2) Determine whether information available in the standardized otolaryngology residency application correlates with competence in performance of the basic surgical task.

Method: Applicants to residency in otolaryngology with the University of Tennessee Health Science Center in 2010 and 2011 constituted the study population. During the interview, the applicant was asked to close a simulated incision with sutures. A blinded observer recorded a 15-point Objective Surgical Assessment of Technical Skill score.

Results: The OSATS score provided a measure of the suturing skills of individuals applying to residency training in otolaryngology. The OSATS score was incorporated into the calculation of an overall OSCE (Objective Structured Clinical Examination) score modified to focus on surgical skill performance and a professionalism measure. Initial data analysis produced a correlation value ( R value) between the OSCE score and data points gleaned from the standardized application (USMLE step I score, prior employment-related surgical experience, hobbies, musical background, athletic background, research experience that includes performance of surgical procedures).

Conclusion: In contrast to other high-skill professions such as the airline industry, surgical educators have not universally developed a practice of testing prospective trainees for aptitudes that can be deemed critical to surgical competence. This study represents a methodology for assessment of a simple surgical skill to which all applicants to otolaryngology training should have been exposed. It also determines correlation with applicant data commonly used in selection, such as USMLE score.

Olaryngologic manifestations in children with chronic neutropenia

OBJECTIVE

Chronic neutropenia of childhood (CNC) is a rare disorder in which the absolute neutrophil count is below 1500/μL over an extended period of time. The objective of this study is to describe the otolaryngolgic manifestations associated with CNC to facilitate diagnosis and treatment of this condition.

METHODS AND MATERIALS

We performed a retrospective chart review of patients with the diagnosis of CNC between 1970 and 2005 at a tertiary pediatric hematology center. After Institutional Review Board approval, 43 patients were evaluated. The average age at hematologic diagnosis was 49 months (range: 1 month - 15 years with 35% <1 year, 44% 1-10 years, 21% >10 years). A total of 2049 encounters were analyzed from the hospital charts.

RESULTS

Twenty four subjects (56%) presented with recurrent otitis media (ROM), sinusitis or pharyngo-tonsillitis, while 11% presented with oral mucosal lesions. After diagnosis, otolaryngologic problems persisted, including ROM (81%), viral upper respiratory tract infection (67%), oral ulcers or gingivitis (53%), tonsillitis (39%) and sinusitis (37%) and were more common than other systemic infections. Myringotomy tube placement, endoscopic sinus debridement, adeno-tonsillectomy or tracheostomy were required in 42% of patients. After G-CSF (granulocyte colony-stimulating factor) became available in the early 1990s, the infection rate markedly decreased. Five deaths occurred (12% mortality) including one due to sepsis from otolaryngologic infection.

CONCLUSION

The majority of children with CNC had otolaryngologic problems at presentation and these continued after diagnosis. While managing common otolaryngologic infections in children, a high index of suspicion for chronic neutropenia is necessary. An otolaryngologist is frequently one of the first physicians to encounter children with this condition. Awareness of CNC and its management will enhance earlier diagnosis and more effective treatment for these children.

Effects of sensory or motor nerve deafferentation on oromotor function in mice

OBJECTIVE

To investigate the effect of sensory or motor nerve damage to the tongue using a mouse model.

STUDY DESIGN

Animal study.

SETTING

Research laboratory.

SUBJECTS AND METHODS

Adult male and female mice from inbred strains B6 (n = 19) and D2 (n = 25). Following lick training, bilateral lingual-chorda tympani nerve cuts (LX) (n = 6 B6, n = 7 D2), unilateral hypoglossal nerve cuts (HX) (n = 7 B6, n = 9 D2), or sham surgery (n = 6 B6, n = 9 D2) was performed. Mice were lick tested postsurgically with both water and sucrose (4 days total). Following testing, post mortem dissections and microscopic analysis of tongue papillae were performed.

RESULTS

In both strains, HX and LX mice demonstrated a significant reduction in volume per lick (VPL) in the surgical groups relative to shams. Neither motor nor sensory nerve transection affected local lick rate. In most LX mice in both strains, taste papillae were reduced compared with HX or sham mice.

CONCLUSION

Mice of either strain with either a sensory or a motor nerve injury have a significant loss of VPL during ingestion of either a neutral (water) or preferred (sucrose) stimulus. This reduction in VPL reflects a deficit in licking. Lick rate was not affected by deafferentation. A reduction in fungiform papillae following LX but not HX mice was noted.

Effects of adeno-tonsillectomy on polysomnography patterns in Down syndrome children with obstructive sleep apnea: a comparative study with children without Down syndrome

OBJECTIVE

To determine if adeno-tonsillectomy (T&A) in children with Down syndrome (DS) improves breathing, measured by apnea hypopnea index (AHI), rapid eye movement AHI (REM-AHI) and the lowest oxygen desaturation (SaO2), and sleep disruption, measured by arousal index (ArI) and time spent in stages 1-4 and rapid eye movement (REM) sleep and compare these results with a group of non-DS children with obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective chart review at pediatric sleep center.

PATIENTS

Eleven DS and nine non-DS children underwent pre- and post-T&A polysomnography between 1997 and 2005.

OUTCOME MEASURES

Pre- and post-T&A polysomnography parameters were compared using paired t-test and independent samples test.

RESULTS

Mean age in DS group was 101 months and non-DS group was 80 months (64% males in DS and 88% in non-DS group). The average BMI was 29.8 and 27.6 for DS and non-DS group. The total AHI showed significant improvement after T&A but this was not as marked as the non-DS group. REM-AHI and lowest SaO2 did not show significant change in the DS children. The non-DS group showed significant improvement in all respiratory parameters. Both groups showed mild improvement in sleep parameters. With the modest overall improvement, 27% of the DS children required no further treatment. However, 73% required CPAP, BiPAP or oxygen for persistent OSA.

CONCLUSION

This study supports the fact that T&A in DS children improves some parameters of OSA, however not as markedly as in non-DS children.

Cleft palate lateral synechia syndrome: an opportunity for unique surgical closure

OBJECTIVES

To report two cases of cleft palate lateral synechia (CPLS) syndrome in a single family and describe surgical closure using the synechia.

STUDY DESIGN

Case report and literature review.

METHODS

A case report is presented with a review of the literature of cleft palate in conjunction with lateral synechia. Clinical presentation with photographic images of surgical repair is presented as well as a genetic workup with pedigree.

RESULTS

A 6-week-old male presented for evaluation of a cleft palate. Mucosa-lined, fibromuscular tissue bands were noted connecting the floor of mouth and the free edges of a bilateral complete secondary cleft palate. No other craniofacial, digital, genital or limb defects were noted. The patient's 13-month-old sister had similar synechial bands and cleft palate at birth. Another older sibling had cleft palate without synechia. The patient's mother and maternal great grandmother had cleft palates at birth without synechia. The three children share a common mother but have three different fathers. Genetic analysis failed to reveal chromosomal defects or a mutation in the interferon regulatory factor 6 (IRF6) gene, a locus linked to Van der Woude syndrome. At 2 years of age, the index patient was growing and feeding well. His intra-oral bands remained intact and were incorporated in the surgical repair using a novel approach.

CONCLUSIONS

Since more otolaryngologists are performing cleft surgeries, the awareness of the differential diagnoses associated with a cleft palate is important. CPLS is an extremely rare condition. The report of this family supports the suspected pattern of autosomal dominant inheritance with variable expressivity. The unusual surgical approach will be discussed.

Aural involvement in loxoscelism: case report and literature review

An 11-year-old male presented with fever, rash, and a necrotic lesion on the lobule of the left ear. The lesion became tender and formed an eschar over 4 days. The patient developed leukocytosis, hemolytic anemia, and proteinuria, and was diagnosed with systemic loxoscelism from a brown recluse spider bite. He was managed with supportive therapy and improved in 4 days. Loxoscelism is a clinical diagnosis which should be suspected in an otherwise healthy patient with a necrotic wound, particulary in the endemic Southern and Midwestern United States. Physicians should be aware of this disease entity and its complications.

Methicillin-resistant Staphylococcus aureus as a pathogen in deep neck abscesses: a pediatric case series

OBJECTIVES

Pediatric deep neck space abscesses are frequently treated by the otolaryngologist. We report four children with deep neck abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA), including the first described case of descending mediastinitis caused by MRSA in a child.

METHODS

Records from March 2001 to April 2002 were reviewed.

RESULTS

Four patients presented with neck swelling, and three of these also had leukocytosis. All abscess cultures were positive for MRSA. Abscess drainage with antibiotic therapy successfully treated three cases without complication. The fourth case developed descending mediastinitis but survived after additional surgical treatment and prolonged antibiotic therapy.

CONCLUSIONS

MRSA should be considered as a potential pathogen in deep neck space abscesses. A high index of suspicion is needed as well as aggressive treatment including incision and drainage along with culture-directed medical therapy. Surgical drainage may be the most important aspect of therapy.

Airway obstruction secondary to tracheobronchial involvement of asymptomatic undiagnosed Crohn's disease in a pediatric patient

Tracheal involvement in Crohn's disease is extremely rare and can present with airway obstruction in any age group, including the pediatric patient. We describe the case of a 9-year-old female who presented with a 2-week history of intermittent stridor, resolving temporarily with the administration of systemic steroids. The patient denied any abdominal complaints and was otherwise healthy. Bronchoscopy revealed progressive tracheal inflammation necessitating an urgent tracheotomy. Subsequent laboratory investigation confirmed the diagnosis of Crohn's disease. This is the first reported case of previously undiagnosed Crohn's disease presenting with airway manifestations.

Hearing loss as a late complication of radiotherapy in children with brain tumors

Late postirradiation hearing loss has been well described in the adult population. Few reports exist on the pediatric population. We conducted a retrospective review of 157 consecutive children with brain tumors treated exclusively with irradiation at St Jude Children's Research Hospital. Twenty-six patients developed a hearing loss, 74 did not, and 57 were excluded because of incomplete records. We report a statistically significant 27.41% cumulative risk of a stringent 20-dB hearing loss in the voice frequency range by the fifth year after radiotherapy. The right side demonstrated a significant frequency effect, with a higher incidence of loss in the higher-frequency region. We found no difference in cumulative incidence of hearing shift between the low-, middle-, and high-frequency ranges for either ear. This risk should be anticipated and managed as part of the treatment plan for radiotherapy for the treatment of malignancies. Radiation-induced hearing loss is important to acknowledge so that techniques of hyperfractionation, total dose, ports, preservative infusion medical therapy, or prolonged medical intervention (such as anticoagulants) can be developed that might reduce this disabling problem of postirradiation sensorineural hearing loss in future patients.

Childhood Primary Parotid Non-Hodgkin's Lymphoma with direct Intracranial Extension: A Case Report

Childhood primary parotid non-Hodgkin s lymphoma (NHL) is a rare but well-recognized entity in the literature. Perineural extension of masses between the head and neck and cranium, although rare, has also been well documented. We report the first documented case, to our knowledge, of a left-sided primary parotid NHL in a child with direct intracranial extension through the foramen rotundum. The mass arose in a 1½-month period. Following evaluation by computed tomography and magnetic resonance imaging, diagnostic procedures (first, fine-needle aspiration and, subsequently, an open biopsy) were undertaken. We discuss the case report and briefly review childhood NHL and perineural metastasis.

Childhood primary parotid non-Hodgkin's lymphoma with direct intracranial extension: a case report

Childhood primary parotid non-Hodgkin's lymphoma (NHL) is a rare but well-recognized entity in the literature. Perineural extension of masses between the head and neck and cranium, although rare, has also been well documented. We report the first documented case, to our knowledge, of a left-sided primary parotid NHL in a child with direct intracranial extension through the foramen rotundum. The mass arose in a 1 1/2-month period. Following evaluation by computed tomography and magnetic resonance imaging, diagnostic procedures (first, fine-needle aspiration and, subsequently, an open biopsy) were undertaken. We discuss the case report and briefly review childhood NHL and perineural metastasis.

Ototoxic protection of sodium thiosulfate: daily vs constant infusion

OBJECTIVE

Compare the effect of a daily dose of sodium thiosulfate (STS) to continuous infusion of STS on Hartley albino guinea pig (HAGP) on cisplatin (CP)-induced sensorineural hearing loss. Study design Prospective randomized pilot study comparing a single daily dose of STS to a constant controlled infusion of STS given the middle ear space (MES) with an ototoxic regimen of CP. The hearing thresholds will be obtained by auditory brainstem response (ABR) 1 week before and after treatment. Treatment effects on responses at 2, 8, and 16 kHz signals will be investigated by an analysis of variance with one between subjects' condition and two within subjects' conditions.

SETTING

Basic science laboratory.

RESULTS

STS protection resulted in significantly less hearing loss post-treatment for the protected ears. Guinea pigs with continuous infusion of STS demonstrated less loss in the protected ear than those who received the single daily dose. As expected, hearing loss at 2 kHz was less than that at 8 and 16 kHz.

CONCLUSION

A continuous infusion of STS directly to the MES is better than a single daily dose of STS to the MES in reducing the ototoxicity of CP.

SIGNIFICANCE

Any targeted protection, whether by continuous infusion or daily dose, is better than no protection against the sensorineural hearing loss of CP.

Airway management of the severely retrognathic child: use of the laryngeal mask airway

Successful airway management of an infant or child with moderate to severe retrognathia first requires recognition of a potential problem. If the child cannot be intubated in a standard fashion, the use of a laryngeal mask airway (LMA) should be considered. We describe two cases wherein a toddler and an infant with severe retrognathia failed multiple attempts at traditional intubation. Both had an anterior larynx and hypoplasia of the mandible. In both cases, a subsequent LMA was successfully placed. The severely retrognathic newborn or child presents to the physician a unique challenge in airway management. Techniques to manage this difficult pediatric airway are different from those used in the adult. Otolaryngologists should be aware of this intubation technique and include it in their armamentarium of airway-management strategies. The LMA is not recommended as the technique of choice for securing a difficult airway, but it is an effective alternative when indicated, and it might be life-saving.

Airway Management of the Severely Retrognathic Child: Use of the Laryngeal Mask Airway

Successful airway management of an infant or child with moderate to severe retrognathia first requires recognition of a potential problem. If the child cannot be intubated in a standard fashion, the use of a laryngeal mask airway (LMA) should be considered. We describe two cases wherein a toddler and an infant with severe retrognathia failed multiple attempts at traditional intubation. Both had an anterior larynx and hypoplasia of the mandible. In both cases, a subsequent LMA was successfully placed. The severely retrognathic newborn or child presents to the physician a unique challenge in airway management. Techniques to manage this difficult pediatric airway are different from those used in the adult. Otolaryngologists should be aware of this intubation technique and include it in their armamentarium of airway-management strategies. The LMA is not recommended as the technique of choice for securing a difficult airway, but it is an effective alternative when indicated, and it might be life-saving.