Principal diagnostic features of paediatric foreign body aspiration.

OBJECTIVES: The aim of this study is to identify the most common and important features within the presenting history, clinical examination and chest radiograph that are associated with foreign body (FB) aspiration in the paediatric population, to support rationalised decision making in regards to proceeding with diagnostic bronchoscopy. METHODS: A retrospective notes review was conducted of 70 patients over a 12-year period at our tertiary referral centre. Their presenting history, clinical and radiographic signs were documented and univariate logistic regression model used to calculate odds ratios. RESULTS: The main features identified within our cohort with a positive FB finding at bronchoscopy were history of a cough (OR 5.1, p = 0.008) and radiographic evidence of hyperinflation or air trapping (OR 7.1, p = 0.016). Zero patients with a FB presented with only a positive history in the absence of other clinical or radiological signs. History of a witnessed choking episode neither increased or decreased the likelihood of as aspirated FB (OR 1, p = 0.967). CONCLUSIONS: We have identified two principal features, as described above, which are associated with paediatric FB aspiration. Reliance on a positive clinical history alone, but specifically the history of a witnessed choking episode, did not support the presence of a FB and other associated signs need to be considered in deciding to proceed to bronchoscopy.

A study evaluating the effects of throat packs during nasal surgery: a randomised controlled trial.

The aims of this study were to identify differences in post-operative nausea and vomiting (PONV) and throat pain between throat packed and non-packed patient groups in nasal surgery. This was a prospective, double blind, randomised controlled trial. A water-soaked throat pack gauze was inserted in the mouth to occlude the oropharynx was used in the throat pack group. The second group received no throat pack. A validated PONV questionnaire was completed 6 h post-operatively. Visual analogue scores (VAS) for throat pain were completed in recovery, 2, and 6 h post-operatively. 80 patients were enrolled (40 into each group based on power calculation). With regard to the primary outcome measure, mean PONV score for the throat pack group was 2.75 [median 0, standard deviation (SD 10.86)] and the mean PONV score for the non-packed group was 0.36 (median 0, SD 1.39). The difference in PONV was not statistically significant [P value 0.375, 95% confidence interval (CI) -1.19 to 3.32]. With regard to throat pain VAS scores (our secondary outcome measure), in recovery, the mean throat pain VAS score for the throat packed group was 2.5 (median 1, SD 2.8) and the mean throat pain VAS score for the non-throat packed group was 1.3 (median 0, SD 2.5). Statistical analysis showed a significant difference between the two groups with the throat pack group experiencing more throat pain in recovery (P value 0.018 (95% CI 1.13-2.52). At 2 and 6 h post-operatively, the mean throat pain VAS scores for the throat packed group were 2.1 and 2.3, respectively, and the mean throat pain VAS score for the non-throat packed group was 2.3 and 1.4, respectively. Statistical analysis showed non-significant difference between the two groups at 2 and 6 h post-operatively. The use of throat packs in nasal surgery does not confer PONV reduction benefit. The use of throat pack, however, is associated with a small but statistically significant more throat pain in the initial recovery period from nasal operations.

Experience of bone-anchored hearing aid implantation in children younger than 5 years of age.

OBJECTIVE: To assess the practicality and benefit of Bone-anchored hearing aid (BAHA(®)) implantation in children younger than 5 years of age. FDA approval for use of BAHA(®) only exists for children 5 years of age and older. Their use in Australia is also rare, however their use for younger children is approved by the European Union. We wish to share our experience of implantation in an antipodean setting in this age group. METHODS: Institutional board approval was obtained for this study. All children undergoing BAHA(®) implantation under 5 years old were included from our prospective database. We examined the variety of surgical techniques, (including skin grafting, limited soft tissue reduction and no soft tissue reduction), BAHA(®) implants and abutments used, and use of the new series 400 hydroxyapatite coatings. Demographic data obtained included age at surgery, follow up duration, gender, ethnicity and indication for surgery. Anonymous benefit questionnaires (Glasgow children's benefit inventory (GCBI) and parents' evaluation of aural performance of children (PEACH)) were completed online as well as a questionnaire on device use. Complications recorded included soft tissue reactions, implant loss/removal, abutment replacement/removal. We also assessed whether patient weight, ethnicity or socioeconomic status were risk factors for these complications. RESULTS: 24 Children (26 ears/26 implants) under five years were identified from the database and included in the study. There was a 14:10 male to female ratio. Patient caregivers reported subjective benefit and improved quality of life (QOL) despite setbacks and complications related to BAHA(®) usage. 10/24 (42%) of children required treatment for significant peri-implant skin reactions whilst 25% required replacement of their abutments and/or implants. An increased risk of major complication was associated with socioeconomic deprived backgrounds and in patients of New Zealand Maori and Pacific Island ethnicity but not in patients with increased weight centiles. CONCLUSIONS: The BAHA(®) implant and hearing aid system is of value to children under age 5 years. Parents tolerate the skin reactions and complications because of the perceived benefit in hearing and quality of life. Careful counselling of parents of potential young BAHA(®) implant candidates is necessary in light of this.

Sarcoid granulomas in the parathyroid gland - a case of dual pathology: hypercalcaemia due to a parathyroid adenoma and coexistent sarcoidosis with granulomas located within the parathyroid adenoma and thyroid gland.

We present a highly unusual and interesting case of coexistent hyperparathyroidism and sarcoidosis leading to hypercalcaemia. A 70 year old female presented with weight loss, constipation and dehydration. Investigations revealed marked hypercalcaemia with a non-suppressed PTH. In view of the degree of hypercalcaemia as well as the unintentional weight loss, investigations for malignancy were conducted -these were negative. Parathyroid imaging was then requested and an adenoma was identified. Surprisingly, surgery revealed the coexistence of a parathyroid adenoma with the unexpected finding of sarcoid granulomas within the parathyroid and thyroid glands. To our knowledge, this is the first such case reported. Further imaging confirmed pulmonary sarcoidosis and a serum ACE was elevated. Serum calcium levels did not respond to parathyroidectomy but eventually fell with steroid therapy.

Adenotonsillectomy for sleep-disordered breathing in children with syndromic craniosynostosis.

Syndromic craniosynostosis (SCS) is known to be associated with sleep-disordered breathing (SDB) in childhood. Problems can occur at various levels, but midface hypoplasia is a major factor in affected infants.Adenotonsillectomy (AT) has been proven to be efficacious as a first-line treatment of SDB in healthy children. However, its role in the treatment of this issue in those with SCS has not been evaluated. Owing to the multiple possible levels of obstruction in such individuals, AT may have no benefit. This study therefore aimed to evaluate the effectiveness of AT in this group of patients.Twenty-six children with SCS with moderate to severe obstructive sleep apnea (OSA) were treated with AT. The mean age at surgery was 4.5 years (range, 1.6-13.9 y). Seven had severe OSA, 11 had moderate OSA, and 7 had mild OSA preoperatively. Of 25 children, 15 (60%) demonstrated an improvement in sleep severity scores postoperatively.Overall, there was a significant improvement in the mean number of saturation dips greater than 4%/h and in the mean nadir of dips in saturation after the operation. There was no significant difference in mean oxygen saturation, number of pulse rate rises per hour, or percentage time spent less than 90% SaO2.Clinically, there is thought to be some benefit in performing AT in these groups of patients. In children with SCS, in whom the cause of obstruction might be at multiple levels, AT should still to be considered as first-line treatment in the management of OSA/SDB.We acknowledge that some children may still go on to require further airway intervention. Further multicenter trials would be useful to examine more closely the significance of the effects of AT in children with craniofacial disorders experiencing SDB.

Aspergillus mastoiditis in a patient with systemic lupus erythematosus: a case report.

Fungal mastoiditis caused by Aspergillus fumigatus predominantly occurs in immunocompromised patients. Invasive temporal bone mycoses are rare. They are usually associated with host immunodeficiency, are difficult to diagnose, and many cases are fatal. Treatment consists of antifungal chemotherapy, surgical debridement, and attempts to control the underlying immunological condition. Published reports describe patients with previous ear pathology and associated facial nerve dysfunction. We report a case in a patient with systemic lupus erythematosus. A good outcome followed surgical debridement and the use of a new triazole antifungal agent, voriconazole. Our patient's facial nerve function was unaffected. The presence of normal facial nerve function, however, does not exclude the possibility of invasive fungal mastoiditis.