Neurological Complications of Acute and Chronic Otitis Media.

PURPOSE OF REVIEW: The aim of this study is to discuss the symptoms, diagnosis, and management of the neurologic complications of acute and chronic otitis media. RECENT FINDINGS: Antibiotic therapy has greatly reduced the frequency of complications of otitis media. However, it is of vital importance to remain aware of the possible development of neurologic complications. There is a trend toward less severe presenting symptoms including otorrhea, headache, nausea, and fever, with altered mental status and focal neurologic deficits presenting later. In order to reduce morbidity, early deployment of a multidisciplinary approach with prompt imaging and laboratory studies is imperative to guide appropriate management. Complications of acute and chronic otitis media may present with neurologic signs and symptoms. It is important to recognize the possible otitic origin of such complications to ensure proper management and to decrease overall morbidity and mortality.

Practice Patterns and Projections for the US Pediatric Otolaryngology Workforce.

IMPORTANCE: This study represents up-to-date information on the current status of and future projections for the pediatric otolaryngology workforce. OBJECTIVE: To provide an update on the practice patterns of and projections for the US pediatric otolaryngology workforce. DESIGN, SETTING, AND PARTICIPANTS: An online survey was sent to all 172 members of the American Academy of Pediatrics Section on Otolaryngology-Head and Neck Surgery and fielded from May 29, 2014, to September 17, 2014. MAIN OUTCOMES AND MEASURES: Current status of and perceived trends in the pediatric otolaryngology workforce. RESULTS: Eighty-four (48.8%) of the 172 members responded to the survey. Not all respondents answered all questions, and so totals and percentages might not reflect a total of 84 for any given response. The demographics and practice characteristics of the responding pediatric otolaryngologists were similar to those noted in a 1997 workforce survey. Fifty-four percent of respondents (n = 38) planned to continue full-time work over the next 5 years, and 47% (n = 31) believed that the number of patients in their practice was increasing. The proportion of those who believed that the need for pediatric otolaryngologists in their community was increasing (31%; n = 21) or decreasing (13%; n = 9) remained relatively constant from the 1997 survey (34% and 12%, respectively). Forty-nine percent (n = 35) reported believing that the number of pediatric otolaryngologists being trained was appropriate and that the need in their community was stable. Eighty-three percent (n = 55) reported believing that employment opportunities for pediatric otolaryngologists in the United States would be plentiful in the near future. CONCLUSIONS AND RELEVANCE: The overall state of the pediatric otolaryngology workforce appears stable. The perceived current and future needs for pediatric otolaryngologists appear to be met by the current number of trainees. Employment opportunities appear promising for future pediatric otolaryngologists based on our respondents' opinions. This represents up-to-date information on the current status of and future projections for the pediatric otolaryngology workforce.

Otologic complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

This case report demonstrates the otologic complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN). A five year-old male was admitted to the burn unit with the diagnosis of SJS/TEN believed secondary to acetaminophen use. After resolution of the acute phase, the patient was left with a severe auricular deformity with scarring and complete occlusion of the right external auditory canal (EAC). The patient underwent meatoplasty, canaloplasty, and tympanoplasty with subsequent placement of a molded stent in order to maintain patency of his EAC. Four years later, the patient has a patent right EAC with adequate hearing.

The role of tonsillectomy in pediatric IgA nephropathy.

OBJECTIVES: To review pediatric cases of IgA nephropathy (IgAN) in 6 patients who underwent tonsillectomy and had marked improvement of their renal symptoms and to review the appropriate indications for tonsillectomy for this disease. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: Six children (age range, 8-15 years) with renal biopsy-proved IgAN who were referred by a pediatric nephrologist for recurrent tonsillitis. INTERVENTION: Tonsillectomy. MAIN OUTCOME MEASURES: Resolution of clinical features of IgAN, including proteinuria, gross and microscopic hematuria, and stabilization of renal function. RESULTS: The 6 patients in this series had marked clinical and laboratory improvement of their nephropathy. CONCLUSIONS: In a select group of pediatric cases of IgAN with mild to moderate disease and recurrent tonsillitis, tonsillectomy can be a useful adjuvant treatment to improve urinary symptoms and renal function. IgA nephropathy is a common indication for tonsillectomy in Japan but is seen less often in the United States. Otolaryngologists should be aware of this indication for tonsillectomy.

Drooling.

PURPOSE OF REVIEW: Drooling is the involuntary spillage of saliva from the mouth. It is a major morbidity associated with cerebral palsy and other neurodegenerative disorders. The consequences of drooling are not restricted to medical issues but can cause major social handicaps. Severe psycho-social consequences, such as social stigmatization and emotional devastation for the patients and their families, may result. This paper reviews recent developments in the management of drooling. RECENT FINDINGS: Recent publications report encouraging results with botulinum toxin A. Several surgeons report on their long-term results. Reviews analyze anticholinergic drugs, surgical options, biofeedback, behavioral and speech therapy, and a multidisciplinary team approach. SUMMARY: A team approach is the key to successful rehabilitation. Oromotor therapy is the most useful nonsurgical option. Drugs are unsuitable for long-term use due to adverse effects causing serious medical complications or noncompliance. Botulinum toxin A injection is promising, but no data exists on optimal dosage, duration of action and frequency of repeat injections. Bilateral submandibular duct relocation with bilateral sublingual gland excision has been shown to be effective and safe in long-term follow-up of the largest series of patients. At present, it is the best available surgical option.

The Ex Utero Intrapartum Treatment (EXIT) procedure used for airway control in a newborn with cervical fetus in fetu: a rare case.

Fetus in fetu is a condition in which there is a monozygotic diamniotic fetus encased within the body of its larger more developed twin. We report a case of airway obstruction in a full-term fetus caused by fetus in fetu. Prenatal ultrasound revealed a large cervical mass compressing the neonate's trachea and esophagus. The Ex Utero Intrapartum Treatment procedure was utilized to secure the fetus's airway. Upon resection, a fetiform structure, covered by skin with vertebral tissue and two appendages was appreciated. To our knowledge, this is the first reported case of cervical fetus in fetu in the literature.

Analysis of possible cross-contamination with the Venturi system atomizer.

BACKGROUND: The physics behind the Venturi atomizers suggest a possibility of bacterial colonization and the potential for patient cross-contamination. A protocol for use of the atomizer and clinically appropriate demonstration of cross contamination has not been established. METHODS: Three sterilized atomizers filled with a solution of 2% Pontocaine and 1% ephedrine (two test and one control) were used during a 5-day study period. Clinic staff was instructed to (1) use a nozzle tip, (2) use a nasal speculum, (3) avoid contact between the atomizer and the patient, and (4) apply a continuous, <1-second spray to the nasal cavity. Samples were obtained from each of the atomizers three times per day and plated on chocolate agar plates. The number and type of bacterial colony were registered. RESULTS: No respiratory pathogens grew from any of the 45 plated samples. Nine of 30 experimental atomizer samples produced 12 bacterial colonies. Of the 12 bacterial colonies obtained, 6 colonies of coagulase-negative Staphylococcus, 5 colonies of Corynebacterium sp., and 1 colony of Bacillus sp. were identified. One of 15 plated control atomizer samples produced two colonies of coagulase-negative Staphylococcus. An average of 1.3 colonies per positive test plate and an average of 2.0 colonies per positive control plate were identified. There was no evidence of an increasing number of colonies per plate or persistence of any particular bacteria identified over time to suggest contamination or colonization of the system reservoir. CONCLUSION: There is no risk of cross-contamination of patients with the use of the Venturi system atomizer as outlined in this study. Culture results from this study were consistent with random culture contamination during the plating and/or culturing period. There was no evidence to support the idea of bacterial colonization of the atomizers. Continued use of the Venturi system atomizer is an acceptable practice.

Effect of perioperative administration of ropivacaine with epinephrine on postoperative pediatric adenotonsillectomy recovery.

OBJECTIVES: To determine whether perioperative administration of ropivacaine hydrochloride with epinephrine decreases postoperative pain following adenotonsillectomy and to determine the pharmacokinetics of ropivacaine following injection. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: University pediatric ambulatory center. PARTICIPANTS: A total of 130 children, aged 2 to 12 years, undergoing adenotonsillectomy. INTERVENTION: Patients received injections, in the tonsillar fossae, of isotonic sodium chloride solution or 0.5% ropivacaine hydrochloride with epinephrine immediately following tonsillectomy. MAIN OUTCOME MEASURES: Modified objective pain score, time to 100 mL of oral intake, serial plasma ropivacaine levels, use of analgesics, incidence of retching and emesis, and other symptoms. RESULTS: Fifty-three patients (80%) in the ropivacaine group had detectable plasma levels in at least 3 of the 4 measurement time periods. The mean +/- SD peak concentration (C(max)) was 0.71 +/- 0.33 micro g/mL and the half-life was 0.96 hours. The average modified objective pain scores over all time points favored the placebo group (P =.06 test of between-subjects effects). Similarly, the average behavior score over time favored the placebo group (P =.046 test of between-subjects effects). Neck pain was better in the placebo group when averaged over postoperative days 1, 3, 7, and 14 (P =.04). The percentage of patients who had retching in the recovery room was greater in the ropivacaine group (41% vs 19%, P =.006). CONCLUSIONS: The injection of 0.5% ropivacaine with epinephrine immediately following adenotonsillectomy results in a measurable plasma level. Ropivacaine with epinephrine injection does not reduce pain postoperatively and adversely affects behavior scores, neck pain scores, and retching frequency compared with placebo. Ropivacaine with epinephrine injection for postoperative analgesia is not recommended for this patient population.

Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery.

UNLABELLED: We enrolled 120 children undergoing bilateral myringotomy and tube placement in this prospective, randomized, observer-blinded study. Patients were randomized into one of four groups: Group 1 (control) was plain acetaminophen 10 mg/kg orally, Group 2 was acetaminophen 10 mg/kg with 1 mg/kg of codeine orally, Group 3 was transnasal butorphanol 25 micro g/kg given immediately after the induction of anesthesia, and Group 4 was ketorolac 1 mg/kg given IM immediately after the induction of anesthesia. All children received oral midazolam (0.6 mg/kg) before surgery. A nurse blinded to the analgesic technique used assessed the child's behavior at the induction of anesthesia and in the postanesthesia care unit using a 4-point scale. Analgesic effectiveness was determined by assessing the child's pain at 5-min intervals using a modified 10-point objective pain scale. In the postanesthesia care unit, rescue pain medication was administered for an objective pain scale >or=4 or a behavior score >or=3. Our data suggest that IM ketorolac is a promising analgesic to be used in this surgical population. Time to first rescue analgesic was longest in the ketorolac group, and there was no associated postoperative vomiting or nausea. IM ketorolac given during surgery was the best analgesic regimen for these procedures. IMPLICATIONS: We compared four different analgesics in the management of pain after placement of pressure equalization tubes during myringotomy in children and demonstrated that ketorolac or butorphanol provided superior analgesia when compared with acetaminophen with codeine or plain acetaminophen. Children who received ketorolac versus butorphanol had less vomiting in the 24 h after surgery.

Ondansetron and dolasetron provide equivalent postoperative vomiting control after ambulatory tonsillectomy in dexamethasone-pretreated children.

UNLABELLED: In this prospective, randomized, double-blinded, placebo-controlled study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of preoperative ondansetron versus dolasetron in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. One-hundred-forty-nine children, 2-12 yr old, ASA physical status I and II, completed the study. All children received standardized perioperative care, including premedication, surgical and anesthetic techniques, IV fluids, analgesics, and rescue antiemetic medications. Patients were randomized to receive ondansetron 0.15 mg/kg, maximum 4 mg (Group 1); dolasetron 0.5 mg/kg, maximum 25 mg (Group 2); or saline placebo (Group 3) IV before the initiation of surgery. In addition, all patients received dexamethasone 1 mg/kg (maximum 25 mg). Rescue antiemetics were administered for two or more episodes of retching/vomiting. The incidence of retching/vomiting before home discharge did not differ between the ondansetron and dolasetron groups and was significantly less frequent compared with the placebo group (10%, Group 1; 8%, Group 2; 30%, Group 3). Similar results were obtained at 24-48 h after discharge (6%, Groups 1 and 2; 18%, Group 3). The need for rescue antiemetics administered after the second retching/vomiting episode was significantly less in Groups 1 (4%) and 2 (6%) compared with Group 3 (22%) before home discharge. The complete response rate, defined as no retching/vomiting and no antiemetic for 48 h, was significantly increased in Groups 1 (76%) and 2 (74%) compared with Group 3 (44%). The antiemetic efficacy of prophylactic ondansetron and dolasetron was comparable in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. IMPLICATIONS: The efficacy of a single dose of prophylactic ondansetron versus dolasetron in conjunction with dexamethasone was studied on posttonsillectomy retching/vomiting and 48-h recovery in children 2-12 yr old. Compared with placebo, ondansetron and dolasetron produced comparable reductions in the incidence of retching/vomiting and the need for rescue antiemetics.