[The by law required assessment by a child psychiatrist before cosmetic interventions; retrospective file research]. / Wettelijk verplicht kinderpsychiatrisch onderzoek voorafgaand aan een esthetische ingreep; retrospectief dossieronderzoek.

BACKGROUND: Surgical and non-surgical cosmetic interventions are on the rise, also in minors. Therefore, the society, healthcare system and government are searching for an ethical-medical-legal framework. Numerous studies have shown the importance of patient selection. The absence of psychopathology correlates with a good outcome of cosmetic interventions. Since July 2013, the law in Belgium requires a consultation with a child psychiatrist or child psychologist before minors are allowed to undergo cosmetic intervention.
AIM: To evaluate the clinical impact and effectiveness of this Belgian law.
METHOD: Retrospective research of all patient evaluations by an independent child psychiatrist in the context of this law at the University Hospital, Free University Brussels from 12/07/2013-12/07/2017. Descriptive analysis of following variables as mentioned in the report of the child psychiatrist: type of cosmetic intervention, socio-demographic data, psychosocial problems, (symptoms of) child psychiatric diagnoses, recommendations.
RESULTS: Thirty-seven patients consulted a child psychiatrist before a planned cosmetic intervention, 36 of them had an otoplasty and 1 a rhinoplasty. Twelve patients had symptoms of at least 2 psychiatric disorders for whom further examination was required. However, these did not constitute a contraindication for the cosmetic intervention. None of the patients had (symptoms of) a body dysmorphic disorder.
CONCLUSION: Mainly patients who underwent otoplasty and with an obvious deviation from appearance that caused suffering were evaluated at the University Hospital, Free University Brussels four years after implementation of the law on cosmetic interventions. No child psychiatric contraindications for the cosmetic intervention were found in this population. It seems more useful to nuance this legislation and ask more specific for advice from a child psychiatrist in patients with risk factors. The identification of patients with a possible (child) psychiatric disorder remains of utmost importance.

Natural history of a squamous cell carcinoma of the lower lip.

Natural history of a squamous cell carcinoma of the lower lip. OBJECTIVE: In lip cancer cases without significant co-morbidities, curative treatment is preferable to palliative; although, the patient may refuse care. This case report describes the natural progression of squamous cell carcinoma (SCC) of the lower lip. CASE REPORT: A 76-year-old, non-smoker, male farmer had a lesion on his left lower lip that was clinically and histological proven to be a T1N0Mx SCC. During the first consultation, no cervical lymph nodes were palpated. Initially, the patient himself treated the SCC with udder ointment. Three years later, he had difficulties eating solid food and his meals consisted mainly of liquid nutrients. The lesion initially progressed slowly, but grew fast after 3 years and Even in this mutilating stage, the patient refused treatment. CONCLUSION: Despite the tumor stage and co-morbidities, the patient makes the treatment decisions; therefore, the implications of these decisions must be discussed.

Basilar skull fractures: the petrous bone.

Basilar skullfractures: the petrous bone. OBJECTIVES: to provide suggestions for the management of three of the most dangerous or important lesions (internal carotid artery lesions, cerebrospinal fluid leaks and facial nerve paralysis) associated with the petrous part of basilar skull fractures, thereby trying to assess categories of evidence and determine strengths of recommendation. METHODOLOGY: A PubMed-based literature review was carried out, as well as a consultation of online sources as encountered in the literature review. Also, a non-systematic search of chapters of well-known books dealing with the subject of temporal bone traumata was conducted. RESULTS: Specific levels of evidence and/or strength of recommendation can be retrieved from the literature, but only with respect to the prophylactic use of antibiotics, the prescription of antithrombotic medications and the indications for angiography. CONCLUSION: The ample amount of available literature allows for sound management decisions, with reference made to algorithms when available in the literature. Nevertheless, for most of the management/search questions, categories of evidence and strength of recommendation are low or lacking.

Critical evaluation of different objective techniques of nasal airway assessment: a clinical review.

Objective tests for the nasal volume flow are needed for the assessment of nasal patency for diagnosis, documentation and medicolegal purposes. Three main techniques are nowadays established: active anterior rhinomanometry (AAR), 4-phase rhinomanometry (4PR) and acoustic rhinometry (AR). Several guidelines and consensus reports and the International Committee on Standardization have clarified the field of interest and the limitations of this technology. In the meantime, technical progress and the development of seemingly new methods have brought up many new facts which necessitate the re-evaluation of the test available. From our method of critical analysis we can conclude that AAR can be still considered as the standard technique for the objective assessment of the nasal airway. AR is a valid technique with limitations and cannot replace AAR because it measures different parameters thus forming a complementary technique. 4PR might provide supplementary information although not yet all open technical and mathematical inconsistencies conjoint with this technique have been clarified. Still the individual subjective sensations of the patient do not always match the objective measurements. In conclusion, a combination of information given by the patient, the rhinoscopic findings and the carefully interpreted results of AAR and AR will increase considerably the success of surgical interventions and the feeling of satisfaction by the patient after surgery, when matched thoughtfully.

Epiglottitis and related complications in adults. Case reports and review of the literature.

Since the introduction of Haemophilus influenza type b (Hib) vaccinations in child immunisation programmes, a significant decline in the incidence of epiglottitis has been observed among children. However, recent studies show an increase in the incidence of adult epiglottitis without any identifiable predominant causative pathogen. Adult disease is known to have a slightly more protracted course. Vigilance is nevertheless indicated due to the risk of a rapidly evolving airway obstruction. In this paper, we discuss three recent cases of adult epiglottitis in a tertiary care unit, and review of the current literature. In two of these cases frank abscess formation was already present at the initial evaluation. In spite of very close monitoring, with securing of the airway, administration of intravenous antibiotics and drainage of the abscess, the eldest patient died. The other patients recovered completely.

Craniofacial embryology and postnatal development of relevant parts of the upper respiratory system.

OBJECTIVES: To compare historical and current knowledge relating to the development of the paranasal sinuses, the nose and face, the Eustachian tube and temporal bones, particularly with respect to chronic inflammation during childhood. METHODOLOGY: Traditional literature data, mainly emanating from text books, were supplemented with information based on a non-structured PubMed search covering the last two decades. RESULTS: Historical knowledge has most often been confirmed, sometimes supplemented and only rarely challenged by present-day studies. Recent studies focus mainly on the clinical application of modern imaging techniques. CONCLUSIONS: Interest in the development of relevant parts of the upper respiratory system remains as lively as ever. Imaging techniques with low or absent radiation exposure may give rise to a novel field of research, especially with respect to paediatric rhinosinusitis.

Different aspects of respiration: relationships between the upper and lower respiratory tracts, and the middle ear cleft, nasal versus oral breathing.

This paper outlines the normal functioning of the child's upper airway: defending the lower airway by means of air conditioning, filtration, initiation of inflammatory reactions or immune responses. We investigate the hypothetical mechanisms that explain the influence of, and interrelations between, mouth breathing and obstructive sleep apnoea on craniofacial development. We advise orthodontic diagnosis and/or intervention at a young age.

Physiology of the mouth and pharynx, Waldeyer's ring, taste and smell.

This paper reviews the contribution of the different parts of the oral cavity and the pharynx to the basic physiology of breathing, phonation, speech, swallowing, and of Waldeyer's ring to the functioning of the immune system. We discuss the development of taste and smell, as well as possibilities for chemosensory testing in children.

Clinical aspects of chronic ENT inflammation in children.

In children, all ENT cavities are particularly prone to the development of chronic inflammation. This is due to many predisposing factors, of which the most common are unfavourable anatomy, absence of nasal blowing, day care attendance, allergy, immature immunity, gastro-oesophageal reflux and tobacco smoke exposure. The aim of this paper is to outline the most specific paediatric clinical aspects of chronic pharyngo-tonsillitis, rhinosinusitis, otitis media, adenoiditis and laryngotracheitis and the important influence that some of these pathologies exert on the others.

A review of nasal dorsal hump reduction techniques, with a particular emphasis on a comparison of component and composite removal.

Nasal dorsal hump reduction is a frequently performed and basic step in non-functional rhinoplasty. The literature has described multiple techniques for nasal hump removal. However, most of the descriptions consider new or modified techniques. No papers have been published comparing any of these different surgical interventions. The aim of this paper is to review several techniques in common use, looking at their inherent advantages and disadvantages in the light of the authors' personal experiences. Particular attention is devoted to a comparison of component and composite hump reduction. The latest trends in hump removal techniques aim for predictable and realistic results with pleasing aesthetic outcomes based on precise resection techniques and the optimal preservation of nasal anatomy and function.

Pediatric tracheotomy: the Universitair Ziekenhuis Brussels' experience.

OBJECTIVE: To investigate indications, features and outcome of pediatric tracheotomy in our ENT department. METHODS: A retrospective chart review of all pediatric patients who underwent tracheotomy between 1992 and 2006 in the Children's Hospital of the Universitair Ziekenhuis Brussel. The main parameters of the study were age, gender, indications, morbidity and mortality rate, time and success of decannulation. RESULTS: Twenty-nine children younger than 16 years of age, 21 males and 8 females, underwent tracheotomy. Indications for tracheotomy fell into two main groups: chronic diseases requiring ventilation support (55%) and relief of airway obstruction (45%). Tracheotomies were mainly performed in young children, 76% were under 3 years of age. In this age group, upper airway obstruction was the most frequent indication. The complication rate was 36%, and the nontracheotomy-related mortality rate was 25%. The tracheotomy-related mortality rate was 3.5%. Successful decannulation was possible in 28% after a mean duration of 24 months after surgery. Of the remaining 72% for whom decannulation was not performed, 35% died mainly because of the underlying disease. Those infants failing decannulation (65%) had neurologic disorders. CONCLUSIONS: In accord with the literature, where a shift towards very young patients and towards indications related to chronic ventilatory support is observed, in this series tracheotomies were mainly performed for the youngest children. Relief of upper airway obstruction was the most frequent indication. Morbidity and mortality rates among this specific patient population should not be ignored.

Tinnitus in children and adolescents.

ENT practitioners are rarely confronted with tinnitus complaints from children. The present paper describes a literature review conducted in an attempt to identify possible reasons for this. Rather than applying the vast amount of information about tinnitus among adults, it seeks to highlight those domains where differences between children and adults are of importance.

Consensus report on acoustic rhinometry and rhinomanometry.

With respect to acoustic rhinometry, new elements concern the problems related to the interpretation of the minimal cross-sectional area, and the presentation of a protocol for a multinational study, which aims to define a normal nose. Also, the previously issued recommendations for standardisation for technical specifications and standard operating procedures are briefly reviewed. For rhinomanometry, new insights into the field of fluid dynamics are highlighted, as well as their repercussion on more recent graphical representations for active anterior rhinomanometry such as four phases rhinomanometry and resistometry. For acoustic rhinometry as well as rhinomanometry, a more stringent standardisation of decongestive procedures is suggested.

Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996.

OBJECTIVES: To (1) provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs; (2) provide indications for microbiological, allergic, and immunologic assessment as well as for imaging studies; (3) suggest standard medical management with judicious use of antimicrobial agents; and (4) discuss indications for surgery. DATA SOURCES: Clinical studies and literature data relevant to the different topics of pediatric rhinosinusitis. CONCLUSIONS: Rhinosinusitis in children is a multifactorial disease in which the importance of several predisposing factors changes with increasing age. Continued study to obtain a better understanding of the disease and carefully controlled comparative evaluations of medical and surgical therapies are suggested.

Epidemiology and prevalence of aspecific chronic sinusitis.

The problems inherent in the gathering of epidemiologic and prevalence data for aspecific chronic sinusitis are outlined. The need for a better understanding of the natural history of chronic sinusitis in children is stressed.

Bacteriology of the middle meatus in children.

Little is known about the bacteriology of the middle meatus in children. Therefore, middle meatal samples were obtained from 50 children who underwent adenoidectomy or adenotonsillectomy, while a group of 50 children submitted to minor non-ENT surgical procedures, were used as a control group. Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae were the most frequent cultured organisms, not only in the ENT group (in 68, 50 and 60% of the children respectively) but also in the control group (40, 34 and 50%). These three potential pathogens were more frequently seen among the children of the ENT group but only for H. influenzae was the observed difference statistically significant (P = 0.009). On semiquantitative analysis, there seemed to be more negative cultures or cultures with only a few colonies in the control group, while the richer cultures were obtained from the ENT group. Again, only for H. influenzae, these differences reached a statistical significance (P = 0.003). Streptococcus viridans and Neisseria species, both organisms that might be able to inhibit colonisation by some of the pathogens, were more frequently cultured in the control than in the ENT group: Strep. viridans 30 vs. 10% (P = 0.025) and Neisseria species 14 vs. 2% (P = 0.069).

Management of rhinosinusitis in children.

The authors provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs. They also provide the indications for CT scan examination and microbiological investigations. In addition, they emphasize the importance of concomitant systemic disease, such as allergy and immunological disorders. The adequate medical management, which is mandatory before any surgery, is considered and discussed, and the indications for surgery are provided.

Nasal provocation with histamine: a comparison of the determination of the threshold of reactivity by three methods of rhinomanometry.

Three methods of rhinomanometry were compared with each other with respect to their ability to determine the histamine threshold (histamine concentration for a 100% increase of the initial total nasal resistance): the active anterior rhinomanometry (P.A.R.). Nasal challenge and consecutive measurement by the three methods of rhinomanometry were conducted in a group of 11 volunteers. The three methods gave significantly different histamine concentration thresholds (p = 0.002). Unilateral histamine thresholds as available from A.A.R. and P.A.R. (at a flow of 250 cm3/sec) did not differ significantly (p = 0.299). For A.A.R. and A.P.R., histamine thresholds were assessed at five different pressure values as well as at five different flow values. The thresholds did not appear to be significantly different at any one of those pressure gradients (p = 0.690) or flow values (p = 0.357).

Prevalence of sinusitis signs on MRI in a non-ENT paediatric population.

In a population of 100 children with suspected intracranial neurological disease, the overall prevalence of sinusitis signs on magnetic resonance images (MRI) is 45%. This figure exceeds the adult prevalence of 39%, while the nature of the lesions is more severe in children. Furthermore, paediatric sinuses seem to be affected according to a different pattern: adults have mainly maxillary and anterior ethmoidal lesions, whereas in children the sphenoidal and posterior ethmoidal sinuses are frequently involved too. Among children, the overall prevalence increases in the presence of a history of nasal obstruction (prevalence: 50%) and recent upper respiratory tract infection (prevalence: 81%) as well as when bilateral mucosal swelling (prevalence: 80%) or purulent secretions (prevalence: 100%) are seen on anterior rhinoscopy.

Microbiology of the middle meatus: a comparison between normal adults and children.

Middle meatal samples were obtained from 52 carefully selected healthy adults. In 75 per cent of the test subjects bacterial organisms were cultured. However, growth was often poor and the predominant species suggest a commensal flora: coagulase-negative staphylococci were retrieved from 35 per cent, Corynebacterium sp. from 23 per cent and Staphyloccus aureus from eight per cent of the adults. These data are very different from those previously obtained among children where--even in the absence of obvious ENT pathology--the most frequently cultured organisms were typical sinusitis pathogens: Haemophilus influenzae present in 40 per cent, Moraxella catarrhalis in 34 per cent and Streptococcus pneumoniae in 50 per cent of children. Furthermore, Streptococcus viridans and Neisseria sp., both organisms that might be able to inhibit colonization by some of the pathogens and found commonly among children, are virtually absent in healthy adults.