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.

[Food allergies in children: which diet?]. / Les allergies alimentaires de l'enfant: quel régime?

Food allergies are very frequent in children (between 4 and 8% of population). There are many clinical manifestations, that can be lifethreatening. In children, compared to adults, a limited number of food allergens are responsible for the disease: egg, cow milk, peanuts, nuts (hazelnut, nut, ...), fish, cereals, exotic fuits, and soya. Eviction of the offending food is the first treatment of allergy. This eviction diet is sometimes difficult to organize and can alter the quality of life (child and family). Diagnosis must be well established; sensitivity to an allergen must be differenciated from real allergy. This can lead to perform a provocation test (oral challenge) in the hospital. It is now proposed that the eviction diet will be less strict than before, adapted according to the allergen, symptoms in each case, age of patient and ideally to the reacted dose of the offending allergen. A collaboration with a dietist is necessary to optimalize the nutritionnal schedule. Induction of oral tolerance seems to be an interesting optional treatment for patients presenting persistant food allergy.

Basophil activation tests for the diagnosis of food allergy in children.

BACKGROUND: Positive skin prick tests (SPT) for food allergens and specific IgE (sIgE) in serum indicate sensitization but do not enable distinction between sensitized but tolerant and clinically allergic patients. OBJECTIVE: Herein, we evaluate the clinical relevance of basophil activation tests (BATs) for peanut or egg allergy diagnosis. METHODS: Thirty-two peanut-allergic, 14 peanut-sensitized (sIgE(+) and/or SPT(+) to peanuts) but tolerant children and 29 controls with no history of an adverse reaction to peanuts were included. Similarly, 31 egg-allergic, 14 egg-sensitized children (sIgE(+) and/or SPT(+) to egg white) and 22 controls were studied. Flow cytometric analysis of CD63 expression or CD203c upregulation on basophils and the production of leukotrienes (LT) were performed in response to an in vitro crude peanut extract or ovalbumin (OVA) challenge. RESULTS: After in vitro peanut challenge, the basophils from peanut-allergic children showed significantly higher levels of activation than those from controls (P<0.001). After OVA challenge, a similar distinction (P<0.001) was observed between egg-allergics and controls. Interestingly, the majority of egg- or peanut-sensitized children failed to activate basophils, respectively, in response to OVA and peanut challenge. The sensitivity of the CD63, CD203c and LT assay was 86.7%, 89.5% and 76.0% with a specificity of 94.1%, 97.1% and 94.6% for peanut allergy diagnosis. The corresponding performances of BATs applied to egg allergy diagnosis were 88.9%, 62.5% and 77.8% for the sensitivity and 100%, 96.4% and 96.4% for the specificity. CONCLUSION: Neither conventional tests nor BATs are sensitive and specific enough to predict food allergy accurately. However, BATs may helpfully complete conventional tests, especially SPT, allowing improved discrimination between allergic and non-allergic individuals.

[Acute respiratory dyspnea in children]. / La dyspnée aiguë chez l'enfant.

Acute respiratory dyspnea is very frequent in children and must be quickly treated to obtain the best prognosis. The diagnosis depends from the natural history of the disease and from the quality of clinical assessment. The use of an algorithm according to the presence of stridor or bronchospasm is very contributive to the diagnosis. The paper reviews the pathophysiology of dyspnea in children and the more common diseases that are causing respiratory distress. Finally, treatment of respiratory failure and management of specific diseases are defined.

[Immunoallergology in children: diagnosis and treatment]. / Immuno-allergologie chez l'enfant: diagnostic et traitement.

Atopy is the most frequent allergic disease in western countries: about 30% of children are suffering from various forms of its manifestations. During the 20th century, its frequency gradually increased. This is not only true for sensitization (presence of specific immunoglobulin E (IgE) in the skin or in the serum), but also for clinical symptoms associated with sensitization. It is usually a disease of skin and mucosae, but atopy can also become systemic (anaphylaxis). Hygienist hypothesis (reduction of infectious diseases and Th1 pressure) gives a possible explanation to the impressive increase of allergic diseases during the last decades. In the child, atopic dermatitis and food allergies are first observed (allergic march): 5 allergens explain more than 85% of cases (white egg, milk, peanuts, fish and nuts). Skin prick tests are more sensible than specific IgE measurements in the serum; they are usually done before. Provocation tests (labial and oral) can confirm the diagnosis when necessary. Four families of aeroallergens are described (pollens, house dust mites, pets and moistures). Eviction is the first line of treatment, than drugs are prescribed to reduce symptoms and inflammation (corticosteroids, antihistamine). Desensitization and immunomodulators that can induce tolerance are also proposed in defined situations.

[Child food allergy: results of a Belgian cohort]. / L'allergie alimentaire chez l'enfant: étude d'une cohorte belge.

INTRODUCTION: Food Allergy is a public health problem because of its increasingly prevalence, its severity and the difficulty of diagnosis. OBJECTIVE: to describe the responsible food allergens and the clinical features of food allergy in a large group of Belgian children. METHOD: 156 cases of food allergy observed between May 2002 and May 2005 were retrospectively reviewed. All patients have specific IgE. Unequivocal history, response to elimination diet, labial or oral food challenge confirmed the diagnostic. RESULTS: Median age is 26 months (range 1 months-14 years) and male to female ratio is 1.6. Fifty-nine percent of the cases are younger than 3 years. Family history of atopic disease is found in 80.3%. Foods most commonly involved are: eggs (31%), tree nuts (18.1% including hazelnuts 12.3%), cow's milk (16.1%), peanuts (13.2%), fish (4.5%), latex fruits (4.5%).The clinical manifestations are: atopic dermatitis (44.2%), urticaria (40.4%), angioedema (36.5%), gastrointestinal symptoms (21.8%), laryngeal edema (11.5%), asthma (9%), oral allergy syndrome (7.7%), systemic reactions (7.7%) and anaphylactic shock (3.8%). Multiple food allergies are rare: 78.9% of our population have one or two food allergies. CONCLUSION: This study confirms the usual distribution of food allergens in children. It shows that only four allergens (egg, tree nut, cow's milk, peanut) are responsible for 78.4% of the reactions and highlights the emergence of tree nuts allergy, particularly hazelnuts, in Belgium.

Size and geometry of hepatic radiofrequency lesions.

AIM: To report and compare the size and geometry of hepatic radiofrequency (RF) lesions using the currently available commercial devices. METHODS: A literature search was carried out for the period from January 1st 1990 to June 15th 2003. The commercial suppliers were asked to provide all available data. For each electrode and protocol, size and geometry of single-cycle thermal lesions were registered. RESULTS: No information at all on size and geometry of the inducible lesions was available for 17 of the 28 current commercial electrodes. Many descriptions of RF lesions are limited to the mean transverse diameter. With normal blood flow, diameter of lesions is often smaller than suggested by the length of the electrode tip or the diameter of the deployed prongs. Lesions are rarely perfect spheres but either ellipses or flattened spheres. Distortion of the RF lesion by nearby blood vessels is very common. Fusion of thermal zones between prongs of expandable electrodes can be incomplete. Blood flow interruption using a Pringle maneuver yields larger lesions that are less distorted and more complete. CONCLUSIONS: There is insufficient experimental data for many electrodes that are currently used in patients. RF companies should provide these data before releasing electrodes for use. For those electrodes for which data exist, coagulation lesions are often smaller, less spherical, less complete and less regular than generally presumed. Accurate knowledge of size and geometry of RF lesions is crucial to prevent local recurrence.

The physiologic effect of the pneumoperitoneum on radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is gaining widespread acceptance as a safe and effective method for liver tumor ablation. Complete tumor ablation is essential for the success of the procedure. Multiple modalities have been explored in an effort to increase the size of the lesion created by RFA. The purpose of this study was to determine the physiologic effects of the pneumoperitoneum on RFA lesion size. METHODS: A total of 32 RFA lesions were created in eight pigs. After the induction of anesthesia, pneumoperitoneums of 2, 12, and 24 mmHg were established sequentially in each animal. After an equilibration period of 2 min, RF was administered with a constant saline-infused (0.9%) needle at 25 W for 3 min. In subsequent and complementary experiments, both before and during RF administration at each intraperitoneal pressure (IPP), Doppler flow was measured by laparoscopic ultrasound in the portal vein and hepatic artery while blood pressure was monitored by a femoral arterial line. The animals were then killed humanely and the livers were harvested. Measurements were taken in three dimensions of the ablated areas, and the volume was calculated. Statistical analyses were performed using analysis of variance (ANOVA) and repeated measures test. RESULTS: The average volumes of the lesions (in cm3) were 3.1 +/- 1.8, 5.2 +/- 1.7, and 6.7 +/- 3.3 for IPP of 2, 12 and 24 mmHg, respectively; there was a significant difference between the area of lesion at an IPP of 2 mmHg and an IPP of 24 mmHg ( p < 0.05). Blood flow in the portal vein also decreased significantly from 1.8 +/- 0.6, 0.98 +/- 0.5, and 0.43 +/- 0.2 at IPP of 2, 12, and 24 mmHg, respectively ( p < 0.001). Hepatic artery blood flow and peripheral blood pressure did not change significantly in the respective IPP groups. CONCLUSIONS: This study indicates that the volume of liver ablated by RF can be increased by augmenting the IPP. Our data support the theory that a decrease in portal blood flow results in decreased heat dissipation during RFA. The laparoscopic approach to RFA offers the advantage of allowing control of the IPP, which may result in a larger volume of ablated tissue per treatment than can be achieved with the percutaneous technique. These preliminary data on normal hepatic tissue must be confirmed clinically in the setting of hepatic tumors.

Thoracic disc herniations: transthoracic, lateral, or posterolateral approach? A review.

BACKGROUND: The choice between transthoracic, lateral, and posterolateral approaches to excise thoracic disc herniations remains controversial. METHODS: The outcome of the three approaches was compared in seven of the authors' cases and in 324 other cases reported in the literature. RESULTS: Partial or total neurological recovery was found in 93% after a transthoracic procedure versus 87% after a posterolateral technique and 80% after a lateral approach (P < 0.05). A trend toward superior results after a transthoracic technique was also noted in subgroups of patients with radiculopathy, patients with intradural disc herniations, and patients with multiple lesions, although statistical significance was not reached. Pulmonary complications occurred in 7% of transthoracic techniques versus 5% in lateral and 0% in posterolateral techniques (p < 0.025). CONCLUSIONS: The transthoracic approach is recommended for all thoracic disc herniations below the T4 level except for patients with serious pulmonary compromise.

Management of oesophageal perforation after delayed diagnosis: the merit of tissue flap reinforcement.

Oesophageal perforation remains a life-threatening situation and its management represents a challenge for the surgeon, especially if diagnosis has been delayed. In most cases, a surgical approach is indicated. Simple primary repair often result in leakage. In order to avoid leakage, the primary repair should be buttressed with some kind of tissue flap. We here report our experience with 15 esophageal perforations and 10 tissue flap reinforcements performed during the last decade. The different types of tissue flap are illustrated and their results are compared with more aggressive alternatives such as oesophagectomy, T-tube drainage and oesophageal exclusion.

A review of the general aspects of radiofrequency ablation.

As an alternative to standard surgical resection for the treatment of malignant tumors, radiofrequency ablation (RFA) has rapidly evolved into the most popular minimally invasive therapy. To help readers gain the relevant background knowledge and to better understand the other reviews in this Feature Section on the clinical applications of RFA in different abdominal organs, the present report covers the general aspects of RFA. After an introduction, we present a simple definition of the energy applied during RFA, a brief historical review of its technical evolution, and an explanation of the mechanism of action of RFA. These basic discussions are substantiated with descriptions of RFA equipment including those commercially available and those under preclinical development. The size and geometry of induced lesions in relation to RFA efficacy and side effects are discussed. The unique pathophysiologic process of thermal tissue damage and the corresponding histomorphologic manifestations after RFA are detailed and cross-referenced with the findings in the current literature. The crucial role of imaging technology during and after RFA is also addressed, including some promising new developments. This report finishes with a summary of the key messages and a perspective on further technologic refinements and identifies some specific priorities.

A novel "cooled-wet" electrode for radiofrequency ablation.

In the light of growing demands for improved applicability of radiofrequency ablation (RFA), recently we have developed a novel "cooled-wet" electrode by taking the advantages of both internally cooled and saline-enhanced electrodes. The efficacy of the electrode was evaluated in both ex vivo and in vivo liver RFA under both low and high power output levels. The ablation volume created with the "cooled-wet" electrode appeared to be much larger than that reported up to now with the use of other monopolar electrodes. The mechanisms on how this device optimizes the RF energy delivery are also discussed.

Complications of radiofrequency coagulation of liver tumours.

BACKGROUND: Radiofrequency coagulation (RFC) is being promoted as a novel technique with a low morbidity rate in the treatment of liver tumours. The purpose of this study was to assess critically the complication rates of RFC in centres with both large and limited initial experience, and to establish causes and possible means of prevention and treatment. METHODS: This is an exhaustive review of the world literature (articles and abstracts) up to 31 December 2001; 82 independent reports of RFC of liver tumours were analysed. RESULTS: In total, 3670 patients were treated with percutaneous, laparoscopic or open RFC. The mortality rate was 0.5 per cent. Complications occurred in 8.9 per cent: abdominal bleeding in 1.6 per cent, abdominal infection in 1.1 per cent, biliary tract damage in 1.0 per cent, liver failure in 0.8 per cent, pulmonary complications in 0.8 per cent, dispersive pad skin burn in 0.6 per cent, hepatic vascular damage in 0.6 per cent, visceral damage in 0.5 per cent, cardiac complications in 0.4 per cent, myoglobinaemia or myoglobinuria in 0.2 per cent, renal failure in 0.1 per cent, tumour seeding in 0.2 per cent, coagulopathy in 0.2 per cent, and hormonal complications in 0.1 per cent. The complication rate was 7.2, 9.5, 9.9 and 31.8 per cent after a percutaneous, laparoscopic, simple open and combined open approach respectively. The mortality rate was 0.5, 0, 0 and 4.5 per cent respectively. CONCLUSION: The morbidity and mortality of RFC, while low, is higher than previously assumed. With adequate knowledge, many complications are preventable.

Treatment of VX2 liver tumor in rabbits with "wet" electrode mediated radio-frequency ablation.

Radio-frequency ablation (RFA) has been considered as an alternative therapy for liver tumors. A "wet" electrode with interstitial infusion of hypertonic saline was tested for the RFA of liver tumor in rabbits. Seventy-eight liver tumors ( 1.5 to 3.0 cm) were induced in 41 rabbits by VX2 carcinoma implantation. Fifty-one tumors in 27 rabbits were treated with RFA. Under laparotomy, the RF energy was delivered while 5 % saline was infused through the electrode into the tumor at 1 ml/min. Six rabbits with 12 tumors were treated with only intratumoral 5 % saline infusion without RFA. Another 8 rabbits with 15 tumors received sham operation as untreated controls. The efficacy of the therapy was evaluated with survival rate, MRI, microangiography, and histopathology. In the RFA group, 6 rabbits survived longer than 6 months (absolute eradication rate 22.2 %); 12 rabbits were found free of viable tumor at the moment when they were sacrificed (relative eradication rate 44.4 %); 9 rabbits showed local tumor relapse and/or lung metastasis 2-10 weeks after ablation (recurrent rate 33.3 %). In control groups of saline infusion and sham operation, all 14 rabbits died within 3 months (mortality rate 100 %). Three-month survival rates between RFA group and control groups were significantly different (p < 0.05). Findings of MRI, microangiography, and histology supported these outcomes. Radical treatment of liver malignancy in rabbits is possible with the present modified RFA technique. Its clinical usefulness has to be further proven.

Proliferative myositis in a child.

A case of proliferative myositis in the lumbar paraspinal muscles in a 14-year-old boy is presented. Imaging investigations including plain radiograph, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), bone scan and positron emission tomography (PET) were suggestive of an inflammatory process such as myositis ossificans. The diagnosis was made by incisional biopsy. More pronounced edema, more muscle fiber necrosis and a higher cellularity were found compared to adult cases. The karyotype of the lesion was normal. Clinically, the mass disappeared spontaneously. After 24 months, asymptomatic bridging ossification between the third and fourth lumbar vertebrae was noted.