Seasonal variations, acute rhinosinusitis and orbital infections in children.

BACKGROUND: Orbital infections in children are commonly secondary to acute bacterial rhinosinusitis (ABRS). It is unclear whether seasonal variations can predispose to these complications mirroring acute rhinosinusitis incidence. OBJECTIVE: To determine the incidence of ABRS as a cause of orbital infections and whether seasonality is a risk factor. METHODS: A retrospective review of all children who presented to West Virginia University children's hospital between 2012 and 2022 were reviewed. All children with CT evidence of orbital infection were included. Date of occurrence, age, gender, and presence of sinusitis were reviewed. Children with orbital infection secondary to tumors, trauma, or surgery were excluded. RESULTS: 118 patients were identified with mean age of 7.3 years with 65 (55.1 %) males. 66 (55.9 %) children had concomitant sinusitis on CT scan, and the distribution of orbital complications per season showed 37 (31.4 %) cases occurred in the winter season, followed by 42 (35.6 %) cases in spring, 24 (20.3 %) cases in summer, and 15 (12.7 %) in fall. Children with orbital infections during winter & spring had sinusitis in 62 % of children vs. 33 % in other seasons (P = 0.02). Preseptal cellulitis was present in 79 (67 %) children, 39 (33 %) children with orbital cellulitis, and 40 (33.9 %) children with abscesses. 77.6 % children were treated with IV antibiotics and 94 % with oral antibiotics, and 14 (11.9 %) with systemic steroids. Only 18 (15.3 %) children required surgery. CONCLUSIONS: There seems to be a seasonal predisposition for orbital complications mainly in the winter and spring seasons. Rhinosinusitis was present in 55.6 % of children presenting with orbital infections.

Surgical causes of failure in endoscopic sinus surgery.

OBJECTIVES: Evaluate causes of surgical failure at time of revision endoscopic sinus surgery. STUDY DESIGN: Prospective review of 682 cases that had endoscopic sinus surgery performed between 1991 and 1995. METHODS: In all cases, variables of age, sex, asthma, allergy, computed tomography stage, associated procedures, complications, and operative findings were collected. Those cases that had a failure after a previous endoscopic sinus procedure and not an intranasal procedure or an external procedure were evaluated. RESULTS: Fifty-two patients (7.6%) were identified. The age range was 24 to 70 years. The most common cause of failure was residual air cells and adhesions in the ethmoid area (30.7%), followed by maxillary sinus ostium stenosis in 27%, frontal sinus ostium stenosis in 25%, and a separate maxillary sinus ostium stenosis in 15% of the cases. CONCLUSION: Review of surgical causes of failure in endoscopic sinus surgery patients revealed that residual air cells and stenotic maxillary or frontal sinus ostium were the most common causes of failures.

Timing of endoscopic sinus surgery in children: is there an impact on outcome?

OBJECTIVES/HYPOTHESIS: Endoscopic sinus surgery in children continues to be a controversial issue. Major factors in determining when to operate are the duration of the disease and duration of medical treatment. STUDY DESIGN: Prospective study of children referred to a tertiary center. PATIENTS AND METHODS: Eighty-three patients underwent endoscopic sinus surgery for refractory chronic sinusitis. All patients were followed prospectively to evaluate their response to surgery for a mean follow-up period of at least 1 year. A chi2 analysis and logistic regression analysis were performed to determine statistical difference between duration of symptoms and outcome. RESULTS: The overall success rate of endoscopic sinus surgery was 80%. Children who had surgery between 6 and 12 months of symptoms despite continued medical therapy had an 84% success rate, those who had surgery between 12 and 18 months had a 74% success rate, and those with more than 18 months of treatment for symptoms had an 81% success rate (P > .05). CONCLUSIONS: Duration of the symptoms of chronic sinusitis in children of more than 6 months was not a predictor of success of endoscopic sinus surgery in these children. Although there seemed to be a trend toward having a more successful procedure in children who had surgery between 6 and 12 months of medical treatment versus those who had surgery after more than 12 months of medical treatment, this did not reach statistical significance. A prospective study with more patients may shed more light on this subject.

Endoscopic sinus surgery in the developmentally delayed child.

Functional endoscopic sinus surgery (FESS) has gained widespread support as the treatment of choice for chronic sinusitis in children. Seven developmentally delayed children were evaluated for chronic sinusitis with symptoms of cough, chronic rhinorrhea, and head banging because of pain. All seven were nonresponsive to repeated courses of oral and sometimes intravenous antibiotics; computed tomography scans on all revealed sinus disease. FESS was performed on all of them. Three children had marked respiratory difficulty at the end of the procedure, with two requiring reintubation. Two children were not able to take oral feedings postoperatively. Because of the complicated postoperative course, a second-look procedure was performed in only two children. We believe that FESS for developmentally delayed children should be tailored accordingly and that a second-look procedure should not be a routine.

Complications of endoscopic sinus surgery in a residency training program.

Endoscopic sinus surgery has emerged in the last decade as the treatment of choice for chronic sinusitis. Reports of complications of the procedure from different centers vary depending on the technique used and the experience of the surgeon. Between August 1990 and August 1993, 337 patients underwent endoscopic sinus surgery at West Virginia University. Most of the cases were performed by senior residents under faculty supervision. Minor complications were encountered in 15.1% of the cases and major complications in 1.5% of the patients. The most common major complication was cerebrospinal fluid leak. All patients with cerebrospinal fluid leaks were diagnosed and treated successfully at the time of surgery. Middle turbinate adhesions and orbital penetration were the most common minor complications. Routine partial middle turbinectomy did not decrease the adhesion rate. Endoscopic sinus surgery is a relatively safe procedure, even when performed by residents under adequate supervision.

Improved postoperative pain control in pediatric adenotonsillectomy with dextromethorphan.

DESIGN: A prospective, randomized, double-blinded, placebo-controlled protocol. SETTING: An academic, tertiary care referral center. PATIENTS: Forty randomly selected children, ages 3 to 13 years, scheduled for adenotonsillectomy without other simultaneous procedures. INTERVENTION: A single, oral dose of dextromethorphan pediatric cough syrup (1 mg/kg) or placebo given 30 minutes before surgery. MAIN OUTCOME MEASURE: Total dose requirement of intravenous morphine within a 6-hour postoperative observation period. RESULTS: During routine postoperative observation, significantly fewer patients in the dextromethorphan group required no intravenous morphine compared with the placebo group (P =.03). Of those children requiring morphine, the mean dose requirement was significantly lower in the dextromethorphan group (P =.02). There was no known drug-related morbidity. CONCLUSION: Dextromethorphan syrup is a safe, non-narcotic medication that significantly reduced the requirement of intravenous morphine after pediatric adenotonsillectomy. Its routine use in this manner is recommended.

Management of tracheostomal stenosis.

BACKGROUND: Tracheostomal stenosis following laryngectomy is a distressing complication with major effects on patient rehabilitation. Management ranges from stenting with a prosthetic device to surgical revision. The goal is a widely patent stoma that is amenable to tracheoesophageal puncture. OBJECTIVE: Review the long-term results of different methods of tracheostomal revision. METHODS: Review of 43 patients with symptomatic tracheostomal stenosis. End point was ability to function with no artificial stenting of their stoma. RESULTS: Forty-three patients underwent 55 revisions. The male-to-female ratio was 1.3:1.0. The age range was from 38 to 81 years (mean age, 59.5 y). Median time to revision was 11 months following the initial surgical procedure (range, 1-150 mo). Thirty-three patients underwent one revision; eight patients, two revisions; and two patients, three revisions. In 40 of 43 patients (93%) revision was successful. Of the last 21 patients who underwent revision, 18 had tracheoesophageal punctures placed. Fifteen developed excellent tracheoesophageal speech. The initial rates of success for these procedures were as follows: advancement flaps, 8 of 9; Z-plasty, 13 of 15; V-Y inset, 8 of 8; other procedures, 2 of 4; and dilation, 2 of 7 (P < .05 for dilation vs. all others). The ultimate success rates for these procedures were as follows: advancement flaps, 8 of 11; Z-plasty, 15 of 18; V-Y inset, 12 of 13; other procedures, 3 of 6; and dilation, 2 of 7. Other procedures and dilation were inferior (P < .05) compared with advancement flap, Z-plasty, and V-Y insets. CONCLUSION: Tracheostomal stenosis can be successfully managed in a multitude of ways.

Adenovirus and respiratory syncytial virus in chronic sinusitis using polymerase chain reaction.

The aim of this study is to investigate the role of adenovirus and respiratory syncytial virus (RSV) in chronic sinusitis using the polymerase chain reaction (PCR) to assay for the viruses. PCR has proved to be more sensitive and specific than viral cultures and immunoassays in the detection of viruses. Adenovirus and RSV are among the most common viruses to cause upper respiratory tract infections. Sinus mucosa biopsies from 20 patients undergoing endoscopic sinus surgery were sterilely collected. Four specimens (20%) tested positive for RSV by PCR and none tested positive for adenovirus. Only one specimen tested positive for RSV and one for adenovirus by viral culture and immunofluorescence. Bacterial cultures tested positive in 40% of the 20 specimens. PCR can be used to detect RSV in patients with chronic sinusitis and PCR is more sensitive than viral culture and immunofluorescence techniques on sinus polyps and mucosa.

Tracheostomal stenosis revision with simultaneous tracheoesophageal puncture.

OBJECTIVES/HYPOTHESIS: Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature. STUDY DESIGN: Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996. METHODS: Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y). RESULTS: All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications. CONCLUSIONS: Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

Penetrating neck injuries during the Lebanese war: AUBMC experience. American University of Beirut Medical Center.

During the last decade 419 patients were admitted to the American University of Beirut Medical Center with penetrating neck injuries mainly due to shrapnel. During the first 8 1/2 years of the war, all patients with wounds penetrating the platysma were explored. During the last 2 years, a more selective approach was used.

Adenoidectomy vs endoscopic sinus surgery for the treatment of pediatric sinusitis.

OBJECTIVE: To compare endoscopic sinus surgery with adenoidectomy for the treatment of refractory chronic sinusitis in children. STUDY DESIGN: Prospective nonrandomized study in a pediatric otolaryngology service of a university teaching hospital. PATIENTS AND METHODS: Sixty-six children consecutively referred to the pediatric otolaryngology service between 1994 and 1997 with computed tomographic documentation of sinusitis subsequently underwent endoscopic sinus surgery or adenoidectomy. Their ages ranged from 2 to 14 years. Sixty-one children received follow-up. Two main outcomes were documented: (1) symptom status at least 6 months after the intervention and (2) requirement of the alternate procedure or a revision procedure. RESULTS: Twenty-four (77%) of 31 children who underwent endoscopic sinus surgery had improved symptoms, compared with 14 (47%) of 30 children who underwent adenoidectomy (odds ratio [OR], 3.9; P = .01). Multivariable analysis demonstrated that endoscopic sinus surgery was significantly better than adenoidectomy after age, sex, allergy, asthma, day care attendance, and computed tomographic stage were adjusted for (OR, 5.2; P = .03). The diagnosis of asthma also appeared to be an independent predictor of success (OR, 4.37; P = .03). CONCLUSION: Endoscopic sinus surgery is better than adenoidectomy for the treatment of refractory chronic sinusitis in a select group of children.

Corticosteroid therapy during endoscopic sinus surgery in children: is there a need for a second look?

OBJECTIVE: To determine whether intravenous administration of dexamethasone during endoscopic sinus surgery in children will decrease scarring and edema during a second-look procedure. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: University medical center. PATIENTS: Forty-eight children undergoing endoscopic sinus surgery for chronic sinusitis. INTERVENTION: Twenty-four children received intravenous dexamethasone and 24 received placebo intraoperatively before the start of the procedure. MAIN OUTCOME MEASURES: The status of the ethmoid cavity, the status of the mucosa in the maxillary sinuses, and the patency of the maxillary sinus ostium during the second-look procedure performed 2 to 3 weeks after the primary procedure. RESULTS: Children who received intravenous dexamethasone had significantly less maxillary sinus mucosal edema, less ethmoid scarring, and a lower incidence of closure of the maxillary ostium (P = .02). During the second-look procedure, 62% of children in the noncorticosteroid group had abnormal findings vs 29% in the corticosteroid group. Patients with asthma, lower computed tomography scores, and no exposure to smoking had a significantly lower incidence of scarring with use of corticosteroids. Children older than 6 years benefited from intravenous corticosteroid therapy vs children 6 years and younger. CONCLUSIONS: Treatment with intravenous dexamethasone during endoscopic sinus surgery was safe and was helpful in reducing scarring and swelling noted during the second-look procedure. Use of corticosteroids was particularly helpful in children with asthma, lower computed tomography scores, and no exposure to smoking and in children older than 6 years.

Laryngeal tuberculosis. A cause of stridor in children.

The number of tuberculosis (TB) cases reported in the United States has been on the decline for the last three decades. This trend has been dramatically reversed in the past few years, largely owing to the human immunodeficiency virus epidemic. Laryngeal TB, while well recognized in the adult population, is a rare disease in children. Only six cases have been described in the world literature since 1960. We describe three children with laryngeal TB who presented with stridor. One child required an emergency tracheotomy for control of the airway. The pathogenesis of laryngeal TB in children is postulated to differ from that in adults. In children primary infection of the larynx occurs, while in adults, laryngeal infection is secondary to pulmonary disease. All patients had triple anti-TB chemotherapy for 1 year. Laryngeal TB, although rare, may be seen more frequently in the near future and the diagnosis should always be considered.

Effect of wound infections on head and neck cancer.

There seems to be a consensus in the surgical literature that wound infections after surgery for cancer have a favorable effect on the course of certain malignant diseases. In a review of laryngeal cancer during a 10-year period, the recurrence rate was statistically lower in the group that suffered wound infections than in the group that did not have a wound infection.

Use of prophylactic otic drops after tympanostomy tube insertion.

In a 1-year prospective study, 60 patients with chronic serous otitis media underwent bilateral tympanocentesis with tube insertion. The right ear was treated with dexapolyspectran (a solution consisting of polymyxin B sulfate, neomycin sulfate, sulfonamide, and hydrocortisone) intraoperatively and for 72 hours afterward, and the left ear served as the control. All patients were followed up at weekly intervals for the first month. Five (8.3%) out of 60 experimental ears had purulent otorrhea within the first 14 days after surgery, compared with eight (13.3%) out of 60 control ears. Statistical analysis showed no difference between the two groups.

The Shaw scalpel and development of facial nerve paresis after superficial parotidectomy.

OBJECTIVE: To evaluate the independent relationship of the Shaw scalpel on the development of facial nerve injury in patients undergoing superficial parotidectomy. METHODS: A retrospective review of 77 cases between 1991 and 1996. Forty-eight percent of the surgical procedures were performed using the Shaw scalpel, and 52% were performed using a cold knife. To assess whether use of the Shaw scalpel is an independent predictor of facial nerve injury, both univariate analysis and regression analysis were used in the statistical analysis of the data. RESULTS: Fifty-four percent of the patients who underwent a parotidectomy in which the Shaw scalpel was used developed postoperative facial weakness, compared with 14% of those who underwent a cold knife parotidectomy (P=.002). CONCLUSION: Multivariate analysis revealed that use of the Shaw scalpel represents an independent risk factor for development of facial nerve weakness after parotidectomy (P=.01), even after other risk factors are controlled for.

Prevalence of IgE-mediated hypersensitivity in children with adenotonsillar disease.

OBJECTIVE: To determine the prevalence of allergy in children with severe adenotonsillar disease and to determine if the persistence of symptoms following tonsillectomy may be related to the allergic state. DESIGN: A prospective study of a cohort of 108 patients. SETTING: Academic tertiary referral medical center. PARTICIPANTS: Consecutive children scheduled to undergo tonsillectomy for obstructive hypertrophy or recurrent infection were eligible to enroll in this study. Over a 17-month period, 108 patients enrolled. One-year follow-up data were obtained on 78% of patients. A group of 59 age-matched controls was used for comparison. INTERVENTION: Radioallergosorbent test analysis was performed on all study patients and controls. The study patients had the following surgical procedures: adenotonsillectomy in 61 cases (55%); adenotonsillectomy-myringotomy tubes in 31 cases (28%); tonsillectomy in 14 cases (13%); tonsillectomy-tubes in one case (< 1%); and adenotonsillectomy-unilateral tube in one case (< 1%). OUTCOME MEASURE: Detection of allergy and postsurgical outcome. RESULTS: Allergy was detected by radioallergosorbent test analysis in 23 (21%) of the study group and 12 (20%) of the control group. Fourteen patients (17%) reported obstructive symptoms unchanged or worse 1 year following surgery. Three of these children were allergic. Sixteen patients (21%) reported allergic symptoms unchanged or worse following surgery. Three of these children were allergic. In six patients (7%), asthma developed following tonsillectomy. None of these children were allergic. CONCLUSIONS: The prevalence of allergy in children with severe adenotonsillar disease is the same as that of age-matched controls. No relationship was detected between resolution of symptoms following tonsillectomy and the presence of allergy. We found no increased prevalence in the development of asthma following tonsillectomy in the allergic child.

Relationship between tympanic membrane perforations and retained ventilation tubes.

OBJECTIVES: To determine the effects of prolonged ventilation tube retention on tympanic membrane healing and the efficacy of patching procedures used concomitantly at the time of tube removal. DESIGN: Retrospective chart review. SETTING: Tertiary referral academic institution. PATIENTS: Seventy-six patients aged 12 years and younger, with a total of 99 ears identified from January 1989 to December 1994. All patients underwent ventilation tube removal for prolonged tube retention or infection unresponsive to medical management. A minimum of 6 months of follow-up was required for inclusion. INTERVENTION: Ventilation tube removal under general anesthesia, with or without concomitant patching. OUTCOME MEASURES: All medical charts were reviewed for age, sex, indications for tube removal, tube retention time, type of patch used (if any), type of tube, outcome after removal, other medical problems, and previous surgical history. RESULTS: The perforation rate was significantly higher in children with tubes retained beyond 36 months (P=.02). History of previous adenoidectomy predicted poor outcome, with a rate of 47% vs 17% in patients with no such history (P=.002). Patching did not improve healing. No other patient factors significantly influenced the perforation rate. CONCLUSIONS: Ventilation tube retention longer than 36 months resulted in an increased perforation rate after surgical removal. Paper patching at the time of tube removal does not improve healing. Prospective studies are needed to confirm these findings and to determine the efficacy of other patching techniques.

Endoscopic treatment of allergic fungal sinusitis.

Fungal sinusitis has been seen increasingly in immunocompetent individuals. The literature has stressed the importance of diagnosing these cases. Surgical debridement is the treatment of choice. Six immunocompetent individuals with allergic fungal sinusitis were seen at West Virginia University between January 1992 and December 1993. After adequate evaluation, endoscopic surgical debridement was performed. After surgery they were treated with systemic or topical steroids and oral antibiotics for several weeks. Two patients required a second procedure within a year. Four of our six patients had positive fungal cultures for Aspergillus or Curvularia. None of our patients had evidence of invasive disease on histopathology, and systemic antifungal therapy was not required. Patient course and response will be discussed in detail along with a brief review of allergic fungal sinusitis.

Is there a conductive type of presbycusis?

Many ears that manifest hearing losses caused by aging show combinations of atrophic change in the sensory cells, cochlear neurons, and stria vascularis. When it occurs in pure form, the loss of sensory cells produces an abruptly sloping high-tone threshold loss, the loss of cochlear neurons decreases the capability for speech discrimination, and the loss of strial tissue produces a flat threshold loss. There remains a fourth group of cases that have gradual sloping high-tone threshold losses for which a pathological correlate has not been identified. We performed a quantitative histologic study, using light microscopy on the temporal bones of such cases, and again could find no pathologic explanation. We believe that the findings of this study support the concept of an alteration in cochlear motion mechanics as the most probable cause for the gradually sloping high-tone hearing loss.