Video fluoroscopy for evaluating adenoid hypertrophy in children.

BACKGROUND: Adenoid hypertrophy is a common cause of upper airway obstruction in children. Traditionally, adenoid size has been evaluated using a conventional lateral skull film. Flexible endoscopy is now the gold standard for the evaluation of the upper airway. Children need to be cooperative in order to complete a videonasopharyngoscopy examination, which is not always possible. OBJECTIVE: The purpose of this paper is to determine the sensitivity and specificity of lateral video fluoroscopy for assessing adenoid size compared to conventional lateral skull films with videonasopharyngoscopy as the gold standard. MATERIALS AND METHODS: Twenty pediatric patients with adenoid hypertrophy demonstrated by videonasopharyngoscopy, and 20 control patients without adenoid hypertrophy were assessed with video fluoroscopy and lateral skull radiograph. Two independent examiners evaluated all studies. Specificity, sensitivity, and predictive values were obtained for findings on video fluoroscopy and lateral skull film. RESULTS: Video fluoroscopy showed 100% sensitivity, and 90% specificity for the diagnosis of adenoid hypertrophy. Lateral skull films showed 70% sensitivity, and 55% specificity. A Spearman correlation coefficient demonstrated a significant correlation (P<0.05) between findings on video fluoroscopy and videonasopharyngoscopy. In contrast, there was a no significant correlation (P>0.05) between lateral skull films and videonasopharyngoscopy. CONCLUSIONS: Video fluoroscopy appears to be a safe and reliable procedure for assessing adenoid hypertrophy in children.

[Metallic ureteral stents. Present and future.] / Stents ureterales metálicos. Presente y futuro.

The management of ureteral obstruction of malignant origin or complicated benign obstruction continues to be a challenge for the urological community. In this sense, the use of metallic stents could be considered a useful alternative to the conventional drainage techniques, because it accomplishes the resolution of obstruction in a single procedure, without external diversions and without the adverse effects of current diversions. Another important advantage they offer is that they do not need replacement as frequently as double J catheters or nephrostomy tubes require. From their first applications in the upper urinary tract until now the design of metallic stents has experienced a notable evolution. The main obstacle at the beginning was the use of stents intended for other organic territories, which caused a high rate of failures, since they did not take into consideration in their designs the hostile environment represented by urine for this type of devices, neither the existence of ureteral peristaltism. Thanks to subsequent metallic designs (Memokath, Uventa, Allium Medical URS-stent, Resonance), the current generation of ureteral metallic stents has improved the success rate in comparison to classical designs, accommodating to ureteral dynamics and improving the coating and alloys. Despite these advances, today, their application is limited to very selected patients due to the onset of undesirable effects still associated with theses stents, such as obstructive urothelial hyperplasia, encrustation or migration. The precise knowledge of the physiopathological mechanisms responsible for the cited adverse effects, together with the application of Bioengineering enabling the development of drug eluting metallic stents, biocoated stents, or new biodegradable metallic materials that mitigate or diminish their effects, may be the key to allow the development of the ideal metallic stent.

Intravesical immunoprophylaxis in recurrent superficial bladder cancer (Stage T1): multicenter trial comparing bacille Calmette-Guérin and interferon-alpha.

OBJECTIVES: To estimate and compare recurrence rates, index of recurrence, and disease-free interval in patients with superficial recurrent bladder cancer receiving bacille Calmette-Guérin (BCG) or interferon (IFN) for immunoprophylaxis. METHODS: One hundred twenty-two patients with recurrent superficial Stage pT1, grade 1 to 3 tumors were enrolled in a randomized, prospective, multicenter trial with two treatment arms of endovesical immunoprophylaxis: 150 mg of BCG versus 54 MU of recombinant IFN-alpha-2a. Administration was weekly during the first month, biweekly for 2 months, and monthly for 9 months. Both groups were similar with regard to tumor stage, grade, size, and number. RESULTS: Sixty-one patients were evaluable in the BCG group and 49 in the IFN group. Tumors recurred in 34 (69.4%) of 49 patients in the IFN group (890 months of follow-up) and in 24 (39.3%) of 61 in the BCG group (1272 months of follow-up). The total number of recurrences (28 for BCG, 47 for IFN), disease-free interval (mean 19.3 months for BCG, 15.3 months for IFN), and index of recurrence (2.2 for BCG, 5.5 for IFN) were statistically significant (P = 0.001) in favor of BCG. Progression to invasive carcinoma was similar in both study arms. Neither systemic nor local side effects were seen in the IFN group. However, the previously reported toxicity of BCG was confirmed. CONCLUSIONS: According to our trial, BCG remains the most efficacious agent for immunoprophylaxis of recurrent superficial bladder tumors.

Respiratory disorders in common variable immunodeficiency.

Common variable immunodeficiency (CVID) is a heterogeneous immunodeficiency syndrome characterized by hypogammaglobulinemia, recurrent bacterial infections, and various immunologic abnormalities. The clinical presentation is generally that of recurrent pyogenic sinopulmonary infections. Our objectives were to study the prevalence of lung involvement and the response to intravenous immunoglobulin replacement therapy in 19 patients with CVID. Nineteen patients (12 men) with a mean age (SD) of 33.1 (17.1) years had a previous diagnosis of CVID and were treated with intravenous immunoglobulin replacement. All patients underwent complete pulmonary function tests and high-resolution computed tomography (HRCT) examination. Bronchiectasis was diagnosed in 11 (58%) patients and eight (42%) were multi-lobar bronchiectasis. Chronic airflow limitation (CAL) was present in 10 (53%) patients and a restrictive pattern was seen in one case. Eleven patients (58%) presented a decrease in single-breath carbon monoxide diffusing capacity of the lung (DL(CO)). Before intravenous immunoglobulin replacement therapy (INIRT), 84% of patients had suffered from at least one episode of pneumonia. Episodes of lower respiratory tract infection decreased significantly from 0.28 per patient and year before replacement therapy to 0.16 per patient and year after treatment. The mean duration of replacement therapy was 7.5 years. In conclusion lung involvement was frequent in patients with CVID. Long-term administration of intravenous gammaglobulin resulted in a substantial reduction of pneumonic episodes.

Velopharyngeal motion after sphincter pharyngoplasty: a videonasopharyngoscopic and electromyographic study.

Sphincter pharyngoplasty is a surgical procedure for managing velopharyngeal insufficiency after palatal closure. This procedure is intended to create an active diaphragm for velopharyngeal closure. The purpose of this study was to evaluate velopharyngeal motion after sphincter pharyngoplasty, by using selective electromyography and simultaneous videonasopharyngoscopy. Twenty-five patients who were subjected to sphincter pharyngoplasty from 1985 to 1996 were reviewed. All conditions were evaluated by using electromyography with simultaneous videonasopharyngoscopy. The following velopharyngeal muscles were examined: superior constrictor pharyngeus, palatopharyngeus, and levator veli palatini. The palatopharyngeus was included in the superiorly based surgical flaps inserted at the posterior pharyngeal wall. Twenty-three patients (92 percent) showed complete velopharyngeal closure. The two patients with residual velopharyngeal insufficiency showed a defect size of 20 and 25 percent. None of the patients showed electromyographic activity at the superiorly based flaps, indicating absence of activity of the palatopharyngeus muscles. However, all patients showed normal electromyographic activity at the superior constrictor pharyngeus and the levator veli palatini. Videonasopharyngoscopy demonstrated that lateral pharyngeal wall movements, which ranged from 25 to 40 percent, were related to strong electromyographic activity at the superior constrictor pharyngeus. It is concluded that the superiorly based pharyngeal flaps of the sphincter pharyngoplasty do not seem to create an active diaphragm for velopharyngeal closure. Moreover, the observed sphinctering seems to be passive, caused by the contraction of the superior constrictor pharyngeus.

Surgical treatment of submucous cleft palate: a comparative trial of two modalities for palatal closure.

Submucous cleft palate is a congenital malformation with specific clinical and anatomical features. It can be present with or without velopharyngeal insufficiency. Surgical treatment of this malformation is indicated only when velopharyngeal insufficiency has been demonstrated. This article compares two modalities of surgical treatment for submucous cleft palate. The first includes a minimal incision palatopharyngoplasty, as described in a previous report. The second combines the first technique with additional individualized velopharyngeal surgery (individualized pharyngeal flap or sphincter pharyngoplasty) performed simultaneously. The individualized part of the procedure was selected and performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy, as reported previously. Two hundred and three patients with submucous cleft palate were studied from 1990 to 1999. Videonasopharyngoscopy and multiview videofluoroscopy demonstrated velopharyngeal insufficiency in 72 patients, who were randomly divided into two groups. Those in group 1 (n = 37) underwent a minimal incision palatopharyngoplasty. Patients in group 2 (n = 35) also underwent that procedure but simultaneously received individualized pharyngeal flap or sphincter pharyngoplasty, according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients from both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after palatal closure was not significantly different in both groups of patients (14 percent versus 11 percent; p > 0.5). The mean size of the gap at the velopharyngeal sphincter during speech was not significantly different in both groups of patients before surgery (23 percent versus 22 percent; p > 0.5). After the surgical procedures, there was a nonsignificant difference between both groups of patients in mean residual size of the gap in cases of velopharyngeal insufficiency (7 percent versus 8 percent; p > 0.5). It seems that minimal incision palatopharyngoplasty is a safe and reliable procedure for palatal closure in patients with submucous cleft palate. The use of additional individualized velopharyngeal surgery performed simultaneously did not seem to decrease the frequency of residual velopharyngeal insufficiency. Moreover, the residual size of the gap at the velopharyngeal sphincter was not significantly reduced when an additional surgical procedure was performed simultaneously with palatal closure.

Speech outcome and maxillary growth in patients with unilateral complete cleft lip/palate operated on at 6 versus 12 months of age.

A prospective study of speech outcome and maxillofacial growth was carried out in cleft palate patients. Seventy-six cleft palate patients were randomly selected for the study group; 41 patients were operated on at 12 months of age, and 35 patients were operated on at 6 months of age. All patients were followed until they were 4 years of age. All patients underwent a complete speech evaluation, videonasopharyngoscopy, videofluoroscopy, and maxillofacial assessment. The rate of velopharyngeal insufficiency did not differ between the two groups (17 to 19 percent; p > 0.05). However, phonologic development was significantly better (p < 0.05) in the patients operated on at 6 months of age. Furthermore, none of the patients operated on at 6 months of age showed compensatory articulation disorder. In contrast, 62 percent of the patients with postoperative velopharyngeal insufficiency operated on at 12 months of age showed compensatory articulation disorder (p < 0.05). Maxillofacial assessment showed that there were non-significant differences (p > 0.05) in maxillofacial growth in both groups of patients. All patients showed similar degrees of maxillary collapse (p > 0.05). The results of this study suggest that cleft palate repair performed at 6 months of age significantly enhances speech outcome and prevents compensatory articulation disorder.

Mothers of children with cleft palate undergoing speech intervention change communicative interaction.

INTRODUCTION: Natural learning must include language learning relationships that provide natural support for communication and language learning. OBJECTIVE: To find out if including the mother as an active participant during speech therapy sessions would improve the communicative style and mode of the interaction of the mothers with their cleft palate children. MATERIALS AND METHODS: Fifty-nine children with cleft palate and their mothers were included in the study group. The patients were divided into two groups randomly. Patients received the same treatment. Twenty-eight of the children were included in the control group. They participated in small working groups comprising the speech pathologist and two children. Thirty-one of the children were included in the experimental group. In this case, the mothers of the children were also included as active participants. The mothers of the patients from the two groups were assessed at the beginning and end of the speech therapy period to find out their style and mode of interaction. Pre- and post-data of the mothers from both groups were compared. RESULTS: Eighty-nine per cent of the mothers of the experimental group modified their patterns of interaction. In contrast, only 19% of the mothers of the control group modified their style and mode of interaction. A Fisher exact test demonstrated that the frequency of mothers from the experimental group that modified their style and mode of interaction was significantly greater as compared to the number of mothers from the control group that were able to modify their style and mode of interaction. CONCLUSIONS: Mothers of children with cleft palate and accompanying language delay modify their communicative style and mode of interaction through active participation in speech therapy.

Linguistic interaction: the active role of parents in speech therapy for cleft palate patients.

As speech and language intervention becomes more naturalistic, it seems obvious that language and other developmental competencies are, in a strong way, a function of the quality and quantity of relationships in which the child evolves. This paper compares two different speech therapy groups of cleft palate children. Children included in the first group received therapy alone with the speech pathologist, whereas children from the second group received speech therapy accompanied by their mothers. The purpose was to evaluate and provide the mothers with interaction modes for facilitating communication. Both groups were evaluated before and after the therapy period in order to measure the advance of each group. The patients accompanied by their mothers showed a significantly higher linguistic advance as compared to patients receiving therapy without their mothers. The results in this study support the statement that linguistic development in the cleft palate child is strongly related to adult-child mode of interaction.

A comparative trial of two modalities of speech intervention for compensatory articulation in cleft palate children, phonologic approach versus articulatory approach.

To compare two modalities of speech intervention (SI) in cleft palate children with compensatory articulation disorder (CAD). The first modality was a phonologic based intervention, the second modality was an articulatory or phonetic intervention. The main purpose is to study whether a phonologic intervention may reduce the total time of speech therapy necessary for correcting CAD in cleft palate children as compared to an articulatory intervention. A prospective, comparative, and randomized trial was carried out. Cleft palate children with velopharyngeal insufficiency and CAD were included in the study group. Only patients with an age ranging from 3 to 7 years were included. A total of 29 patients were selected and were divided randomly into two groups. Fifteen patients were included in the first group (control) and received articulatory SI. Fourteen patients were included in the second group (active) and received phonologic SI. The speech pathologist in charge of the SI was the same in all cases. A blind procedure was utilized whereby each patient was evaluated independently by two speech pathologist every three months until both examiners were convinced that CAD had been completely corrected. The mean total time of SI required for the normalization of speech in the two groups of patients was compared. Median age in the control group was 54 months, and 55.50 months in the active group (P > 0.05). The mean total time of SI in the control group was 30.07, and 14.50 in the active group. A Student's t-test demonstrated that the total time of SI was significantly reduced (P < 0.001) when a phonological intervention was utilized. Phonologic based SI significantly reduced the time necessary for correcting CAD in cleft palate children.

Short latency and long latency auditory evoked responses in children with attention deficit disorder.

INTRODUCTION: Children diagnosed with attention deficit disorder (ADD) can present with different abnormalities in electrophysiological studies. OBJECTIVE: The purpose of this paper is to compare brainstem auditory (short latency) evoked responses (BSAER) and long latency auditory evoked responses (LLAER) in school children with and without ADD. MATERIALS AND METHODS: A normative study was carried out, 20 normal subjects were studied. All these patients underwent a study protocol including BSAER and LLAER. Eighteen school children diagnosed as ADD were included in the active group. Eighteen school children were selected as controls. All children from both groups underwent BSAER and LLAER. BSAER and LLAER results from both groups of patients were compared. RESULTS: Brainstem transmission was significantly longer in children with ADD. The latency of P300 was significantly longer in children with ADD. Also, mean amplitude of P300 was significantly decreased in children with ADD. CONCLUSION: The results of this study indicates that school children with ADD show significant abnormalities in BSAER and LLAER. These electrophysiological procedures involving the auditory system can be useful for the diagnosis of children with ADD.

Videonasopharyngoscopy as an instrument for visual biofeedback during speech in cleft palate patients.

Videonasopharyngoscopy was used as an instrument for visual biofeedback during speech in cleft palate patients. Seventeen cleft palate patients were randomly selected for the study. All patients showed velopharyngeal insufficiency (VPI), compensatory articulation (CA) and negative movement of lateral pharyngeal walls (NMLPW) during speech. Nine patients received speech therapy for correcting CA. Eight patients received speech therapy and underwent videonasopharyngoscopy as an instrument for visual biofeedback of the velopharyngeal sphincter. After 12 weeks, NMLPW was modified in the patients receiving speech therapy and visual biofeedback. In contrast, NMLPW was still present in eight out of nine patients receiving only speech therapy. These patients received visual biofeedback and NMLPW was corrected in all cases. After six months, all 17 patients had corrected CA during isolated speech. All patients received a tailor-made pharyngeal flap. VPI was completely corrected in 15 cases. In the two cases in which VPI was still present postoperatively, the size of the defect at the velopharyngeal sphincter had been significantly reduced. In these two patients, visual biofeedback was used postoperatively for increasing lateral pharyngeal walls (LPW) motion towards the borders of the flap. After 18 months since the onset of speech therapy all the patients had normal nasal resonance and normal articulation during connected speech.

Linguistic development in cleft palate patients with and without compensatory articulation disorder.

INTRODUCTION: Cleft palate patients frequently show compensatory articulation disorder (CAD). CAD severely affects speech intelligibility and requires a prolonged period of speech intervention. CAD has been considered a phonologic disorder. Thus, it seems necessary to explore the relationship between CAD and language development. OBJECTIVE: To study the relationship between language development and the presence of CAD in cleft palate patients. MATERIALS AND METHODS: Cleft palate children with residual velopharyngeal insufficiency (VPI) after palatal closure, with and without CAD were studied. Only patients with an age ranging from 3 to 8 years were included in the study group. Twenty-nine cleft palate patients with residual VPI and CAD were included in the first group (active). The second group was assembled with 29 cleft palate patients with residual VPI without CAD, matched by age and sex (control). For evaluating language development, all patients were analyzed using the Situational-Discourse-Semantic (SDS) Model [13]. This Model is a valuable tool for conducting naturalistic observation and descriptive assessment of language development. The SDS Model provides a detailed description of three contexts (situational, discourse, and semantic) in ten levels of cognitive and linguistic organization. RESULTS: In all contexts considered by the model of cognitive and linguistic organization used for this study, i.e. SDS, a Fischer exact test demonstrated that patients with CAD showed a significantly higher frequency of language delay as compared with patients without CAD. None of the patients present with CAD showed an adequate level of language development. The degree of language delay was greater in the situational context as compared to the semantic and discourse contexts. CONCLUSIONS: Cleft palate patients present with CAD, demonstrated a significantly higher frequency of delay in language development as compared with cleft palate patients present with VPI without CAD. From the results of this paper, it seems that a detailed evaluation of all aspects of cognitive and linguistic organization should be performed in cleft palate patients, especially in patients present with CAD. Moreover, it seems that speech intervention in cleft palate patients with CAD should address not only the articulation process, but also specific aspects of language development.

Surgical correction of velopharyngeal insufficiency with and without compensatory articulation.

The final speech outcome in cleft palate patients depends on two elements: normalization of nasal resonance and correction of compensatory articulation (CA). The purpose of this paper is to demonstrate whether early surgical correction of velopharyngeal insufficiency (VPI) may decrease total time of speech therapy (ST) necessary to completely eliminate CA. A group of 29 cleft palate patients in which VPI and CA were demonstrated, were selected for the study group. Fourteen patients were randomly selected and underwent surgical correction of VPI as soon as placement of articulation during isolated speech was normal. The other 15 patients underwent speech therapy aimed to correct CA, these patients were followed until articulation was normal during connected speech. At this point in time they underwent surgical correction of VPI as the other 14 patients. Success rate for correcting VPI after the operation was not significantly different for both groups. Furthermore, total time of ST was not significantly different for both groups. It is concluded that normalization of nasal resonance before articulation is corrected during connected speech does not seem to reduce total time of ST necessary to completely correct CA in cleft palate patients.

Videonasopharyngoscopy in patients with 22q11.2 deletion syndrome (Shprintzen syndrome).

INTRODUCTION: Velo-cardio-facial syndrome (VCFS) (also known as DiGeorge sequence, conotruncal anomaly face syndrome, 22q11.2 deletion syndrome among other labels) is now recognized as the most common syndrome associated with cleft palate and velopharyngeal insufficiency. VCFS has been associated with medially positioned internal carotid arteries. This anomaly has been associated with obvious posterior pharyngeal pulsations seen on videonasopharyngoscopy. The purpose of this paper is to study the role of videonasopharyngoscopy for the evaluation of patients with VCFS and submucous cleft palate. MATERIALS AND METHODS: Twenty patients with submucous cleft palate, velopharyngeal insufficiency, and 22q11.2 deletion as demonstrated by fluorescence in situ hybridization (FISH) were studied. Also, 20 patients with submucous cleft palate, and without abnormalities in the FISH procedure, were studied as controls. All patients from both groups underwent videonasopharyngoscopy. A double-blind procedure was utilized whereby all videonasopharyngoscopies were independently revised by the two examiners. RESULTS: Both examiners coincided that 17 patients with VCFS demonstrated obvious posterior pharyngeal pulsations seen on videonasopharyngoscopy. In contrast, both examiners agreed that none of the patients from the control group showed posterior pharyngeal pulsations. CONCLUSIONS: Videonasopharyngoscopy seems to be a safe and reliable procedure for evaluating patients with VCFS. The observations of posterior pharyngeal wall pulsations on videonasopharyngoscopy should alert clinicians to the diagnosis of VCFS. Also, the findings of videonasopharyngoscopy can be useful for preventing the risk of damage to the carotid arteries during velopharyngeal surgery. This indicates another important role of videonasopharyngoscopy in the preoperative assessment of children for palatopharyngoplasty.

Active participation of mothers during speech therapy improved language development of children with cleft palate.

Whole language intervention uses the principles of natural language learning, which consider language not as an independent system but as a system intimately related to other cognitive and social abilities. This paper compares the outcome of speech therapy given in different settings to two groups of children with cleft palate. Those in the first group were treated by the speech pathologist alone (control group), whereas those in the second group were treated by the speech pathologist but were also accompanied by their mothers (experimental group). The purpose of this study was to find out if including the mother as an active participant in speech therapy sessions would improve the language development of children with cleft palate who also had additional language delays. Both groups were evaluated before and after treatment to evaluate the advance of each group. The patients accompanied by their mothers had significantly better language skills compared with patients treated without their mothers. The results support the statement that language development is related to mother-child mode of daily life interaction in children with cleft palate.

[Extrinsic stenosis of the ureter. Our caseload and review of the literature]. / Estenosis extrínseca de uréter. Nuestra casuística y revisión de la literatura.

Obstructive uropathy is the common presentation course for various processes with an origin either intraluminar, parietal or extraluminar. A retrospective analysis of 41 cases of extrinsically originated obstructive uropathy seen in our Urology Unit from 1976 to 1991 was carried out. The cases were divided in three groups following an exclusively etiological criterion: 21.9% (9 patients) corresponded to primary retroperitoneal fibrosis; 51.2% (21 patients) to tumoral ureteral obstruction; and 26.8% (11 patients) to non-tumoral processes. For each division established, the features of clinical presentation, performance of the various diagnostic procedures used, and different therapy approaches are described also including a review on the current literature.

[Urethral diverticulum in women. Echographic diagnosis]. / Divertículos uretrales femeninos. Diagnóstico por ecografía.

Review of clinical, radiological and ecographical data observed in 11 cases of diverticulum of urethra in women. Mictional cystourethrography was performed to all patients and acography through suprapubic route to 7 of them. The results from the radiological study and ecography findings are discussed; also the differential diagnosis with other masses in the same location.

[Nephrogenic adenoma in urethral diverticulum in women]. / Adenoma nefrogénico en divertículo uretral femenino.

Nephrogenic adenoma is a benign metaplasic lesion of uncertain aetiology. The tenth case of this curious entity in a diverticulum of urethra in women is presented here. The probable factors which intervene in its pathogenesis are discussed in this paper, including a short review of the literature.