A randomized, controlled trial of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome.

OBJECTIVE: We carried out a prospective, randomized, controlled trial to clarify the effect of tonsillectomy on the clinical course of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. STUDY DESIGN: Twenty-six consecutive children (mean age 4.1 years) with at least 5 PFAPA attacks were recruited from 3 tertiary care pediatric hospitals during 1999-2003 and randomly allocated to tonsillectomy or follow-up alone. They were all followed up with symptom diaries for 12 months. Tonsillectomy was allowed after 6 months in the control group if the attacks recurred. RESULTS: Six months after randomization all 14 children in the tonsillectomy group and 6/12 children in the control group (50%) were free of symptoms (difference 50%, 95% confidence interval 23% to 75%, P < .001). Tonsillectomy was performed on 5/6 of the patients in the control group who still had symptoms after 6 months. The remaining unoperated child in the control group had recurrences of the fever episodes throughout the follow-up, but the symptoms became less severe, and the parents did not choose tonsillectomy. CONCLUSION: Tonsillectomy appeared to be effective for treating PFAPA syndrome. The fever episodes ceased without any intervention in half of the control subjects. We conclude that although the mechanisms behind this syndrome are unknown, tonsillectomy can be offered as an effective intervention for children with PFAPA.

Recurrent otitis media during infancy and linguistic skills at the age of nine years.

OBJECTIVE: To assess the effects of early recurrent otitis media on linguistic development in children. We especially wanted to determine the possible significant consequences of early recurrent otitis media at school age. METHODS: We collected data retrospectively on recurrent otitis media episodes from the parents of 394 children in 18 school classes selected at random in a middle-sized city in Finland. Auditory comprehension was tested with a subtest of the Illinois Test of Psycholinguistic Ability, picture vocabulary with the Peabody Picture Vocabulary Test (revised test version), morphologic competence with a Finnish Morphological Test and reading comprehension with a test designed for this purpose. RESULTS: Children with more than four otitis episodes before the age of 3 years performed less well in the reading comprehension test (P = 0.01 to 0.02) than children with fewer otitis media episodes. Multiple regression analysis adjusted for the confounding variables showed early otitis media to be associated with impaired reading comprehension test scores (regression coefficient -0.1245, 95% confidence interval -0.2245 to -0.0245, P = 0.01), which also correlated significantly with the teachers' evaluation of the student's reading comprehension (Spearman rank correlation r = 0.5, P < 0.01). Otitis episodes after the age of 3 years were not associated with abnormal test results. CONCLUSION: Middle ear disease in infancy had a significant adverse effect on reading comprehension as late as 9 years of age, even among children whose acute episodes were effectively treated.

Lack of specific symptomatology in children with acute otitis media.

Although the symptoms of the acutely ill child are important both in the diagnosis and follow-up of acute otitis media (AOM), data about them are quite limited. We carried out a prospective survey by collecting information on 354 consecutive children visiting a pediatrician, otolaryngologist or general practitioner because of any kind of acute symptoms to compare symptoms of children with acute otitis media with those of children with other acute infectious diseases. The symptoms and signs observed at home were recorded by the parents before the visit and the findings in the physical examination were recorded later by the physician. AOM was diagnosed in 191 patients (54.0%). The most important symptoms increasing the likelihood of AOM significantly were ear-related symptoms, such as earache (relative risk (RR) 5.4; P < 0.001), rubbing of the ear (RR 5.0; P < 0.001) and feeling of blocked ear (RR 4.5; P < 0.05). However, only 67.7% of children younger than 2 years of age with AOM had any ear-related symptoms. The children with tympanostomy tubes had earache (47.8%) and rubbing of the ear (58.8%) of the same magnitude as did children without tubes. Rhinitis increased the likelihood of AOM (RR 2.3; P < 0.001) as did excessive crying in children older than 2 years of age (RR 3.0; P < 0.001). Fever, earache or excessive crying was present in 90.1% of patients with AOM but also in 72.4% of patients without AOM.(ABSTRACT TRUNCATED AT 250 WORDS)

Autologous and homologous fibrinogen sealants: adhesive strength.

The adhesive strength of autologous fibrinogen sealants prepared from the individual patient's blood with the help of ammonium sulphate or polyethylene glycol was compared to that of a homologous commercial fibrinogen sealant. The concentration of the fibrinogen harvested by each method was measured. The bonding power measurements were carried out by gluing pieces of human dura, rat skin, or cotton cloth together. The commercial fibrinogen sealant yielded the highest concentration of fibrinogen and also proved to be the strongest of the glues tested. The PEG glue was better than the AS glue. Humidity did not have a significant influence on adhesive strength, nor did deep-freezing worsen the properties of the fibrinogen sealants. In addition to the commercial products, the self-made fibrinogen glues, especially the PEG glue, were also strong enough for otolaryngological use.

General anesthesia with and without nitrous oxide (N2O) and the weight of middle ear effusion in children undergoing adenoidectomy and tympanostomy.

This study was designed to explore the effect of nitrous oxide (N2O) on the amount of middle ear effusion. Seventy-six children referred for adenoidectomy or tympanostomy tube placement were divided into two groups in the basis of the method of anesthesia. One group of 39 children was ventilated with a mixture of 30% oxygen and 70% nitrous oxide, while the other group of 37 patients was ventilated with a mixture of oxygen and air. The amounts of middle ear effusion obtained in myringotomy were weighed and compared between these groups. Preoperative and perioperative tympanograms were performed. Ventilation with nitrous oxide caused a distinct rise in middle ear pressure. The amount of the middle ear effusion, however, remained the same in the two groups. It is concluded that the operating surgeon can rely on the myringotomy finding even when nitrous oxide anesthesia is used.

Preoperative embolization in the management of neck paragangliomas.

Surgery of neck paragangliomas carries inherent risks of excessive blood loss and cranial nerve injury. Preoperative embolization has been used to lessen the morbidity of surgery. We sought to characterize our experience with preoperative embolization by evaluating safety, efficacy, and surgical data. During a period of 22 years (1974 to 1996), 19 consecutive patients with 27 histopathologically confirmed neck paragangliomas were surgically treated at the Oulu University Hospital. All patients underwent preoperative arteriography and 17 patients had cervical ultrasonography (US). Eleven patients with 15 tumors were operated on without embolization and nine patients with 12 tumors were preoperatively embolized with 150- to 250-microm polyvinyl alcohol (PVA) particles. The mean blood loss during surgery in the nonembolized group was 1374 mL (range, 100 to 4500 mL) and the mean operation time was 4 hours and 48 minutes (range, 1.5 to 9 hours). In the embolized group the mean blood loss was significantly less (588 mL; range, 100 to 1800 mL; P = 0.04) and the mean operation time shorter (3 hours 24 minutes; range, 2 to 5 hours; P = 0.05). No embolic complications were recorded after the embolization. We conclude that preoperative embolization of neck paragangliomas 3 cm or greater in diameter with PVA particles is safe. Embolization to minimize operative bleeding facilitates surgery, shortens the operation time, and lessens the surgical risks.

Tularemia in otolaryngologic practice. An analysis of 127 cases.

Ulceroglandular, glandular, and oropharyngeal forms of tularemia may occur in otolaryngologic patients, frequently causing diagnostic difficulties. A retrospective analysis of 127 patients with serologically proved tularemia in the head and neck region is presented with special reference to diagnostic difficulties. Short case reports of six patients are included. Difficulties seemed to appear especially in the diagnosis of glandular tularemia. Oropharyngeal tularemia is easily confused with infectious mononucleosis. A high degree of suspicion of tularemia is recommended in endemic areas.

A nation-wide, population-based survey of otitis media and school achievement.

The purpose of the study was to evaluate whether there is an association between early recurrent otitis media and later school achievement. A nation-wide, population-based random cluster sampling of 1708 children in 119 school classes was performed throughout Finland. Data were collected with questionnaires sent to the parents and teachers of the children. Teachers evaluated each child's performance at school, and the association between the number of episodes of early otitis media and school achievement was determined. Recurrent otitis media episodes before the age of 3 years associated significantly with lower performance in mathematical skills (risk ratios [RR] 1.2-1.4, 95% confidence intervals [95% CI] 1.0-1.7, P-values 0.04-0.02) and classroom concentration (RR 1.4, 95% CI 1.1-1.8, P-value 0.02) among the girls. The boys with recurrent otitis episodes performed more poorly in reading (RR 1.3, 95%, CI 1.0-1.6, P-value 0.05) and oral performance (RR 1.2, 95% CI 1.1-1.4, P-value 0.01). No association between otitis episodes after the age of 3 years and school achievement was found. Our findings suggest that recurrent otitis media episodes before the age of 3 years have adverse long-term consequences even when treated actively. Even though the risk ratios were low our finding is important because recurrent otitis media is a common problem during infancy and school achievement has many practical influences on a child's future.

Pneumococcal bacteriology after pneumococcal otitis media with special reference to pneumococcal antigens.

Fifty-four ears with evidence of pneumococcus (Pn) in the first acute otitis media (AOM) in 38 infants and with prolongation or recurrence of the MEF during the follow-up were observed for 7-22 months for the presence of Pn by culture or of pneumococcal antigen (Pn-ag) by counterimmunoelectrophoresis or latex agglutination methods in their MEFs. During the first three 1-month observation periods, Pn and/or Pn-ags were detected in 24% to 9% of these ears, always of the initial type/group. Later on new Pn types/groups appeared also. In two of the 9 MEFs persisting for greater than or equal to 3 months, initial Pn-ag, with culturable Pn, was repeatedly found but not for longer than 5 months. Of the 12 ears resulting in secretory otitis media (SOM) only one showed initial Pn-ag (and Pn) in the MEF of SOM. Pneumococcal type/group pattern associated with prolongation or recurrence of infection did not differ from that of initial AOM. In another series of 151 SOM ears in 97 children, Pn-ags were detected in 7 MEFs. Four of them grew Pn, each of the corresponding group. Our studies suggest that the persistence of Pn-ags in the middle ear after AOM is limited and their occurrence in the MEFs of SOM is rare. Thus, the role of the persistence of Pn-ags in prolonged, recurrent or secretory otitis media seems questionable.

Streptococcus pneumoniae and Haemophilus influenzae in nasal cultures during acute otitis media.

Middle ear fluid (MEF) aspirates and nasal swabs of children with acute otitis media (N = 255, age 2-6 yrs) were cultured by standard bacteriological methods. In addition, counterimmunoelectrophoresis and latex agglutination were applied to detect pneumococcal polysaccharide antigens (Pn-ag) in MEF. When the nasal culture grew Streptococcus pneumoniae (Pn), Pn was also present in 49% (73/148) and Pn-ag in 64% of the MEF cultures. If Haemophilus influenzae (Hi) appeared in the nasal culture. Hi was present in 41% (25/61) of the MEFs. There was a negative correlation between the growth of Pn or Hi in the nasal culture and the presence of other bacteria in the MEF. However, in spite of these correlations the nasal culture was concluded not to be useful in predicting the MEF bacteria.

Secretory antibodies specific to Streptococcus pneumoniae, Haemophilus influenzae and Branhamella catarrhalis in middle ear effusion during acute otitis media.

The occurrence of specific secretory antibodies against the type-specific capsular polysaccharide of Streptococcus pneumoniae (Pn) and against the whole cell antigen of Haemophilus influenzae (Hi) and Branhamella catarrhalis (Br) were measured by the ELISA method in 211 middle ear effusion (MEE) samples of 85 children with acute otitis media (AOM) during the course of the disease. Antibodies against at least one of those bacteria were detected at the initial visit in 33.6% of the ears and later in 20%. All in all, such antibodies could be found in 50% of the ears during the follow-up. Pneumococcal secretory antibodies were found in 5 out of 116 ears only, anti-Hi antibodies in 52 and anti-Br antibodies in 42 ears. The specific secretory antibodies were detected against all these bacteria regardless of the bacterial etiology of the AOM attack in question. The AOM attack was prolonged more often if such antibodies were not found in the MEE sample taken at the initial visit. The appearance of such antibodies during the disease seemed to imply termination of the AOM episode in question. The conclusions of this study are that during an AOM attack a local production of antibodies in middle ear against the three most common bacteria. Pn, Hi and/or Br, causing AOM may be induced. The appearance of such antibodies in MEE seems to be beneficial for the resolution of AOM.

Risk factors affecting the occurrence of acute otitis media among 2-3-year-old urban children.

The factors affecting the occurrence and recurrence of acute otitis media (AOM) were studied among 471 2-3-year-old children in two cities in Finland. Of these children, 188 had experienced greater than or equal to 3 attacks of AOM, 76 had had 1-2 attacks and 207 no otitis attacks (= control group). The study showed that the risk of recurrent AOM was increased among those children attending day-care nurseries as well as among those who had several siblings. Proneness to rhinorrhea and exposure to passive smoking at home was associated with an increased risk of AOM, while prolonged breast-feeding (greater than 6 months) seemed to reduce it. No correlation was found between the risk of recurrent AOM and the place of residence or type of housing, the parental otitis history, or atopic diathesis of a child. Thus the study suggested that to protect a young child from AOM we should promote breast-feeding and home-care for babies as well as avoid smoking in the home.

Pneumococcal middle ear fluid antibodies after pneumococcal acute otitis media in infants.

Forty-one infants, who during their first (initial) acute otitis media (AOM) had culturable S. pneumoniae (Pn) in 57 middle ear fluids (MEFs) which prolonged or recurred during the follow-up, were observed for 7-15 months for the presence of Pn, Pn-antigens (Pn-ags) and initial-type/group Pn-antibodies (Pn-abs) in these MEFs. Initially, Pn-abs were found in only 3 MEFs. During the follow-up a total of 20 ears (35%) were, at various time-intervals, positive for Pn-abs; they belonged to all three major Ig-classes, but were often slight in quantity. Most regularly, and often with distinct positivity, Pn-abs were found to type 3, 9N and 14. Secretory abs were detected in 5 ears. Within one month after initial AOM, Pn-abs appeared in 9 of the 41 ears with MEF (22%); six of them cleared soon after that. MEFs with Pn-abs usually did not show initial-type Pn/Pn-ag, but new Pn/Pn-ag could later be simultaneously present in recurrent MEF. So, pneumococcal AOM may cause a local and/or systemically mediated immune response in the middle ear in infants. The response may protect the ear from homologous, but still be present in apparently non-homologous otitis media.

Incidence of acute otitis media.

The occurrence of acute otitis media was studied over a one-year period in a total population of 146822 persons living in different parts of Finland. Of these 146822 persons, 4583 experienced a total of 6518 otitis attacks giving an annual incidence rate of 4.44% (4.48% in males and 4.07% in females, P less than 0.001). Acute otitis media was strikingly concentrated in the youngest age groups, with the highest annual incidence rates, in the order of 50%, found in infants younger than 2 years. Half of all the episodes occurred before the age of 33 months. The relative risk of getting acute otitis media was about 200 times higher during the first 2 years of life than as an adult. The occurrence of otitic episodes followed seasonal variations, and in urban areas the incidence was significantly (P less than 0.001) higher than in the countryside.

Antibodies against Streptococcus pneumoniae, Haemophilus influenzae and Branhamella catarrhalis in middle ear effusion during early phase of acute otitis media.

Serum type (IgG, IgM and IgA-class) and secretory type antibodies specific to Streptococcus pneumoniae (Pn), Haemophilus influenzae (Hi) and Branhamella catarrhalis (Br) were measured by enzyme-linked immunosorbent assay (ELISA) in 46 serum and 114 middle ear effusion (MEE) samples from 85 children with acute otitis media (AOM). The samples were obtained within 12 h from the onset of the ear symptoms. Serum (but not secretory) type antibodies to the infecting Pn serotype were found in 24% of the MEE samples of the patients with Pn AOM and, correspondingly, serum and/or secretory type antibodies to Hi and Br were seen in 54% and 63% of the MEE samples of the patients with Hi or Br AOM, respectively. Moreover, antibodies against bacteria other than the causative one could also be found in the MEE. The occurrence of the serum type antibodies against these bacteria in the MEE was closely correlated with their serum levels. The findings of this study indicate that during the very early phase of AOM, the MEE contains both serum type antibodies originating from the serum, and secretory antibodies of middle ear origin. Among them there are antibodies specific to the three most common bacteria causing AOM (Pn, Hi, and Br) regardless of the bacterial etiology of the AOM attack in question.

Occurrences of antibodies against Streptococcus pneumoniae, Haemophilus influenzae and Branhamella catarrhalis in middle ear effusion and serum during the course of acute otitis media.

The occurrence of IgG, IgM and IgA class antibodies against a type-specific capsular polysaccharide of Streptococcus pneumoniae (Pn) and against a whole cell antigen of Haemophilus influenzae (Hi) and Branhamella catarrhalis (Br) was studied using the ELISA method on middle ear effusion (MEE) samples of 85 patients and paired serum samples of 40 patients during the course of acute otitis media (AOM). Although specific antibodies to all of these three bacteria appeared in MEE during the course of an AOM episode, antibodies against the infecting bacteria of that particular AOM episode were more often prominent. The antibodies were also detectable in the MEE without simultaneous presence in the serum. The middle ear infection was prolonged more often if specific antibodies to the infecting bacterium could not be detected in the MEE obtained at the beginning of the AOM attack. The present study indicates that AOM caused by Pn, Hi or Br may induce both a systemic and a local production of specific antibodies against the causative organisms during the course of otitis media. The occurrence of such antibodies in MEE seems to play a major role in the resolution of AOM.

Branhamella catarrhalis in acute otitis media.

A total of 5217 middle ear fluid (MEF) samples obtained from 1203 children with otitis media, aged 3 months to 6 years, were studied for the presence of Branhamella catarrhalis (Br) between Oct. 1977 and Sept. 1981. Br grew in 10.2% of 3497 MEFs of acute otitis media (AOM), with almost the same frequency in the very first and subsequent attacks. During the first 4 years of life the percentage did not vary much; among older children it seemed to decrease. The overall prevalence of Br in AOM did not change during the study period. Br alone grew in 72.4% of acute MEFs with Br; with other bacteria the respective figure was 82.9% (p less than 0.001). Acute attacks with bilateral Br were found in 22.8% of attacks with Br. In 1720 non-acute MEFs obtained at postacute control visits, Br was isolated in only 7.0%. The proportion of beta-lactamase-producing strains among the 2419 otitis-Br strains tested in two laboratories of the two study regions showed an increase from 27.1% and 21.1% in 1980 to 57.6% and 38.6% in 1983, respectively (p less than 0.001).

Haemophilus influenzae in acute otitis media.

We studied the occurrence of Haemophilus influenzae (Hi) in 2625 middle ear fluid (MEF) specimens obtained from 523 children with otitis media, aged 3 months to 6 years, between October 1977 and May 1979. In clinically acute cases 12.3% of the MEFs grew Hi; 6.3% (13/206) of the strains were of type b and 4.9% (10/206) were beta-lactamase producing. In the very first acute case of a child 8.0% (21/263) of the MEFs grew Hi, but in acute recurrences it was cultured in 17.0% (184/1082) (p less than 0.001). In non-acute persistent MEFs obtained during control visits Hi was found in no less than 21.7% (198/913); as many as 12.6% (25/198) of them were beta-lactamase producing. Both of these figures, but not the proportion of type b strains (8.6%), were significantly (p less than 0.001 and p less than 0.01, respectively) greater than in clinically acute MEFs. Hi was grown in 13.1% of the acute MEFs taken from children less than 4 years old, but in only 8.6% of the older children (p less than 0.05). The annual survey of all the 1816 Hi strains isolated from the MEFs of acute or subacute cases of otitis media in one laboratory in 1976-81 showed the proportion of beta-lactamase producing strains of all Hi strains to be gradually increasing from 8.0% (17/212) in 1976 to 15.2% (16/105) in 1981 (p less than 0.05).

Efficacy of pneumococcal vaccination against recurrent otitis media. Preliminary results of a field trial in Finland.

For this study, 781 children, and 3 to 83 months, after presenting with acute otitis media, were immunized with either 14-valent pneumococcal or Haemophilus influenzae type b capsular polysaccharide vaccine. The vaccines were tolerated well. Antibody responses to the 14 pneumococcal polysaccharide types, measured by radioimmunoassay, were fair to good and increased with age, with the exception of types 1, 6 and 12 to which the responses were generally poor. During the follow-up of 1-17 months, average 13 months, 45 vaccine type (except type 6) pneumococcal recurrences were met among 456 pneumococcal-vaccinated and 45 among 288 H. influenzae-vaccinated children, at least six months old (P < .05). The corresponding protective efficacy by the pneumococcal vaccine was 37%, for the first six months, 51% (P < .01). No protection by the pneumococcal vaccine was seen against group 6 pneumococci, nor among 19 infants under six months of age. Nonvaccine type pneumococcal ad H. influenzae recurrences did not significantly concentrate in either of the vaccination groups. Thus, it seems that parenteral immunization of children can reduce the recurrence rate of otitis media caused by pneumococci of types (except type 6) present in the vaccine.

Secretory IgA, secretory component and pathogen specific antibodies in the middle ear effusion during an attack of acute and secretory otitis media.

The total concentration of secretory IgA (SIgA) and secretory component (SC) as well as the occurrence of pathogen specific serum type (IgG, IgA and IgM) and secretory type antibodies against Streptococcus pneumoniae and Haemophilus influenzae in the middle ear effusion during an attack of otitis media were studied by using the ELISA method. The middle ear effusion samples were taken at 2 to 4 weeks' intervals from patients with recurrent acute otitis media (RAOM) or secretory otitis media (SOM). In the samples of the RAOM patients the SC/SIgA ratio was 2.2, while in the SOM samples the ratio was 13.6. Both serum and secretory type antibodies to the infecting bacteria could be detected in the middle ear effusions in both of the patient groups. The results of this study show that the middle ear can develop antigenic specific antibodies against the infecting bacteria. The increased production of SC seems to be related to the pathogenesis of SOM.