Pediatric dysphonia: It's not about the nodules.

OBJECTIVE: Despite the fact that vocal nodules are the most common cause of chronic dysphonia in children, uncertainty and lack of consensus complicates practically every diagnostic and management decision. Selecting an optimal staging system is fundamental to understanding a disease process, mandatory for uniform reporting, and crucial to predicting natural history and treatment outcomes. The ideal prognostic model for vocal nodules is under intense debate. The purpose of this study was to analyze the predictive power of vocal nodule grade to severity of voice metrics in children. METHODS: Seventy-nine patients diagnosed with vocal cord nodules between 2006 and 2012 were drawn from UPMC Children's Hospital of Pittsburgh Voice, Resonance and Swallowing Center Research Registry. Subject age at time of diagnosis, nodule grade, relevant co-morbidities, scores on The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), parent-reported Pediatric Voice Handicap Index (pVHI), the phonotraumatic behaviors profile, habitual speaking pitch fundamental frequencies, pitch range, volume intensity, and s/z ratio were recorded and compiled into a de-identified database for analysis. RESULTS: Based on the Kruskal-Wallis H Test, there was no statistically significant correlation between nodule grade and total pitch range (p = .21), s/z ratio (p = .50), volume intensity (p = .33), overall CAPE-V Scores (p = .15), or pVHI Scores (p = .29). Chi-squared tests also revealed no significant associations between nodule grade and abnormality in habitual speaking pitch (p = .14 for fundamental frequency while sustaining a vowel sound, p = .37 for fundamental frequency while speaking structured tasks i.e. counting, or p = .76 while speaking in conversation). CONCLUSION: The current "gold-standard" for grading vocal nodule size suggests that the nodules themselves are not driving the standard dysphonic metrics that are most commonly collected and monitored in such children. This outcome is consistent with other studies reporting similar findings and was expected based on the inconsistencies in the reported literature to date. By extension, the conventional wisdom of avoiding surgical treatment of vocal nodules in children seems prudent as there is little evidence to suggest that the nodules themselves are "driving" the severity of the dysphonia. Ultimately identifying the true "drivers" of dysphonia in children will suggest alternative therapies that are more specific and directed to the pathophysiology. Most pediatric voice care professionals will welcome such discoveries as those in the front line of patient care are often rendered helpless and frustrated.

Diagnosis and treatment of Gardner syndrome with gastric polyposis: a case report and review of the literature.

Gardner syndrome (GS) is an autosomal dominant disease characterized by the presence of colonic polyposis, osteoma and soft tissue tumors. It is regarded as a clinical subgroup of familial adenomatous polyposis (FAP) and may present at any age from 2 mo to 70 years with a variety of symptoms, either colonic or extracolonic. We present a case of a 23-year-old female patient with GS who presented with gastric polyposis and was successively treated with restorative proctocolectomy in combination with ileal pouch anal anastomosis (RPC/ IPAA), ileostomy, ileostomy closure operation, snare polypectomy during 8 mo. After operation, the patient took oral traditional Chinese medicine pills made of Fructus mume and Bombyx batryticatu for about 6 mo. The innutrition and anaemia of this patient were gradually improved. Gastroscopy showed that the remnant gastric polypi gradually decreased and finally disappeared 19 mo after the first operation. The patient had 2-3 times of solid stool per day at the time we wrote this paper.

Hyperplastic polyps of the gastric antrum in patients with gastrointestinal blood loss.

The significance of hyperplastic polyps of the gastric antrum in anemic patients with suspected gastrointestinal bleeding has not been determined. The aim of this study is to evaluate the prevalence and prognosis of such polyps in this patient group. Clinical records of patients referred to our endoscopy lab from November 1999 to February 2003 for the evaluation of iron deficiency anemia or suspected gastrointestinal bleeding were reviewed. There were 987 patients. Fourteen patients (1.4%) had hyperplastic polyps in the gastric antrum. Five of the patients reported melena, but the rest were asymptomatic. Multiple antral polyps were present in seven cases. The largest polyp measured 5.0 cm. Helicobacter pylori infection was present in one patient. All patients were anemic and nine had documented iron deficiency. No follow-up information was available in four patients. Hyperplastic polyps of the gastric antrum are a rare but significant cause of gastrointestinal blood loss in older patients. Removal of the polyps using endoscopic or surgical methods may be required for resolution of the blood loss along with iron supplementation. Gastroenterologists should be aware that hyperplastic polyps of the gastric antrum might result in gastrointestinal blood loss and iron deficiency anemia.

Voice disorders and gastroesophageal reflux.

Gastroesophageal reflux (GER) can cause serious voice problems and laryngopharyngeal disorders influencing the patient's quality of life. Forty-three patients with suspected laryngopharyngeal reflux (LPR) were included into a prospective study. The diagnosis was made on the basis of the patient's history, the videoendolaryngoscopy, the oesophago-gastroscopy and the biopsy of the oesophageal mucosa. All the LPR patients were treated with esomeprasol for eight weeks. An acoustic analysis of the vowel /a/ samples was performed in the LPR group before and after the treatment. Thirty-six patients with vocal fold polyps served as the control group for a subjective estimation of the voice problems. All the patients from both groups subjectively evaluated their voice problems using the Voice Handicap Index (VHI) questionnaire. The results of VHI showed that the severity of the voice problems of the patients with LPR could be compared to that experienced by the patients with vocal fold polyps. Videoendolaryngoscopy and history proved LPR in all 43 patients. Oesophago-gastroscopy combined with the histopathological examination of the oesophageal biopsy specimens detected signs of possible GER in 38 patients (88%). The results of the videoendolaryngoscopy combined with a subjective and objective voice assessment, performed before and after treatment with a proton-pump inhibitor, showed a significant improvement in most of the studied parameters by the end of the therapy. In the diagnostics of LPR, the patient's history and videoendolaryngoscopy demonstrated to be superior to oesophago-gastroscopy. Videoendolaryngoscopic assessment of the laryngeal mucosa, and oesophago-gastroscopy supplemented with a biopsy of the oesophageal mucosa, showed to be a convenient diagnostic method when GER and LPR were suspected. Esomeprasol proved to be very effective in the treatment of LPR. LPR should not be overlooked in the treatment of dysphonic patients.

Six thousand office diagnostic-operative hysteroscopies.

OBJECTIVE: To compare CO(2) and normal saline as distention media in office diagnostic hysteroscopy. METHODS: The outcome of more than 6000 office hysteroscopies was analyzed. We used carbon dioxide or saline as distension medium. Minor hysteroscopic techniques were performed when indicated. RESULTS: The major indication was abnormal uterine bleeding (45%). Satisfactory hysteroscopy was achieved in 92. 4% with CO(2) and in 98.3% with saline (P<0.05). Local anesthesia was used in 54 patients (1.5%) with CO(2) and in three patients (0. 1%) with saline (P<0.001). Four hundred and two women (16.3%) underwent hysteroscopic procedures under saline hysteroscopy. Endometrial polyps were removed in 281 patients, 75 IUDs were removed, 14 fibroids were extracted, uterine septa were excised in 11 cases and mild and moderate adhesions were transected in 21 patients. CONCLUSION: Saline office diagnostic hysteroscopy offers at least all the advantages of the CO(2) hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.

Tiflitis aguda: a propósito de un caso / Acute typhlitis: a case report

Se presenta un caso clínico de un paciente varón de 51 años que ingresó en nuestro hospital por presentar rectorragia. En el enema opaco se apreció una imagen de defecto de repleción en el ciego y en la colonoscopia una masa cecal necrosada que posteriormente expulsó con la defecación, siendo el resultado histopatológico de necrosis. Se decidió realizar una laparotomía exploradora encontrando como hallazgos significativos la inflamación de todo el ciego y del apéndice, así como la escara de implantación del pólipo expulsado y una masa submucosa paraapendicular, por lo cual se continuó la intervención con una hemicolectomía derecha. El diagnóstico de anatomía patológica fue de tiflitis aguda, una rara enfermedad cecal de la cual comentaremos algunos aspectos (AU)

La radiografía simple de abdomen previa al enema opaco: ¿es exacta?, ¿es eficaz?, ¿es necesaria? / Plain abdominal radiography prior to barium enema: is it accurate? is it effective? is it necessary?

Objetivo: Valorar la eficacia de la radiografía simple de abdomen previa al enema opaco como sistema de evaluación de la limpieza intestinal.Material y métodos: Estudio observacional, transversal, unicéntrico, no controlado, abierto, fase IV, en 150 voluntarios a los que se les realizó una radiografía simple de abdomen y un enema opaco ambulatoriamente. En ambas exploraciones se valoró la limpieza intestinal como deseable o insuficiente (ausencia o presencia de restos fecales significativos que podrían dificultar la exclusión de lesiones polipoideas con diámetro 1 cm). Se determinó si la radiografía simple predijo correcta o incorrectamente la limpieza deseable y la insuficiente, utilizando como elemento de referencia la valoración en el enema opaco.Sobre la base de estos datos se calcularon la sensibilidad, la especificidad y los valores predictivos de la radiografía simple.Resultados: La radiografía simple de abdomen predijo el grado de limpieza intestinal con una sensibilidad de 96,22 por ciento, una especificidad de 20,45 por ciento, una tasa de falsos negativos de 3,77 por ciento, una tasa de falsos positivos de 79,54 por ciento, un valor predictivo negativo de 69,23 por ciento, un valor predictivo positivo de 74,45 por ciento, y un valor predictivo global (o exactitud predictiva) de 74 por ciento.Conclusiones: La radiografía simple de abdomen previa al enema opaco valora la limpieza intestinal de forma inexacta y poco efectiva (AU)

[Ultrasonic ethmoidotomy combined with intracavitary magnetotherapy in chronic polypous ethmoiditis]. / Ul'trazvukovaia étmoidotomiia v sochetanii s vnutripolostnoi magnitoterapiei pri khronicheskom polipoznom étmoidite.

The efficacy of ultrasonic ethmoidectomy combined with magnetic therapy was investigated in 90 patients. Ultrasonic ethmoidectomy was applied with the help of a LORA system consisting of a generator and an acoustic unit connected to a waveguide with a spoon-shaped end (44 Hz frequency and 35-40 microns amplitude). Under visual control the ultrasonic spoon was inserted into the meatus nasi medius, and the injured medial, superior and some anterior cells of the ethmoidal bone were opened. Bone trabecules of the cells were removed together with the polypous mucous membrane and polyps, by moving the concave surface forwards and keeping the long axis of the bent portion of the spoon in the vertical position. Follow-up of the treated patients during 6 months to 4 years revealed the absence of polyps in 79.7%. Repeated application of this treatment in the case of severe recurrent forms of polypous ethmoiditis improved the therapeutic efficacy.

Early detection of colonic neoplasia in patients at high risk.

An abnormal zone of DNA synthesis at the surface and upper portion of colonic crypts has been thought to be related to future adenomatous polyp development and to express a regulatory defect in the mechanism that normally terminates synthesis in the upper third. As part of a screening program for early colon cancer detection, patients over 40 years of age found to have occult blood in their stool (Ho+) are evaluated by barium enema and colonscopy as well as isotopic incorporation studies of biopsy and lavage specimens. This proliferative abnormality occurred most frequently among patients with an adenoma or adenocarcinoma although the frequency varied among simultaneous biopsies from the same patient. Specimens from Ho+ patients with a tumor often contained small areas of focal atypism in the biopsy or fragments of atypical epithelial cells in the lavage sample. A small group of Ho+ patients in whom no overt neoplasm could be detected also demonstrated surface-labeled epithelial cells with morphological alteration of these cells. Based on the microscopic findings presented, continued surveillance of these patients is suggested, as well as extension of these studies to include other high risk groups.