Standardization of CT depiction of cochlear implant insertion depth.

BACKGROUND AND PURPOSE: Imaging a cochlear implant with CT is challenging because of implant-induced artifacts, anatomic cochlear variations, and lack of standard terminology for cochlear anatomy. The purposes of this project were to determine whether the cochlear implant tip was more accurately located on oblique CT reformations than on standard images, to review radiology reports for accurate cochlear implant locations, and to assess agreement between an implant surgeon and neuroradiologist by using standardized cochlear anatomy terminology for cochlear implant depth. MATERIALS AND METHODS: In this retrospective study, a neuroradiologist and an implant surgeon independently viewed temporal bone CT images of 36 ears with cochlear implants. Direct axial images, standard coronal reformations, and oblique reformations parallel to the cochlea were compared to determine implant tip location, which was described by using a proposed standardized quadrant terminology. Implant locations were compared with the initial formal report generated by the original interpreting neuroradiologist. RESULTS: Thirty-six temporal bones with cochlear implants underwent CT interpretation for implant location. Interobserver agreement was similar when comparing cochlear implant tip location by using a quadrant nomenclature on axial and coronal images and on oblique reformations. Clinical radiology reports all were imprecise and ambiguous in describing the location of the cochlear implant tip. CONCLUSIONS: Accurate determination of insertion depth of the cochlear implant array can be determined by assessment of the implant tip on axial, coronal, and oblique CT images, but description of the tip location can be inaccurate due to lack of standardized terminology. We propose using a standardized terminology to communicate tip location by using the round window as the zero reference and quadrant numbering to describe cochlear turns. This results in improvement in radiology report accuracy and consistency regarding the cochlear implant insertion depth.

Pars flaccida retraction and mastoid size: relationship in clinically normal specimens.

BACKGROUND: The relationship of pars flaccida retraction with epitympanic aeration and mastoid size is ill-defined. Both pars flaccida retraction and small mastoid size are traits of nearly all clinical entities of otitis media. OBJECTIVES: To determine, in clinically normal specimens, the relationship of pars flaccida retraction with mastoid pneumatisation and epitympanic aeration. STUDY DESIGN: Post-mortem anatomical dissection of 41 bequeathed adult crania without clinical otitis. METHODS: Pars flaccida retractions were viewed with an operating microscope and judged using Sade's classification. Mastoid sizes were determined radiographically (by plain Law lateral images). Ten crania, five with the largest mastoids and five with the smallest mastoids, were studied by computed tomography. RESULTS: No specimen had a retraction worse than Sade grade two (i.e. retracted onto the neck of the malleus). Retractions were unrelated to the extent of mastoid pneumatisation. All epitympani were found to be normal on both anatomical dissection and computed tomography imaging. CONCLUSION: Pars flaccida retraction is probably related to prior, presumably transient, non-aeration of Prussak's space.

Heterotopic neuroglial tissue causing airway obstruction in the newborn.

BACKGROUND: Heterotopic neuroglial (brain) tissue is a rare cause of airway obstruction in newborns. Fewer than 30 cases have been reported in the English literature. Brain heterotopias can mimic more common congenital anomalies of the head and neck. OBJECTIVE: To review our experience in the diagnosis and treatment of children with heterotopic pharyngeal neuroglial tissue. DESIGN: Case series. SETTING: Tertiary care children's hospital. PATIENTS: Four newborns with airway obstruction caused by heterotopic neuroglial tissue. RESULTS: All patients were infants (3 full-term girls and a 32 weeks' gestation boy) who had airway obstruction in the newborn period. All patients underwent preoperative computed tomography and magnetic resonance imaging, which revealed a heterogeneous mass involving the pharynx, neck, and parapharyngeal space. Bony deformities of the skull base and mandible were present in all patients, although intracranial connection was absent. Multiple surgical procedures were performed in all 4 patients. Tracheotomy was performed in 2 patients, gastrostomy tube placement was required in 3, and a nasopharyngeal tube was used in 1. Combined cervicofacial and transoral approaches were used for resection, preserving vital structures. Histopathologic evaluation revealed mature glial tissue and choroid plexus-like structures. CONCLUSIONS: Heterotopic neuroglial tissue must be considered in the differential diagnosis of airway obstruction in the newborn. Management is surgical resection, with attention to vital structures and function-analogous to surgery for lymphangioma. Multiple surgical procedures might be necessary in the treatment of these patients.

Safety of neck rotation for ear surgery in children with Down syndrome.

OBJECTIVE: Seek information about spinal cord safety for children with Down syndrome positioned for ear surgery. STUDY DESIGN: Prospective consecutive patients, each serving as his or her own control. METHODS: Somatosensory evoked potentials were recorded from 17 children who were undergoing elective otolaryngological surgery. None of the patients had neurological symptoms or physical examination findings suggesting cervical spinal cord embarrassment. Specifically, muscle tone was normal or mildly reduced globally, consistent with Down syndrome, and deep tendon reflexes were normal and not appreciably different in the upper and lower extremities. On plain lateral radiographs obtained in the neutral, flexed, and extended positions, the patients' cervical spines were normal. RESULTS: When the anesthetized children had their necks placed in either right or left 60 degrees rotation, no significant change in somatosensory latency or amplitude was found. With more than 99.999% certainty, neurologically intact children with Down syndrome with normal plain cervical spine radiographs were not exposed to extra risks by 60 degrees neck rotation during surgery. CONCLUSION: Patients with Down syndrome who are neurologically intact and who have normal lateral neck radiographs do not appear at great risk with neck rotation.

Incidence and prevalence of recurrent respiratory papillomatosis among children in Atlanta and Seattle.

The incidence and prevalence of recurrent respiratory papillomatosis (RRP) for children aged <18 years were estimated in 2 US cities, Atlanta and Seattle, in 1996. All otolaryngologists in a 24-county area in metropolitan Atlanta (101 physicians) and an 8-county area in metropolitan Seattle (139 physicians) agreed to participate in the study. Medical record chart abstraction was performed only for children with documented current residence in the study area (21 patients in Atlanta and 14 patients in Seattle). The incidence rate for juvenile RRP was 1.11/100,000 population in Atlanta and 0.36/100, 000 in Seattle. The prevalence rate was 2.59/100,000 population in Atlanta and 1.69/100,000 in Seattle. In neither city did prevalences differ significantly when stratified by sex or race. Extrapolation of these estimates to the US population suggests that 80-1500 incident cases and 700-3000 prevalent cases of juvenile RRP will occur in the United States during 1999.

Child and family factors associated with deaf children's success in auditory-verbal therapy.

OBJECTIVES: To identify the general demographics of children who had Auditory-Verbal therapy and to identify child and family factors associated with differences between those children for whom Auditory-Verbal therapy led to success and those for whom it did not. SETTING: Private tertiary care facility. POPULATION: Children who had hearing losses ranging from mild to profound. INTERVENTION: Auditory-Verbal therapy, a therapeutic intervention designed to teach parents to educate their young deaf and hearing-impaired children to use residual hearing and to speak, was used. MAIN OUTCOME MEASURES: Clinic files, parent questionnaires, and parent report of current success were used to determine efficacy of treatment. RESULTS: Fifty-seven percent of the clients who remained in this program for over 1 year were fully integrated into regular education, with no services from a teacher of the deaf. The population was affluent, with more females than expected. Those who left dissatisfied tended to be males with greater degrees of hearing loss who left the program soon after 1 year. CONCLUSIONS: Auditory-Verbal therapy provides successful intervention to students with a particular set of demographic characteristics.

Paranasal sinus development and choanal atresia.

BACKGROUND: Although the determinates of paranasal sinus development and sinusitis are not well defined, a candidate factor is blockage of the choana. HYPOTHESIS: Maxillary sinuses ipsilateral to unilateral choanal atresia are comparatively small and have more evidence of sinusitis than do the contralateral sinuses. DESIGN: Retrospective. SETTING: Children's hospitals. PATIENTS: Sixteen nonsyndomic children with isolated unilateral congenital choanal atresia. MAIN OUTCOME MEASURES: Determination of maxillary sinus volumes and mucoperiosteal thickening on preoperative computed tomograms. RESULTS: Maxillary sinuses ipsilateral to unilateral choanal atresia have slightly larger volumes than, and mucoperiosteal thickening that is similar to, the contralateral sinuses. CONCLUSION: These data suggest that maxillary sinus development and sinusitis are independent of posterior nasal ventilation and drainage.

Developmental changes in aural acoustic admittance measurements.

Tympanometry is a clinical measurement routinely included in the assessment of middle ear function. Despite its widespread use, however, fundamental questions remain regarding the need for age-dependent normative data. This study examines normal developmental changes associated with four tympanometric measurements: (1) ear canal volume, (2) peak compensated acoustic admittance, (3) tympanometric width, and (4) tympanometric peak pressure. Of 221 infants and children, aged 6 months to 5 years, enrolled in this study, 99 met the criteria for normal middle ear function as determined via pneumatic tympanoscopy by an experienced pediatric otolaryngologist, and data analysis was confined to those 99 volunteers. Analysis of variance revealed statistically significant main effects showing increases in ear canal volume and peak compensated acoustic admittance and decreases in tympanometric width as age increased. Statistically significant differences were not achieved for tympanometric peak pressure. Although statistically significant differences were found, the differences were small and of questionable clinical significance.

Gender and intra-observer agreement about laryngoscopy of papilloma.

BACKGROUND: The gender of the observer may bias data. OBJECTIVE: Compare the intra-observer agreements of male and female pediatric otolaryngologists about videotaped images of laryngeal papilloma. DESIGN: Five male and six female pediatric otolaryngologists independently viewed videotapes of ten children undergoing treatment for laryngeal papilloma. Each of 12 anatomic sites was categorized as disease present, absent, or indeterminate. Each observer estimated the percent overall airway obstruction. 5-24 weeks later, each observer repeated his/her assessments. RESULTS: The mean intra-observer agreements for both male and female pediatric otolaryngologists were good, and identical (kappa 0.63; proportion of positive agreement 0.82; proportion of negative agreement 0.72). Females more frequently categorized a site as indeterminate. Males more frequently categorized a site oppositely on repeat assessment. The males' indeterminate/opposite ratio was less than that of the females' (P = 0.03). Intra-observer estimates of overall airway obstruction have wide variability: for male pediatric otolaryngologists, differences exceeding 30% are significant; for females, 40%. CONCLUSION: Male and female pediatric otolaryngologists had equally good and identical intra-observer kappa scores and proportions of positive and negative agreement. However, males used the indeterminate category less than did the females, and males more often gave an opposite categorization at the second viewing session. Estimates of overall airway obstruction have much intra-observer variability.

Resuscitation of the newborn with airway compromise.

Respiratory problems in the newborn period are a diagnostic and therapeutic challenge. The goal of expeditious airway establishment may not be straightforward. Familiarity with features of the normal and abnormal infant airway anatomy, physiology, as well as intubation equipment and alternatives to intubation is essential. A systemic approach provides clues that are helpful in the successful management of the neonate in respiratory distress.

What your colleagues think of tympanostomy tubes--28 years later.

OBJECTIVE: Assess the changing opinions of otolaryngologists about tympanostomy tubes, including indications, tube material and shape and size, placement sites, and complications. STUDY DESIGN: Cross-sectional survey, compared to the same survey done 28 years earlier. METHODS: Questionnaires mailed to the 441 active fellows and 86 candidates of the Triological Society. Response rate 69.3%. RESULTS: The preference for polyethylene has decreased from 75% to 13% of respondents. Preferred insertion sites are more anterior. The proportion of respondents who have seen a permanent perforation as a consequence has increased from 26% to 93%. The proportion of respondents who have seen a tube-attributable cholesteatoma has increased from 8% to 38%. The average tube duration has increased from 4 months to 18 months. Teflon and Silastic are now the materials most often used. As 28 years earlier, about 19% of patients get a subsequent tympanostomy tube. Anesthetics most commonly used now are general or topical phenol. CONCLUSION: The consensus on several aspects of tympanostomy tubes has changed during 28 years. Controversy continues about the indications for using tubes. Although not a not cure-all for otitis media, tympanostomy tubes have proved useful.

Multicentric infantile myofibromatosis.

Infantile myofibromatosis (IM) is a rare tumor of infancy and childhood, typically presenting as a firm, nodular mass involving soft tissue, bone or viscera. Approximately one-third of cases involve the head and neck. These tumors can be solitary or multicentric. Biopsy reveals tumor cells that resemble myofibroblasts. Spontaneous regression may occur. A high degree of suspicion is necessary to differentiate this entity from other more aggressive processes histiocytosis, fibrosarcoma, rhabdomyosarcoma. We describe the case of a male infant with multicentric myofibromatosis, presenting with multiple thoraco-abdominal subcutaneous nodules and lytic mass lesions of the temporal bone and calvarium. The characteristic clinical, radiologic and histopathologic features of this process are reviewed along with diagnostic and therapeutic options.

Cranial anatomy and otitis media: a cadaver study.

BACKGROUND: The eustachian tube is regarded as an etiologic factor for otitis media. Although anatomic cranial differences also are suggested as a factor, few scientifically rigorous studies of these differences have been reported. MATERIALS: Thirty-five adult cadaveric crania were examined. METHODS: Multiple (32) linear and angular cranial measurements were performed. For evidence of prior otitis media, there were two indicators: small mastoid pneumatization seen radiographically and abnormal tympanic membranes at photographic tympanoscopy. Each measurement and each categorization were done twice, independently. The average of the two measurements was used for each comparison. Only consistent categorizations were used for comparison. RESULTS: Relatively short eustachian tubes were found to associate with both indicators of childhood otitis: r=0.39, p < 0.05. A relatively short distance from midsella turcica to staphylion, and short distance between the ears, also were associated with otitis. No angular relation of either the bony or cartilaginous eustachian tube correlated with the otitis indicators. Bilateral symmetry of pneumatization and tympanoscopic categorization, and of the various linear and angular measurements, was apparent. CONCLUSIONS: The association of otitis media with some cranial base anatomic differences is endorsed. Comparatively long eustachian tubes, long distance from midsella to staphylion, and large interear length correlate with indicators of healthy middle ears.

Tracheostomy decannulation in children: approaches and techniques.

Various approaches and techniques are used in discontinuing tracheostomy in children. The variability in the use of resources is considerable. The objective of this study was to assess decannulation in children attended in a university-affiliated children's hospital. A retrospective analysis was made of the medical records of patients who had both tracheostomy (n = 177) and decannulation (n = 30) from 1985 to 1994. Tracheostomies, placed at a mean age of 38 months, were discontinued (on the average) 22 months later. Most children underwent airway endoscopy in the operating room in preparation for decannulation. Twenty-four children had downsizing, then capping of the tracheostomy as a functional trial. Six children underwent staged laryngotracheoplasty before decannulation. Two children had decannulation as part of a single-stage laryngotracheoplasty. Attention to at least one comorbid factor (e.g., pulmonary, neurologic, or cardiac disease) was important in the decannulation of each patient in this series. The individualization of tracheostomy decannulation is necessary for children.