Efficacy and safety of a single daily dose of gentamicin in hospitalized Indian children: a quasi-randomized trial.

OBJECTIVES: To compare the clinical efficacy, pharmacokinetic profiles and safety of once-daily dosing (ODD) and multiple daily dosing (MDD) of gentamicin in hospitalized Indian children. PATIENTS AND METHODS: Four hundred children admitted to our hospital were studied prospectively. The patients were randomized to ODD or MDD groups alternately. The primary outcomes were: (i) a good clinical outcome, as defined; and (ii) occurrence of side effects, if any. Clinical efficacy was determined by comparing the proportion of patients with a favourable response between the two groups, while pharmacokinetic profile was assessed by comparing the peak and trough concentrations of the drug in a subgroup of patients. Safety of the two regimens was compared, besides recording any symptoms due to side effects of the drug, with the help of serum creatinine and brainstem-evoked response audiometry (in a subgroup of the patients). RESULTS: We found ODD of gentamicin in hospitalized Indian children to be efficacious and safe. A favourable clinical response was achieved in 167 of the 188 patients (89%) in the ODD group and in 161 of the 212 patients (76%) in the MDD group. Similarly, a higher number of patients in the ODD group showed favourable gentamicin peak concentrations as compared with the MDD group (100% versus 87%). The MDD group showed a higher number of trough concentrations in the undesirable range as compared with the ODD group (17% versus 0%). CONCLUSIONS: The study supports extended-interval (single daily) dosing in hospitalized Indian children due to its efficacy and safety with the added advantage of needing fewer injections.

Pre-decannulation Peristomal Findings in Tracheostomized Cases and Their Effect on the Success of Decannulation.

Decannulating a patient on a tracheostomy is a procedure that has to be dealt with vigilantly. This study evaluated both external and telescopic/bronchoscopic findings at the peristomal level of subjects being considered for decannulation. The patients did not undergo any intervention after above observations and before attempting decannulation. Thereafter peristomal findings and their contribution towards failure to decannulate were correlated. Thirty subjects were studied prospectively, of whom 21 (70 %) demonstrated peristomal complications including granulation tissue, ulceration, mucopurulent discharge, suprastomal granulations, suprastomal collapse and suprastomal flap. Complications were more common in the younger age group (p = 0.007) as well as in tracheostomies of longer duration with mean duration >20 months (p = 0.045). However there was no statistically significant correlation between the success of decannulation and various peristomal findings. Therefore the success of decannulation in a particular case cannot always be correctly predicted by peristomal assessment.

Simple method of vocal cord lateralization in bilateral abductor cord paralysis in paediatric patients.

OBJECTIVE: To simplify the procedure of suture lateralization of a vocal cord in children with bilateral abductor cord palsy and to evaluate its results. METHODS: Ten tracheostomised infants and children with bilateral abductor cord palsy where there was either minimal or no recovery of vocal cord movement even after 2 years' observation were taken up for suture lateralization of one vocal cord. In this simplified procedure needles were passed twice through the larynx from one side of neck to the other. The aim was to reduce the microlaryngoscopic or telescopic manipulation inside the small larynx. Two techniques (1 and 2) were used to carry out this procedure. In technique 1 the needle used was one with a slit in the eye situated at its tail end whereas in technique 2 it was a lumbar puncture needle. Patient follow-up ranged from 6 months to 5 years. RESULTS: Intraoperative manipulation inside the larynx was considerably reduced. The technique 2 was even simpler and faster than technique 1. With both techniques the placement of suture was accurate without any knot inside the larynx. All the patients could be decanulated with only minimal stridor on exertion in two and an acceptable voice in all. CONCLUSIONS: Suture lateralization of one vocal cord using technique 2 can be tried as the first line of management in cases of bilateral abductor cord palsy requiring lateralization.

Intramural foreign body in oesophagus.

Intramural foreign body in oesophagus is very rare and is mostly associated with complications leading to high morbidity and mortality. Recently we came across a coiled metallic wire discovered unexpectedly in a chest X-ray of a 6-month-old male baby. This was further investigated and was found to be located intramurally in the oesophagus. It was successfully removed with rigid oesophagoscopy performed under telescopic guidance. No such foreign body has been reported in an infant so far in English literature.

Is there a functioning vestibulocochlear nerve? Cochlear implantation in a child with symmetrical auditory findings but asymmetric imaging.

The finding of an abnormally narrow internal auditory meatus during the assessment of a child for cochlear implantation raises the possibility that the meatus may not contain the normal number of nerves. Even with currently available MRI techniques it may be extremely difficult to decide whether or not to offer cochlear implant in such cases. We present a child of 4 1/2 years, assessed for cochlear implantation. MRI and CT imaging suggested aplasia of one vestibulocochlear nerve and hypoplasia of the other. However, audiological tests showed clear responses to sound in both ears and functional use of sound in her daily life. This child was eventually implanted with encouraging postoperative results.

Bronchial foreign body presenting as an accidental radiological finding.

The aspiration of a foreign body in an airway is usually associated with respiratory distress, wheeze and persistent cough. The highest incidence of foreign body inhalation occurs between the age of 1 and 3 years [Ann. Otol. Rhinol. Laryngol. 89 (1980) 434: Med. J. Aust. 2 (1983) 322]. Asymptomatic and long standing foreign bodies may lead to complications such as recurrent pneumonia, bronchiectasis, atelectasis and even death. We present here a case of a metallic bronchial foreign body, which was discovered only as an accidental radiological finding on a chest X-ray, which was done for a mild lower respiratory tract infection, presumably 4 months after such an aspiration.

Adult tracheocele with large cervical presentation.

A case is described in which a middle-aged male presented with a large tracheocele in the neck arising from the right postero-lateral aspect of trachea at the level of T2 vertebra. It was not associated with any predisposing factors and except for the swelling in the neck the patient was asymptomatic. It was excised completely through the cervical approach and there has been no recurrence in two years follow-up.

Tubercular retropharyngeal abscess in early childhood.

We present two cases of Pott's lower cervical spine with retro-pharyngeal abscess presenting at an unusually young age. These children presented with a life threatening respiratory distress; one of them had neurological deficit in the form of paraparesis. External drainage of abscess without anterior cervical fusion was adequate as a surgical measure for their prompt recovery while these cases were on conventional anti-tubercular therapy.

Rigid pediatric bronchoscopy for bronchial foreign bodies with and without Hopkins telescope.

This study was undertaken to evaluate the merits and demerits of pediatric bronchoscopy with or without the use of Hopkins telescope in 60 pediatric patients at the Otolaryngology clinic of tertiary level teaching hospital. Group-I comprised of 30 children who underwent a non-telescopic procedure, while Group-II included another 30 who went through a telescopic-guided removal using standard forceps. It was observed that due to better illumination, higher optical resolution and magnification owing to the use of the telescope, foreign body removal using this technique was completed with minimal complications. The precision in foreign body removal using telescopic-guided procedure in Group-II cases was immense though the operative time in comparison to the non-telescopic one was found to be statistically higher (P = 0.0019). This group also had a shorter hospital stay. The use of standard forceps in place of optical forceps gave an easier maneuverability through small-sized pediatric bronchoscopes, thereby giving an edge over the latter.

Foreign body aspiration.

OBJECTIVE: To analyze the clinical and radiological profile of foreign body aspiration in children reaching a tertiary care center and identify areas of possible interventions for proper management of such cases. SETTING: Tertiary level teaching hospital. SUBJECTS: Case records of patients suspected to have foreign body aspiration over the past four years were analyzed. Clinico-radiological features, types and location of foreign bodies were studied. RESULTS: Of 75 children who underwent rigid bronchoscopy, 70 had tracheo-bronchial foreign bodies. History of choking was elicited in 90 percent cases. In 30 percent cases chest radiographs were non-contributory, while the commonest finding (63 percent) was distal emphysema. Over three-fourth of the cases were below the age of 2 years. Vegetative foreign bodies, mainly peanuts, were commonly present. In many cases, referral was delayed as the diagnosis was missed initially. CONCLUSION: Foreign body aspiration remains a common unintentional childhood injury due to improper exposure of young children to otherwise innocuous looking nuts and other small objects.

Rigid endoscopic evaluation of conventional curettage adenoidectomy.

OBJECTIVES: To evaluate the results of conventional adenoidectomy, using rigid endoscopy of the nasopharynx, and to establish the role of such evaluation in facilitating complete adenoid removal via the curettage technique. DESIGN: Descriptive rigid endoscopic evaluation of the nasopharynx before and after adenoid curettage, and following subsequent endoscopy-assisted adenoidectomy. SETTING: Tertiary referral centre. PATIENTS: Forty-one consecutive children with symptomatic adenoid hypertrophy scheduled to undergo adenoidectomy. RESULTS: Rigid endoscopic evaluation indicated that conventional curettage, used alone, failed to completely remove adenoid tissue from the superomedial choanae and anterior vault in all cases; incomplete removal was also seen in other parts of the choanae (in 67.2 per cent of patients), the eustachian tube opening (63 per cent), the nasopharyngeal roof (61.78 per cent) and the fossa of Rosenmuller (61 per cent). Subsequent rigid endoscopy-assisted adenoidectomy successfully removed the residual adenoid tissue from all nasopharyngeal sites, except the eustachian tube opening in two cases. CONCLUSION: Conventional curettage adenoidectomy misses a substantial amount of adenoid tissue. Rigid endoscopy-assisted adenoidectomy improves this result by enabling localisation of any residual adenoid tissue.

Common carotid artery pseudoaneurysm formation following foreign body ingestion.

OBJECTIVE: To report an unusual case of pseudoaneurysm formation following ingestion of a thin wire. METHOD: Case report, including management, and review of the world literature concerning pseudoaneurysm and its management. RESULTS: A 15-year-old boy presented as an emergency with a two-week history of painful swallowing, and a one-week history of a progressively enlarging, right-sided swelling of the lower neck. A foreign body had been ingested two weeks previously. Radiological investigation showed a pseudoaneurysm of the right common carotid artery. The neck was explored, the foreign body removed and the common carotid artery repaired. The patient was discharged on the 10th post-operative day without neurovascular complication. CONCLUSION: This is an unusual presentation of pseudoaneurysm of the common carotid artery following accidental ingestion of a foreign body, reported for its rarity and management.

"Safety pin"--a question to its safety!

Foreign body ingestion is not an uncommon problem in children. They can ingest various foreign objects and one of such objects is a safety pin. The ingestion of such foreign body is not widely reported in the literature. This case highlights the risk of accidental ingestion of safety pin used on child's clothing to protect him from cold that can result in lethal complications. In a poor developing country like Nepal, this case serves to address all mothers alerting them of their ignorance while using safety pin in infants. In addition, physicians are reminded to obtain a detailed inquiry of suspected foreign body ingestion in every child with the history of dysphagia.

Penetrating neck injury by an arrow: a paradigm of age old assault.

Penetrating neck injuries by traditional weapons are rare entity in the modern era of sophisticated weapons. We report an unusual case of penetrating neck injury by a metallic arrow entering anterior neck in zone II and its tip coming out of neck posteriorly causing difficulty for patient to lie down as well as posing challenge to intubate. Arrows are low velocity projectile and from a close proximity they can cause penetrating trauma similar to a low powered handgun. Management of the case was discussed.

Comparative evaluation of conventional versus endoscopic septoplasty for limited septal deviation and spur.

OBJECTIVE: To compare the procedure, results and complications of conventional septoplasty with those of endoscopic septoplasty, in cases of limited septal deviation and septal spurs. DESIGN: Prospective study; interventional type; randomised block design; comparative clinical trial. METHODS: We included in the study 80 patients presenting with limited septal deviation, septal spur with nasal obstruction, or deviated septum with septal correction was required in order to access the ostio-meatal complex (OMC) for functional endoscopic sinus surgery. Of these 12 were children with septal deviation producing significant nasal obstruction. All patients were divided into two groups- with one undergoing conventional and the other endoscopic septoplasty. Post-operative assessment was carried out one month, three months and one to two years after the procedure. RESULT: Post-operative complications such as haemorrhage, infraorbital oedema, nasal pain and in-patient hospital was slightly more in the conventional septoplasty group. CONCLUSION: No statistically significant difference was found between the conventional and endoscopic septoplasty groups, as assessed by subjective and objective evaluation.

An alternative strategy for universal infant hearing screening in tertiary hospitals with a high delivery rate, within a developing country, using transient evoked oto-acoustic emissions and brainstem evoked response audiometry.

OBJECTIVE: To formulate an alternative strategy for universal infants hearing screening in an Indian tertiary referral hospital with a high delivery rate, which could be extended to similar situations in other developing countries. The system should be able to diagnose, in a timely fashion, all infants with severe and profound hearing losses. METHODS: One thousand newborn were randomly selected. All underwent testing with transient evoked oto-acoustic emissions (TEOAE) in the first 48 hours of life. All TEOAE failures were followed up and repeat tests were performed at three weeks, three months and six months of age. Infants with acceptable TEOAE results at any of the four ages were discharged from the study. Infants with unacceptable TEOAE results at all the four ages underwent brainstem evoked response audiometry and oto-endoscopy. The 'pass rate' for TEOAE testing was calculated for all four ages. The time taken to perform TEOAE and brainstem evoked response audiometry was recorded for all subjects. These recordings were statistically analysed to find the most suitable strategy for universal hearing screening in our hospital. RESULTS: The pass rate for TEOAE was 79.0 per cent at < or =48 hours, 85.0 per cent at three weeks, 97.0 per cent at three months and 98.0 per cent at six months. The average time taken to perform the test was 12 minutes for TEOAE and 27 minutes for brainstem evoked response audiometry. Obstructed and collapsed external auditory canals were the two factors that significantly affected the specificity of TEOAE in infants < or =48 hours old. CONCLUSION: The concept of screening all neonates within the first 48 hours of life is impractical because the specificity of TEOAE is lowest at that age. Many false positive results are generated, such that a larger number must undergo brainstem evoked response audiometry, wasting time and resources. This can easily be avoided by delaying TEOAE screening until three months of age, when it has a substantially lower false positive outcome. We expect that implementation of this alternative strategy in our hospital will maximise the benefits of such a programme.