Ultrasound-guided contrast-enhanced sentinel node biopsy of the head and neck in a porcine model.

OBJECTIVE: To test the feasibility of contrast-enhanced ultrasound (CEUS)-guided sentinel lymph node biopsy (SNB) of the head and neck in a porcine model. STUDY DESIGN AND SETTING: In this prospective, nonrandomized study, methylene blue and Sonazoid were injected into the lateral tongue or floor of mouth (FOM) of four swine. Real-time CEUS was used to identify contrast in the lymphatic channels flowing to the sentinel lymph node (SLN). Endoscopic or open SNB was performed. Neck dissection was then performed, and the residual nodal packet was examined for remaining contrast-enhancing or blue dye-stained nodes. RESULTS: In all eight procedures, the SLN was visualized with ultrasound and blue dye. Seven procedures identified a single SLN, and one identified two SLNs. Subsequent neck dissections revealed no other nodes containing methylene blue or contrast in the nodal specimen or operative bed. CONCLUSION/SIGNIFICANCE: CEUS-guided SNB of the head and neck in swine is feasible, with success comparable to blue dye-guided SNB. This technique may offer several advantages over traditional techniques, and warrants further study.

Detection of gastric pepsin in middle ear fluid of children with otitis media.

OBJECTIVE: We sought to confirm the finding of pepsin/pepsinogen in the middle ear fluid of children with otitis media in a larger sample size using a sensitive and specific pepsin assay. STUDY DESIGN AND SETTING: We evaluated 152 children (225 ear samples) in a prospective study at a tertiary care children's hospital. The presence of pepsin in middle ear aspirates was determined using enzymatic assay. RESULTS: Of the patients, 14.4 percent (22 of 152) had detectable pepsin activity in one or both of the ear samples with no pepsin activity detected in control serum. Average pepsin concentration in the samples was 96.6 +/- 170.8 ng/ml, ranging from 13 to 687 ng/ml. Pepsin concentration in the middle ear of children younger than 1.0 year was significantly higher than in older age groups. CONCLUSION AND SIGNIFICANCE: Results indicate that pepsin/pepsinogen is present in the middle ears of children with otitis media, although not at the high rate previously reported. Gastric reflux may be one causative factor in the pathogenesis of otitis media.

Granular cell tumor of the trachea in pregnancy: a case report and review of literature.

OBJECTIVES/HYPOTHESIS: The objectives were to present a case report of a woman with recurrent disease during consecutive pregnancies and to discuss the diagnosis and management of granular cell tracheal tumors, with particular attention to pregnancy and hyperestrogenic states. STUDY DESIGN: Case report and literature review. METHODS: A Medline search and comprehensive review of literature to assess all cases of granular cell tumors of the trachea were compared and collected, with particular attention to individual cases of pregnancy or cases related to the hyperestrogenic state. RESULTS: Thirty-two cases of granular cell tumors of the trachea were found. Only a few cases related to the hyperestrogenic state were obtained. The case report describes a woman with recurrent disease in subsequent pregnancies during the later stages of pregnancy. CONCLUSION: Few cases of granular cell tumors of the trachea have been reported, with even fewer being pregnancy related. The diagnosis and management of these tumors include careful attention to patient symptoms and airway management.

The role of extraesophageal reflux in otitis media in infants and children.

OBJECTIVES/HYPOTHESIS: Gastroesophageal reflux disease (GERD) is common in children, and extraesophageal reflux disease (EORD) has been implicated in the pathophysiology of otitis media (OM). We sought to 1) determine the incidence of pepsin/pepsinogen presence in the middle ear cleft of a large sample of pediatric patients undergoing myringotomy with tube placement for OM; 2) compare this with a control population of pediatric patients undergoing middle ear surgery (cochlear implantation) with no documented history of OM; 3) analyze potential risk factors for OM in children with EORD demonstrated by the presence of pepsin in the middle ear cleft; and 4) determine if pepsin positivity at the time of myringotomy with tube placement predisposes to posttympanostomy tube otorrhea. STUDY GROUP: prospective samples of 509 pediatric patients (n = 893 ear samples) undergoing myringotomy with tube placement for recurrent acute OM and/or otitis media with effusion in a tertiary care pediatric hospital with longitudinal follow-up of posttympanostomy tube otorrhea. CONTROL GROUP: prospective samples of 64 pediatric patients (n = 74 ears) with negative history of OM undergoing cochlear implantation at one of the three tertiary care pediatric hospitals. A previously validated, highly sensitive and specific modified enzymatic assay was used to detect the presence of pepsin in the middle ear aspirates of study and control patients. Risk factors for OM and potentially associated conditions, including GERD, allergy, and asthma were analyzed for the study group through review of the electronic medical record and correlated topresence of pepsin in the middle ear space. Study patients were followed longitudinally postoperatively to determine the incidence of posttympanostomy tube otorrhea. RESULTS: The incidence of pepsin in the middle ear cleft of the study group was 20% of patients and 14% of ears, which is significantly higher than 1.4% of control patients and 1.5% of control ears (P < .05). Study patients younger than 1 year had a higher rate of purulent effusions and pepsin in the middle ear cleft (P < .05). Patients with pepsin in the middle ear cleft were more likely to have an effusion at the time of surgery than patients without pepsin in the middle ear cleft (P < .05). There was no statistical association found between the presence of pepsin and clinical history of GERD, allergy, asthma, or posttympanostomy tube otorrhea. CONCLUSIONS: Pepsin is detectable in the middle ear cleft of 20% of pediatric patients with OM undergoing tympanostomy tube placement, compared with 1.4% of controls; recovery of pepsin in the middle ear space of pediatric patients with OM is an independent risk factor for OM. Patients under 1 year of age have a higher incidence of purulent effusions and pepsin-positive effusions. Clinical history of GERD, allergy, and asthma do not seem to correlate with evidence of EORD reaching the middle ear cleft. The presence of pepsin in the middle ear space at the time of tube placement does not seem to predispose to posttympanostomy tube otorrhea.