Acute mastoiditis in infants aged six months or younger.

OBJECTIVE: Bibliographic data for the management of acute mastoiditis in infants aged six months or less are very limited. This study investigated the presenting symptomatology, diagnostic and treatment options, and final outcomes in this age group. METHOD: A retrospective review was conducted of all infants aged six months or less suffering from acute mastoiditis, admitted to our department between 2007 and 2017. RESULTS: Eleven infants were identified. All of them developed the typical symptomatology of acute mastoiditis, while a higher rate of subperiosteal abscess formation was observed. Imaging was necessary in three cases only. Parenteral antibiotics and myringotomy were applied in all infants. A drainage procedure was also included in the infants with a subperiosteal abscess. Antrotomy was reserved for non-responsive cases. No intracranial complications were observed. All infants were cured without further complications or sequelae. CONCLUSION: Acute mastoiditis in infants aged six months or less can be safely diagnosed and treated using a standardised algorithmic approach, similar to that used for older children.

Mastoid subperiosteal abscess in children: drainage or mastoidectomy?

OBJECTIVE: To evaluate the management of mastoid subperiosteal abscess using two different surgical approaches: simple mastoidectomy and abscess drainage. METHOD: The medical records of 34 children suffering from acute mastoiditis with subperiosteal abscess were retrospectively reviewed. In these cases, the initial surgical approach consisted of either myringotomy plus simple mastoidectomy or myringotomy plus abscess drainage. RESULTS: Thirteen children were managed with simple mastoidectomy and 21 children were initially managed with abscess drainage. Of the second group, 12 children were cured without further treatment while 9 eventually required mastoidectomy. None of the children developed complications during hospitalisation, or long-term sequelae. CONCLUSION: Simple mastoidectomy remains the most effective procedure for the management of mastoid subperiosteal abscess. Drainage of the abscess represents a simple and risk-free, but not always curative, option. It can be safely used as an initial, conservative approach in association with myringotomy and sufficient antibiotic coverage, with simple mastoidectomy reserved for non-responding cases.

Incidence of non-infectious 'acute mastoiditis' in children.

OBJECTIVE: The temporal bone may be the first involved site in cases of systemic disease, and may even present with acute, mastoiditis-like symptomatology. This study aimed to evaluate the incidence of such non-infectious 'acute mastoiditis' in children. MATERIALS AND METHODS: Retrospective chart review of 73 children admitted to a tertiary referral centre for acute mastoiditis. RESULTS: In 71 cases (97.3 per cent), an infectious basis was identified. In the majority of cases (33 of 73; 45 per cent), the responsible bacteria was Streptococcus pneumoniae. However, histopathological studies revealed a non-infectious underlying disease (myelocytic leukaemia or Langerhans' cell histiocytosis) in two atypical cases (2.7 per cent). CONCLUSION: 'Acute mastoiditis' of non-infectious aetiology is a rare but real threat for children, and a challenging diagnosis for otologists. A non-infectious basis should be suspected in every atypical, persistent or recurrent case of acute mastoiditis.

Results of endoscopic assisted probing for congenital nasolacrimal duct obstruction in older children.

PURPOSE: To evaluate the results of lacrimal probing with the use of nasal endoscopy and identify the anatomical anomalies responsible for the symptoms in older children. METHODS: Fifty-two eyes of 40 children with congenital nasolacrimal duct obstruction underwent primary probing of the lacrimal duct under general anaesthetic in conjunction with nasal endoscopy. Patients followed up for at least 6 months. Cure was defined as complete resolution of symptoms or minimal symptoms brought on by cold or wind. RESULTS: The age range was 12-126 months. In 30/52 (57.7%) eyes the symptoms were attributed to a single mechanical obstruction. Seven eyes had canalicular stenosis. Three eyes had upper nasolacrimal duct obstruction. Nine eyes had narrow duct and nine eyes had atresia of the distal end of the duct. Two eyes had only intranasal abnormalities. In 16/52 (30.76%) eyes a combination of anomalies was responsible for the symptoms. Nine eyes had canalicular stenosis in association with: either a membrane at the valve of Hasner in four, or a narrow duct in three, or intranasal anomalies in two. Two eyes had punctual stenosis and narrow duct. Two eyes had narrow duct and tight inferior turbinate. Three eyes had abnormal openings in association with stenotic ducts. Six (11.54%) eyes had functional blockage. With the use of endonasal endoscopy, intranasal anomalies identified in 12 eyes and treated in nine. One eye had large inferior conchae. One eye had inferior concha adherent to lateral nasal wall. One eye had redundant nasal mucosa. Three eyes had tight inferior turbinate. Three had abnormal openings. In three eyes the probe went submucosally. The overall success rate was 84.6% (44/52 eyes). Eight eyes remained unchanged. Endoscopically treated cases contributed to the overall success by 17.31%. CONCLUSION: Multiple anatomical anomalies within the lacrimal system and abnormalities of the nose are quite common in older children. Lacrimal probing remains the primary treatment and nasal endoscopy is a useful adjunct to probing increasing the success rate of the procedure.

Long-term effects of chemotherapy for acute lymphoblastic leukemia on the medial olivocochlear bundle: effects of different cumulative doses of gentamicin.

OBJECTIVE: The treatment of acute lymphoblastic leukemia (ALL) often combines a neurotoxic chemotherapeutic protocol such as Berlin-Frankfurt-Munster-95 (BFM-95) with gentamicin, an antibiotic known to have an early and quickly reversed impact on olivocochlear reflex in animal studies. This study investigates whether this combination has any long-term side effects on the medial olivocochlear bundle (MOCB). METHODS: In all 47 children of the study suppression of distortion product otoacoustic emissions (DPOAEs) by contralateral application of white noise (WN) was used to assess the function of the MOCB. The population was divided into three groups depending on the time interval between the end of therapy and examination. The group examined shortly after chemotherapy included 12 children who had received low gentamicin doses (less than 13 days). The group evaluated 2 years after therapy involved another 12 children who had required medium gentamicin doses (more than 13, less than 23 days). The group examined 3 years after therapy included a subgroup of 12 children to whom low gentamicin doses were infused and another 11 children with high gentamicin doses (more than 23 days). RESULTS: Three years after therapy the olivocochlear reflex was efficiently produced in both subgroups of low and high gentamicin doses. Two years after therapy, contralateral WN induced increase of DPOAEs at 4 of the 12 examined frequencies. Shortly after therapy, WN increased, instead of suppressing, DPOAEs at five frequencies. CONCLUSION: This abnormal result of contralateral noise application perceived as impaired cochlear efferent innervation may indicate that ALL-BFM-95 exerts a toxic effect on the MOCB, which is slowly reversed within the first 3 years after chemotherapy and does not seem to be affected in the long term by different cumulative doses of gentamicin.

Neurotoxicity of vincristine on the medial olivocochlear bundle.

OBJECTIVE: Vincristine is a well known neurotoxic chemotherapeutic agent. Dose dependent and cumulative peripheral neuropathy is the main dose limiting side effect of chemotherapy with vincristine. The mechanisms responsible for the neurotoxic effects of vincristine have not yet been fully understood. This prospective study was directed at determining whether vincristine treatment interferes with the function of the medial olivocochlear bundle. DESIGN: Fifteen children suffering from leukemia were subjected to tympanogram, stapedial muscle reflex, pure tone audiometry and transient evoked otoacoustic emissions (TEOAEs) in the absence and presence of contralateral white noise on day 1 and on day 22 of treatment with vincristine. The function of the medial olivocochlear bundle was assessed by the phenomenon of suppression of otoacoustic emissions by contralateral application of white noise. RESULTS: The study revealed a statistically significant decrease of contralateral suppression amplitudes in all cases after three sessions of chemotherapy with vincristine. On the contrary no alterations were observed in pure tone audiometry thresholds. A non-significant decrease of the mean TEOAEs' amplitudes was also noted. When analyzed by frequency, however, this decrease reached the level of statistical significance at two frequencies. CONCLUSION: Vincristine treatment seems to exert a neurotoxic effect on the efferent olivocochlear system, which takes place early in the course of chemotherapy. This is a new aspect to be added to the possible mechanisms underlying the toxicity of vincristine in the auditory periphery. Whether changes in efferent function might contribute to understanding the mechanisms of neurotoxicity caused by vincristine, or find any clinical application as a predictor or early detector of neurological side effects of vincristine still remains to be seen.

The effect of treatment with vincristine on transient evoked and distortion product otoacoustic emissions.

OBJECTIVE: Vincristine chemotherapy is mainly associated with neurotoxic effects. The ototoxicity of vincristine has been related to high dosage, while low and moderate doses do not seem to induce significant hearing impairment when measured by pure tone or speech audiometry. Otoacoustic emissions have been reported to be more sensitive in early detection of ototoxicity than conventional pure tone audiometry. The present study was directed at determining whether vincristine treatment interferes with outer hair cell function in the absence of measurable changes in pure tone audiometry. METHODS: We studied prospectively a cohort of ten children suffering from leukemia. All children were subjected to tympanogram, stapedial muscle reflex, pure tone audiometry, transient evoked (TEOAEs) and distortion product (DPOAEs) otoacoustic emissions on day 1 and on day 22 of treatment with vincristine. TEOAEs were analyzed in terms of emission level and reproducibility as a function of frequency. DPOAEs were obtained as DP-grams and were analyzed in terms of amplitude. RESULTS: The analyzed parameters of TEOAEs and DPOAEs revealed a declining tendency, although changes did not reach statistical significance. Pure tone audiometry and stapedial reflex thresholds were not altered. CONCLUSION: For the population of this study, vincristine did not seem to cause significant alterations of otoacoustic emissions' recordings and consequently significant outer hair cell damage.

Etiological diagnosis of bilateral, sensorineural hearing impairment in a pediatric Greek population.

Early diagnosis, evaluation and treatment of childhood deafness are essential for a child's normal growth. Etiological diagnosis of hearing loss makes prevention, family scheduling and more effective therapy feasible goals. Etiological assessment of sensorineural deafness still remains difficult although recently with the progress of genetics it has become more efficient. In this retrospective study, the etiology of bilateral, sensorineural hearing loss with indication for hearing aids has been studied in 153 hearing impaired children. Etiological diagnosis was based on family and patient record, physical, audiological and laboratory examinations. Among the 94 children who completed the diagnostic protocol etiological groups revealed the following distribution: non-hereditary acquired hearing impairment was present in 36 children (38%) and hereditary was present in 44 (47%) children. The etiology remained unknown in 14 (15%) children. Non-syndromic autosomal dominant type accounted for 13 (29% of hereditary hearing loss) children, non-syndromic autosomal recessive type for 21 (48%) children and syndromic deafness for 10 (23%) children. Modern diagnostic methods, such as genetic testing, help diminish the number of cases with hearing impairment of unknown etiology, for the benefit of children who receive early and appropriate medical, audiologic, genetic and educational counseling based on the etiology of their hearing loss.

Hearing evaluation with distortion-product otoacoustic emissions in young patients undergoing haemodialysis.

Sensorineural hearing loss is frequently reported in young patients with chronic renal failure having haemodialysis. The effect of a single session of haemodialysis on hearing acuity was assessed prospectively in nine children with end-stage renal disease using pure-tone audiometry (PTA) and distortion-product otoacoustic emissions (DPOAEs). Results were compared with those obtained from nine audiologically normal healthy children also tested with PTA and DPOAEs twice during a 4-h interval. Sensorineural hearing loss of unknown aetiology was found in 55.5% of renal patients, mainly in the higher frequencies. Patients on HD had mean PTA thresholds significantly poorer than those of the control group in the frequency range 1000-12 000Hz (P < 0.05). Their mean DPOAE amplitudes were significantly lower in all frequencies > 1184 Hz (P < 0.05). Furthermore, patients' ears with normal PTA thresholds between 250 and 4000 Hz also had decreased DPOAE amplitudes. No significant changes in PTA thresholds or DPOAE amplitudes were encountered in renal patients before and after a HD session (P > 0.05). Changes in PTA thresholds or DPOAE amplitudes were not significantly different than those in the control group (P > 0.05). In conclusion, sensorineural hearing loss of unknown origin, especially in high frequencies, is frequent in young renal patients under HD and single HD sessions do not seem to alter the hearing acuity of these patients. DPOAEs seem to be more sensitive to incipient cochlear damage than behaviour thresholds in monitoring renal patients.

Hearing loss in speech-language delayed children.

An infant begins to communicate with his/her environment from the first months of life. However, true words do not appear until the age of 12-15 months, following a rather predictable sequence. Delay or failure of normal language development is not a rare situation in childhood and may be due to a variety of reasons. Among these, hearing undoubtedly plays a leading part in the language acquisition process. The purpose of this study was to assess the percentage of hearing-impaired children in a group of phenotypically healthy children presenting with speech-language delay. Between March 1993 and March 1999, 726 speech-language delayed children were examined in our department. In 72 of them, various diseases or syndromes had already been diagnosed and so they were excluded from the study. The remaining 654 apparently healthy children entered the study and underwent a thorough audiological assessment for determination of their hearing thresholds. Eighty-seven children (13.3%) showed various degrees of hearing loss. Most of them (55 children, 8.4%) suffered from sensorineural hearing impairment, while in 32 children (4.9%) a conductive hearing loss was discovered. The increased prevalence of hearing impairment found in our population mandates a thorough hearing evaluation for every case of speech-language delay, even for those children who show no evidence of other handicaps. This will help in the early diagnosis of hearing loss, allowing proper management to be instituted as early as possible.

Incidence of hearing loss among children presented with speech-language delay.

Infants' first attempts to communicate with their environment begin shortly after birth. However, real words appear by age of 12-15 months. Any delay in expressing their needs verbally beyond this age is defined as speech delay and may be associated with a variety of pathological conditions. The aim of this study is to investigate the incidence of hearing impairment in those children presented with speech delay. Ninety-one speech-delayed children were audiologically assessed between March 1993 and March 1995. In 25 out of 91 children (27.4%) a moderate to severe hearing loss was detected, either sensorineural or conductive. The increased incidence of hearing impairment found in this group mandates a thorough hearing evaluation for any case of speech-language delay.

Towards a universal newborn hearing screening.

Hearing loss is a common problem which, if remaining undetected during early childhood, could affect the patient's linguistic and mental abilities permanently. Although recommended, mass hearing screening has so far been problematic or even impossible due to several reasons. The available otoacoustic emission devices appear to be effective tools for universal hearing screening. The aim of this study is to evaluate the reliability and practicability of a new device for recording click-evoked otoacoustic emissions (cEOEs) on a pediatric population. Sixty children aged between 6 days and 14 years were evaluated audiologically both by auditory brainstem responses (ABR) and otoacoustic emissions. The latter were obtained by using the well-known ILO88v3.92 otoacoustic analyser and a new, portable device ('Echocheck', Otodynamics Ltd, UK). Sensitivity and specificity of cEOEs recorded by 'Echocheck'was found to be 93% and 91%, respectively, when compared to ABR results. Additionally, 'Echocheck' recordings were proved to be much easier to perform, needing considerably less time in comparison with those of the ILO88 system. In our opinion, 'Echocheck' as well as all similar portable devices--screeners--may represent a much-desired solution for implementing universal hearing screening programmes.

Isolated inverted papilloma of the sphenoid sinus.

Inverted papilloma is a rare benign sinonasal tumour, characterized by a potentially invasive nature. The lateral nasal wall represents the most common site of origin, whereas paranasal sinuses are quite frequently found to be involved by extension. In contrast, primary sinus inverted papillomas have rarely been reported. The present study describes an extremely rare case of inverted papilloma, isolated to the left sphenoid sinus, that was treated by a transnasal endoscopic procedure. The therapeutic approach chosen is discussed and the results of a two-year follow-up are also presented.

Otoacoustic emission-based hearing screening of a Greek NICU population.

The pressing need for early identification of hearing-disabled children has led to the development of several neonatal hearing screening programmes world-wide. Today otoacoustic emissions represent a widely used methodology for identification of neonatal hearing impairment. The purpose of the present study is to determine the sensitivity and specificity of click-evoked otoacoustic emissions (cEOAEs) in a Greek NICU population and compare the cEOAE data to the final hearing status of these children. A total of 438 ears of 223 neonates at high risk for hearing impairment were tested with both brainstem response audiometry (ABR) and cEOAEs. In 107 neonates the final hearing status was determined by using behavioural and playtone audiometry, at an age greater than 2 1/2 years. The sensitivity and specificity of the cEOAEs were found to be 90 and 92.4% when compared to ABR results and 90.9 and 91.1% when compared to the children's hearing status, respectively. Click-EOAEs have been proved to be highly effective in determining whether or not hearing impairment really exists. Since conventional ABR does not meet the requirements for large scale screening programmes, the cEOAEs represent a reliable alternative.

Isolated sphenoid sinus aspergillomas.

Fungi are more often than previously believed to be the causative organisms of paranasal sinusitis. Aspergillus, a fungus belonging to the Ascomycetes class, accounts for the majority of these infections, which affect not only debilitated patients but healthy people as well. There are two distinct clinical forms of Aspergillus sinusitis, invasive and non-invasive, and each of them is further divided in two subtypes. Isolated aspergillosis of the sphenoid sinus is a rare disease, which is usually misdiagnosed for a long time because of its varying symptomatology. In the present study, four cases of isolated sphenoid Aspergillus disease are described and the recent literature is reviewed. Physicians should be aware of this rare clinical entity, as in many cases early diagnosis and appropriate treatment provide the key to achieve favourable outcomes.

Profound hearing loss and presence of click-evoked otoacoustic emissions in the neonate: a report of two cases.

Evoked otoacoustic emissions using click stimulus (cEOEs) were recorded in 450 consecutive children over a 12-month period. Of this group, 102 were babies treated in neonatal intensive care unit (NICU), classified as High Risk neonates according to the criteria of the Joint Committee on Infant Hearing. Audiologic examination in the latter was completed by auditory brainstem responses (ABR). Two of the neonates showed a profound hearing loss accompanied by strong cEOEs. The two cases are described and discussed together with the possibilities and limitations of transient evoked otoacoustic emissions in the auditory screening of the neonatal population. Despite the reported rare possibility of pure retrocochlear disorders, when cEOEs are used for neonatal screening purposes there is an actual risk of missing a profound hearing loss. Nevertheless, the use of cEOEs in combination with ABR may contribute to the differential diagnosis between cochlear and retrocochlear lesions.

Multiple-frequency tympanometry in children with otitis media with effusion.

Multifrequency tympanograms were recorded from 76 ears of 43 children affected by otitis media with effusion (OME) and 90 ears of normal-hearing children to obtain data for resonance frequency (RF) and changes in phase angle. There was found to be a statistically significant decrease (p < 0.01) in both RF values and change in phase angle in ears with OME compared to normative data. This decrease may be interpreted by considering OME as a mass pathology. Multiple-frequency tympanometry seems to be a useful method for determining the effect of various middle-ear pathologies on the mechano-acoustical status of the middle-ear system.