Head shaking during Dix-Hallpike exam increases the diagnostic yield of posterior semicircular canal BPPV.

OBJECTIVES: To examine whether shaking the head during the DH exam (HSDH) may improve diagnosis of posterior semicircular canal benign paroxysmal positional vertigo (pBPPV) in patients with a negative Dix-Hallpike (DH) examination. STUDY DESIGN: A prospective cohort clinical study on consecutive patients with dizziness, who were seen by 2 experienced neurotologists. Patients underwent a complete neurotology examination, including positioning testing with roll test and DH. Patients with a negative DH underwent a HSDH. Patients with a positive DH (Group 1) or only with a positive HSDH (Group 2) underwent a particle reposition maneuver (PRM), which was a modification of the Epley maneuver. Variables including sex, age, the duration of symptoms until diagnosis, and the number of visits required until cure were examined in each group. SETTING: A tertiary dizziness clinic and in 2 private clinics. SUBJECTS AND METHODS: All patients diagnosed with pBPPV. MAIN OUTCOME MEASURES: DH test after head shaking and comparison of variables between the 2 study groups. RESULTS: Sixty nine patients were diagnosed with pBPPV (Group 1). Twelve additional patients were negative on DH but were found positive on HSDH (Group 2), improving the diagnostic yield by 14.8%. There was no statistical relation between the 2 groups and the variables examined; however, there was a trend for longer duration of symptoms (44.3 versus 64 d) and less visits until cure (1.5 versus 1.7 visits) in Group 2. CONCLUSION: Patients with a negative DH should undergo a HSDH. Patients only diagnosed as pBPPV by a positive HSDH may represent a subgroup with a milder form of disease.

Epiglottic abscess as a complication of acute epiglottitis.

OBJECTIVE: An epiglottic abscess is considered a life-threatening medical situation that can cause death by obstruction the upper airways. We describe a 58-year-old man who presented to our hospital with sore throat, dysphagia and dysphonia. MATERIALS AND METHODS: A fiberoptic laryngoscope (FOL) demonstrated beefy red edematous epiglottis with edema extending from the base of the tongue to the aryepiglottic folds and arytenoids. CT scan showed multiple air bubbles inside the swollen epiglottis, in keeping with the diagnosis of necrotizing epiglottic abscess. RESULTS: Under local anesthesia we performed puncture of the abscess at the tip of the epiglottis. He was dismissed 5days from his admission to the hospital after an improvement was noticed in his epiglottis. CONCLUSION: Treatment consists of airway management if needed under anesthesia and draining of the abscess. An IV antibiotics plus corticosteroids should be administrated the moment a suspicion of epiglottitis is present.

Involvement of minor salivary glands in the pathogenesis of peritonsillar abscess.

OBJECTIVES: To study the relationship between peritonsillar abscess (PTA) and minor salivary glands surrounding the palatine tonsils. STUDY DESIGN: Prospective population-based study. SETTINGS: Tertiary care university hospital. SUBJECTS AND METHOD: Prospective study including 41 patients with PTA and 6 patients with a neck abscess. Amylase levels of the pus and serum were measured and compared between the 2 groups. Clinical data regarding hospitalization length and recurrence rate were also collected. RESULTS: Of the 41 patients with PTA, 7 suffered from recurrent PTA. Average level of amylase in the pus of the PTA group was 3841 U/L versus 7.7 U/L in the neck abscess group (P < .001; median, 62 vs 9.5). Serum amylase was higher in the PTA group (49.3 U/L vs 37.3 U/L; P = .008). There were no recurrences in PTA patients with amylase greater than 65 U/dL in the pus in 0 of 20 (0%) versus 7 of 21 (33%) for amylase lower than 65 U/L (P = .01). CONCLUSION: High amylase in the pus lends further support for involvement of minor salivary glands. However, high recurrence rates related to low amylase in the pus imply an additional pathogenesis possibly related to tonsillar infection. It is possible that both minor salivary glands as well as tonsillar infection play a role in the pathogenesis of peritonsillar infections.

B-type natriuretic peptide and cardiovascular function in young children with obstructive sleep apnea.

OBJECTIVE: N-terminal pro-B-type natriuretic peptide (NT-proBNP), a marker of ventricular strain, and C-reactive protein (CRP), a marker of inflammation, are reportedly elevated in school-aged children with obstructive sleep apnea (OSA). We hypothesized that cardiovascular morbidity affects circulating markers and their echocardiographic and polysomnographic (PSG) correlates in young children with OSA. METHODS: We assessed young children undergoing adenotonsillectomy (TA) for OSA by polysomnography, echocardiography, and serum CRP and NT-proBNP levels. RESULTS: A total of 90 children with OSA (mean age 19 +/- 7 months; 71.2% male; BMI, z = 0.62 +/- 1.04) and 45 age- and sex-matched controls were included. Three months following TA, 72 children were reassessed for NT-proBNP and CRP. NT-proBNP level (pg/mL) was higher in subjects with OSA (189.1 +/- 112.7) vs control subjects (104.8 +/- 49.5; P = .006). Both NT-proBNP (187.8 +/- 114 vs 86 +/- 32.6; P = .002) and CRP levels (mg %) (0.49 +/- 0.41 vs 0.1 +/- 0.17; P < .05) decreased following TA. Doppler pulse wave measuring tricuspid regurgitation (TR), a reflection of pulmonary hypertension, correlated with CRP (r = 0.61, P < .01) but not NT-proBNP (r = -0.14, P = .53) levels. Left ventricle end-diastolic diameter (LVEDD) was at the maximal normal range (0.91 +/- 0.11), but did not correlate with CRP or NT-proBNP levels. Both CRP level and TR correlated with PSG variables reflecting nocturnal hypoxemia, whereas NT-proBNP level and LVEDD did not. Echocardiography in 40 children (out of 90) showed a decline in TR that was abnormal before TA and correlated with the decrease in CRP following TA. CONCLUSIONS: NT-proBNP levels are increased in children with OSA and decrease following TA. Echocardiographic parameters suggesting increased pulmonary pressure in young children with OSA are related to nocturnal hypoxemia and systemic inflammation, which also decrease following therapy.

Gelfoam plug tympanoplasty concomitant with removal of retained ventilation tubes.

OBJECTIVE: To review the charts of patients treated using a gelfoam plug and to determine the efficacy of its use as a grafting material for prevention of perforation when removing retained ventilation tubes. METHOD: Following removal of the retained tube, excision and debridement of the rim of the perforation, the perforation was plugged with gelfoam material. Between February 1998 and July 2002, we used this procedure in 27 patients aged 15 years and younger, on a total of 36 ears. RESULTS: In all 27 cases, complete healing of the perforation was attained. CONCLUSION: A minimal tympanoplastic procedure using gelfoam graft concomitantly with tube removal is effective in prevention of perforation resulting from delayed spontaneous extrusion.