Contemporary outcomes for ulcerative colitis inpatients admitted to pediatric hospitals in the United Kingdom.

BACKGROUND: Pediatric ulcerative colitis (UC) care is variable with a lack of appropriate guidelines to guide practice until recently. METHODS: UC inpatients <17 years old admitted to 23 U.K. pediatric hospitals had clinical details collected between September 2010 and 2011. Comparative data for 248 patients were available from a previous audit in 2008. RESULTS: One hundred and seventy-six patients (98 males) of median age 13 years (interquartile range, 10-13) were analyzed; 23 were elective surgical admissions, 47 new diagnoses, and 106 needed acute medical care for established UC. Median length of stay was 6 days (interquartile range, 3-10) with no deaths. Eighty-eight of 126 patients (70%) with active disease had standard stool cultures performed (3 [2%] were positive), and 57 (45%) had Clostridium difficile toxin tested (none positive). Twenty-five of 66 (38%) emergency admissions had an abdominal x-ray on admission, and 13 of 66 patients (20%) had a Pediatric Ulcerative Colitis Activity Index score. There were 3 cases of toxic megacolon and 2 thromboses. Eighty-one of 116 patients (71%) responded to steroids. Nineteen patients who did not respond adequately to steroids received rescue therapy (7 infliximab, 11 ciclosporin, and 1 both) with overall response rate of 90%; 7 patients needed surgery acutely, 5 without previous rescue therapy. Compared with the 2008 data, stool culture rates improved significantly (86 of 121 [71%] versus 76 of 147 [52%], P = 0.001) as did heparinization rates (15 of 150 [10%] versus 5 of 215 [2%], P = 0.002) and rescue therapy usage (17 of 33 [52%] versus 10 of 38 [26%], P = 0.03). CONCLUSIONS: There were signs of improving UC care with significantly increased rates of stool culture and rescue therapy. The majority of sites, however, did not use Pediatric Ulcerative Colitis Activity Index scores.

Repair of a large septal perforation with a radial forearm free flap: brief report of a case.

We treated a 38-year-old man who had a large septal perforation that had been caused by chronic nasal inhalation of cocaine. We were able to repair the perforation with a left radial forearm free flap. Long-term followup indicates a successful closure of the defect and a natural thinning of the flap. The patient remains symptom-free more than 2 years following surgery.

Xerostomia: a prevalent condition in the elderly.

Although xerostomia is associated with aging, studies have determined that salivary gland function is well preserved in the healthy geriatric population. Therefore, dry mouth is probably not a condition of aging, but most likely one of systemic or extrinsic origin. Saliva seems to undergo chemical changes with aging. As the amount of ptyalin decreases and mucin increases, saliva can become thick and viscous and present problems for the elderly. One of the most prevalent causes of xerostomia is medication. Anticholinergics, such as psychotropic agents and antihistamines, and diuretics can dry the oral mucosa. Chronic mouth breathing, radiation therapy, dehydration, and autoimmune diseases, such as Sjögren's, can also diminish salivation, as can systemic illness such as diabetes mellitus, nephritis, and thyroid dysfunction. Xerostomia can lead to dysgeusia, glossodynia, sialadenitis, cracking and fissuring of the oral mucosa, and halitosis. Oral dryness can affect denture retention, mastication, and swallowing. Dry mouth symptom can be treated with hydration and sialagogues or with artificial saliva substitutes. Because patients are at risk for dental caries, they should be referred to a dentist for preventive care. In patients with Sjögren's syndrome and in those who have undergone radiation therapy, pilocarpine has been used recently with good results.

Laryngeal manifestations of vasculitic disease.

Vasculitis can involve the larynx in 4% to 10% of cases and can cause arthritis, edema, or upper airway obstruction within the larynx. Since most of these laryngeal manifestations are nonspecific, the clinician needs to keep a high index of suspicion when a patient complains of hoarseness or laryngeal discomfort and chronic constitutional symptoms. We present a case of crescentic glomerulonephritis associated with antineutrophil crytoplasmic autoantibody (ANCA). In addition, we discuss the usefulness and indications of ANCA serology and review multiple laryngeal manifestations that have been associated with common vasculitides and reported in the medical literature.

Analysis of short-term outcome after office-based laser-assisted uvulopalatoplasty.

To determine the short-term effectiveness and outcome of office-based laser-assisted uvulopalatoplasty, a prospective statistically controlled study was done at the Department of Otolaryngology, Cleveland Clinic Florida. Thirty-eight consecutive snoring patients underwent a total of 98 laser-assisted uvulopalatoplasties, and data were gathered through examination, interview, and analog scales of snoring, pain, and other morbidity. In addition, a failure analysis was performed. Data were analyzed by descriptive statistics, confidence intervals, and adjusted analysis of variance (p < 0.008). Our results suggest that snoring decreased significantly around each laser-assisted uvulopalatoplasty treatment performed (4 to 8 weeks apart). Postoperative pain diminished after the first two laser-assisted uvulopalatoplasty treatments. The only morbidity in the series was the result of significant pain, causing 77% of laser-assisted uvulopalatoplasty failures.

Proposed algorithm to aid the diagnosis of cerebellopontine angle tumors.

Hearing and/or balance disorders are symptoms that may be associated with tumors of the cerebellopontine angle (CPA). Between March 1988 and May 1995, 22 patients had diagnosis or evaluation of CPA tumors at Cleveland Clinic Florida. The most common presenting signs or symptoms included unilateral low-frequency tinnitus, unsteadiness, and/or asymmetric hearing loss. On the basis of our experience, we have constructed an algorithm to help identify and manage acoustic nerve dysfunction. We compare our findings with national epidemiologic data and current medical reports.

Extraparotid Warthin's tumor: clinical manifestations, challenges, and controversies.

Extraparotid Warthin's tumors continue to challenge the head and neck surgeon's diagnostic and therapeutic skills. A series of six extraporotid Warthin's tumors are presented to illustrate the need to keep a high index of suspicion for this lesion in the workup of cystic masses involving cervical levels II and III or in the event of a concomitant neck mass and a parotid Warthin's tumor. Discussion of the debate surrounding the embryogenesis and histogenesis of extraparotid Warthin's tumors follows. Clinical guidelines are suggested for the diagnosis, treatment, and follow-up of patients with extraparotid Warthin's tumors.

Diagnosis and management of laryngeal trauma in sports.

The management of sports-related laryngeal trauma presents a diagnostic and therapeutic challenge. The application of basic treatment principles such as airway monitoring, thorough physical examination, and fiberoptic laryngeal examination will direct the management. Further radiologic examination or surgical intervention may be required to adequately assess and manage the injury. We review the diagnosis, treatment, and management in a case of laryngeal fracture that occurred during a National Hockey League game.

Tinnitus: a stepwise workup to quiet the noise within.

Patients with tinnitus--ringing in the ears or head--frequently present initially to their primary care physician. Tinnitus may be subjective (audible only by the patient) or objective (audible to the examiner). Subjective tinnitus is more common and may be due to peripheral or central auditory pathology, a metabolic abnormality, or anxiety/depression. Objective tinnitus is rare and is frequently due to a vascular or neuromuscular condition, intracranial or head/neck tumor, or some specific structural defect of the ear, cochlea, or retrocochlear area. The stepwise workup of tinnitus includes a comprehensive history and physical exam, audiologic evaluation, blood profile analysis, and referral when necessary. Treatments include hearing aids, masking devices, drugs, and biofeedback.

Transcervical approaches to the prevertebral space.

The anterolateral and posterolateral transcervical approaches were used to expose the prevertebral space in patients with diffuse idiopathic skeletal hyperostosis. In a series of six patients, both techniques produced equally effective palliation of dysphagia without associated morbidity. Theoretically, the anterolateral approach better preserves the carotid sheath neurovascular bundle, although the risk of injuring the recurrent laryngeal nerve is greater. The posterolateral technique offers a wider exposure of the prevertebral space but requires more retraction of the carotid sheath and increases the risk of injury to the sympathetic chain. Either exposure may be used depending on the preference of the attending surgeon.

Unusual anatomic presentations of inverting papilloma.

Due to their tendency to recur, and a potential for malignancy, inverting papillomas of the nasal cavity and paranasal sinuses pose a challenge to the head and neck surgeon. Although the majority of these benign neoplasms arise from the lateral nasal wall, middle meatus, and ethmoid complex, they occasionally originate from atypical areas in which Schneiderian membrane is present. Four unusual anatomical presentations of inverting papilloma are presented and discussed.

Incidence of cranial nerve dysfunction following carotid endarterectomy.

An analysis of postoperative injuries to the recurrent laryngeal, hypoglossal, marginal mandibular, and superior laryngeal nerves was undertaken in 517 patients who underwent 535 carotid endarterectomies between April 1978 and March 1981 at The Cleveland Clinic Foundation. A review of the literature is presented followed by the results of this analysis and a discussion of the findings. Suggestions for decreasing or avoiding such injuries are made. Conclusions are drawn to help the otolaryngologist identify the endarterectomized patient with an impaired upper aerodigestive tract.

Surgical experience with nasopharyngeal angiofibroma.

Recent reports have suggested that radiotherapy may be preferable to other forms of treatment of juvenile nasopharyngeal angiofibroma. There are, however, potentially serious short- and long-term complications associated with the use of radiotherapy in the head and neck. For the past three years, ten consecutive patients with juvenile nasopharyngeal angiofibroma have been treated at The Cleveland Clinic Foundation with an approach that permits accurate removal with minimal complications. With this method of treatment, intraoperative blood loss, the necessity for blood transfusion, and length of hospital stay have been greatly decreased. There have been no substantive complications and no recurrences to date. If further experience with this approach to management in a larger series of patients has the same results, it would seem that radiotherapy should be relegated to a secondary position in the treatment of juvenile nasopharyngeal angiofibroma, except for cases wherein intracranial extension would prevent total excision.