Clinical aspects of chronic ENT inflammation in children.

In children, all ENT cavities are particularly prone to the development of chronic inflammation. This is due to many predisposing factors, of which the most common are unfavourable anatomy, absence of nasal blowing, day care attendance, allergy, immature immunity, gastro-oesophageal reflux and tobacco smoke exposure. The aim of this paper is to outline the most specific paediatric clinical aspects of chronic pharyngo-tonsillitis, rhinosinusitis, otitis media, adenoiditis and laryngotracheitis and the important influence that some of these pathologies exert on the others.

Necrotic adenoids in post-transplant lymphoproliferative disorders.

PROBLEM: Post-transplant lymphoproliferative disorders (PTLD) are a potentially fatal complication after solid organ transplantation. The majority of cases are associated with Epstein Barr virus infection (EBV). The first manifestations of PTLD are frequently observed in the ENT area with adenoidal and/or tonsillar enlargement. METHODOLOGY: We present the case of a 12-year old girl with a total nasal obstruction and tonsillitis five months after a kidney transplantation for bilateral congenital kidney hypoplasia. RESULTS: The EBV genome was detected by polymerase reaction three months after surgery. Fiberoptic examination revealed an obstructive necrotic mass in the naso-pharynx. The anatomic-pathologic analysis revealed necrotic adenoids. CONCLUSIONS: Necrotic tonsillitis is common. Necrosis of the adenoids, although rarer, can also occur and explains the important respiratory distress. Since two thirds of PTLD patients present with clinical symptoms in the ENT area, the otorhinolaryngologist should be aware of this complication.

Apertura pyriformis stenosis in the newborn.

Apertura pyriformis stenosis in the newborn. Respiratory distress in the newborn can have a variety of aetiologies, the best known of which are cardiac and pulmonary diseases. Major nasal airway obstruction is probably often overlooked when acute desaturation of the neonate requires reanimation procedures, although it is well established that the baby is an obligate nose breather at birth. Nasal airway stenosis or atresia could account for a number of unexplained deaths in the delivery room. In the differential diagnosis of major nasal airway obstruction in the newborn, choanal atresia is by far the most common aetiology. However, a few cases of pyriform aperture stenosis have been reported. One child presenting this pathology was recently treated at the Brussels University Children's Hospital. Unexpectedly, the baby survived until 3 months without any medical support but had severe feeding problems. The diagnosis was confirmed by naso-sinusal CT scan. Surgery was performed at 4 months through an unusual endonasal approach which seems to be less traumatic than the classical sublabial approach. The post-operative course was satisfactory. The 9-month-old patient does not now show residual breathing problems. The presentation will focus on this unusual case.

Meningitis following basal skull fracture in two in-line skaters.

INTRODUCTION: In-line skating has been reported to cause severe head injury. Basilar skull fracture (BSF) is associated with a high risk of complication. CASE REPORT: We report two children who had bacterial meningitis following seemingly trivial in-line skating injuries. In both, anterior BSF was diagnosed retrospectively following occurrence of Streptococcus pneumoniae meningitis. DISCUSSION: The clinical signs indicating BSF depend on the fracture location. Plain skull radiography and computed tomography (CT) are not sensitive enough to detect thin fractures in the anterior cranial fossa. We argue that high resolution multiple-plane CT and coronal T2-weighted magnetic resonance imaging are indicated to diagnose BSF.

Skull base chordoma: CT and MRI features.

We report the case of a 10-year-old boy who presented an intracranial chordoma and we stress the importance of sectional imaging to approach the diagnosis. Clinical presentation is related to local invasion. Lesion of the body of the clivus can extend ventrally or dorsally and cause cranial nerve palsies, brain stem compression or hydrocephalus. Pathologically, they form soft, grey masses that are histologically benign but locally invasive and destructive. Both computed tomography (CT) and magnetic resonance (MR) imaging clearly depict the lesion. CT better demonstrates bone destruction and intralesional calcifications. In our case, MR was performed first and showed all the classical signs of skull base chordoma. CT provided complementary information about bone destruction which are also usual in this type of lesion. Major differential diagnoses of the chordoma in the clivus are the other central skull base masses. Biopsy and histology make the diagnosis. Usually treatment consists in surgery and radiotherapy but more recently proton beam therapy is used and seems to yield better results.

Chronic rhinosinusitis in cystic fibrosis (mucoviscidosis).

The authors present two clinical studies performed in the ENT departments of two Belgian Universities. A total of 248 patients with mucoviscidosis (cystic fibrosis, CF) were assessed by means of nasal endoscopy. One hundred eighteen underwent computed tomography of the paranasal sinuses (CT) and 55 were endoscopically operated. This allowed the observation of different clinical patterns of rhinosinusitis: mucopyosinusitis (pseudomucocele) of the maxillary antrum with bulging of the lateral nasal wall (LNW), nasal polyposis with erosion of the LNW, and chronic purulent rhinosinusitis with an isolated prominent uncinate process. The treatment of those patients could be tailored to the individual clinical pattern. Medical therapy consisted of systemic antibiotics and topical drugs delivered by sprays or by lavages with a nose can. Surgery was mainly aimed at removing the massive polyposis when it interfered with the daily life activities. The use of the endoscope enabled to perform safely more extensive procedures resulting in a lower recurrence rate. In patients with chronic rhinosinusitis without polyposis, yet presenting ostiomeatal obstruction, a limited and more functional endoscopic surgery was indicated in order to restore some drainage and to improve the penetration of topical drugs into the affected sinus. A short addendum presents two studies: one about genetics and the other about prevalence of middle ear disease in CF. The first concluded that no clear correlation was found between DF508 (the most common CF mutation) and nasal polyposis. The second revealed that in contrast with the extremely high prevalence of sinus problems, there was no clear evidence of an increased prevalence of middle ear disease in CF.

Inflammatory cells and mediator concentrations in nasal secretions of patients with cystic fibrosis.

In this study, cytological examination of nasal secretions of 17 patients with cystic fibrosis (CF) was combined with quantitative determination of common inflammatory mediators. Results showed a normal cytogram in these patients. However, obvious mucosal inflammation is evidenced by significantly higher concentrations of leukotriene C4 (LTC4) and eosinophil cationic protein (ECP). The activation of other common inflammatory cells such as mast cells (or basophils) and neutrophils could not be demonstrated since their mediators (histamine, tryptase and myeloperoxidase) are not raised. Increased concentrations of LTC4 and ECP indicate the active participation of eosinophils, and can contribute to the new concept of non-infectious inflammatory involvement of the nasal epithelium of patients with CF.

[Results of ethmoidectomy in children with mucoviscidosis]. / Resultaten van ethmoïdectomieën bij kinderen met mucoviscidosis.

Eighteen children with cystic fibrosis who underwent in total 30 sinus interventions were examined in a retrospective study. There was 44% of recurrence. A review of the literature shows that sphenoethmoidectomy gives better results than nasal polypectomy.

Pathological changes of the lateral nasal wall in patients with cystic fibrosis (mucoviscidosis).

In a prospective clinical study, 84 patients aged 3 months to 34 years (mean age: 12 years; 53 males and 31 females), with cystic fibrosis systematically underwent an ENT examination, including rigid endoscopy of the anterior nasal cavity and lateral nasal wall. In 28 cases, CT-scan of the sinuses was performed. Mucopyosinusitis of the maxillary sinus with medial projection of the inter-naso-sinusal wall was present in 10 children (12%, mean age: 4 years; range: 3 months to 8 years). Nasal polyposis was present in 37 patients (45%) from the age of 5 years on (mean age: 15 years). Nasal obstruction was the main complaint when the condition was severe. The routine use of the endoscope makes it possible to diagnose early pathological changes of the lateral nasal wall. Local treatment could then help slow down progress evolution toward a more massive involvement.

Fluctuating hearing loss in sarcoidosis.

Sarcoidosis is a systemic granulomatous disease, which can affect the vestibulo-acoustic system at any level, causing vertigo and/or hearing loss. The main mechanism could be vasculitis. One patient with fluctuating hearing loss as the first manifestation of a systemic sarcoidosis is presented. Diagnostic modalities, especially different sites of biopsy or needle aspiration are discussed. The treatment is steroid therapy. Hearing will be restored provided no irreversible changes of the VIIIth nerve and/or the inner ear have occurred.