["Audio 4": a simple and quick speech audiometry test for moderate hearing loss screening in four-year-old children]. / "Audio 4": un test vocal simple et rapide pour le dépistage des surdités moyennes des enfants à l'âge de quatre ans.

UNLABELLED: The need for repeated auditory screening throughout early childhood faces the obstacle of the lack of objective validated material. OBJECTIVES: The goal of this two-year prospective study was to create and validate frequency-based word/picture lists appropriate for four-year-olds. Words were chosen not on the basis of the acoustic frequency of phoneme production, but on frequencies corresponding to their optimal recognition. Responses thus were to predict pure-tone threshold curves. MATERIAL AND METHODS: First of all, the linguistics laboratory created lists. Next, we proceeded to validate the form of the test: this involved verifying that the words selected on the basis of their frequency characteristics were common and well-known to children of this age. During the first year of the study, the picture boards were tested in a hospital otolaryngology service (66 children) and in a public health service (500 children) and corrected. RESULTS: All of the words and pictures were known during the next year by 5088 children. The second step was the audiometric validation of the test in a paediatric otolaryngology service. We compared classification of normal and impaired ears according to tonal audiograms and according to "Audio 4": 360 children were tested. Results were the following ones: Se: 0.81, Sp: 0.96, PPV: 0.91, NPV: 0.93. "Audio 4" therefore allows for prediction of pure-tone curves. CONCLUSION: This gives us hope that, directly interpretable by physicians, Audio 4, a rapid test which is attractive to children, will be used in diagnostic paediatric examinations whenever necessary.

[Recurrent respiratory tract infections: how should we investigate and treat?]. / Infections respiratoires récidivantes: quels bilans, quels traitements ?

Recurrent respiratory tract infections are a common reason for visits to primary care practitioners or hospital physicians. They are placed at the junction of several medical specialities: paediatrics, ENT, pneumology, allergology, immunology, infectiology. The great diversity of the laboratory tests requested and on the other hand the proposed treatments, are the consequences of the diversity of the patients encountered and the paucity of the evidence based-medicine studies in this setting. The dilemma is how to identify the child for which recurrent respiratory tract infections are the witness of underlying condition, without performing repeated medical examinations, laboratory tests and treatments for normal children for which immunologic development occurs normally. The essential tools are the history analysis, physical examination and few laboratory tests. The other questions are how to include, for these patients, influenza and pneumococcal vaccines in the immunization program and how to assess the benefit/risk ratio and the cost of surgical treatments. This paper presents the thought of an expert group trying to define the situations where biological tests or treatments are useful.

[Acute mastoiditis in children: clinical and bacteriological study of 17 cases]. / Mastoïdite aiguë de l'enfant: étude clinique et bactériologique de 17 cas.

OBJECTIVE: Acute mastoiditis (AM) represents the most frequent complication of acute otitis media (AOM) in children. In the literature, its incidence is stable but with an impressive increase in pneumococci with reduced sensitivity to penicillin (PRSP). The aim of this study was to assess the incidence of AM in the area of Tours and the prevalence of PRSP. METHOD: This was a retrospective study of children admitted to the regional paediatric centre in the Tours area, between January 1994 and May 2001. The coded AM files were analysed, excluding all the sub-acute forms or those complicating a cholesteatoma. The criteria studied concerned the clinical signs on admission, the imaging data and the bacteriological samples and the results of treatment. RESULTS: Seventeen children (8 boys, 9 girls) were admitted for an AM during the study period. Their mean age was of 3.2 years (range: 6 months to 13 years). In 24% of cases, the mastoiditis existed on admission and in 59% of cases it complicated an AMO already treated with antibiotics. In 3 cases (18%), the AM was complicated on admission with peripheral facial paralysis in one case and thrombosis of the lateral sinus in 2 cases. The germ responsible was identified in 14 cases (82%) with a predominance of pneumococci (11 cases). Eight were PRSP-type. Scan of the pars petrosa identified a subperiosteal abscess in 13 cases. Fourteen mastoidectomies were performed and the mean duration of antibiotic therapy was of 23 days. The outcome was always good. CONCLUSION: Over the past 7 years, the incidence of AM has been estimated at 1.2/100 000 children aged under 15 per year. The prevalence of PRSP is high but does not change the principles or the results of the treatment of AM.

[Teratoma of the rhinopharynx and the infratemporal fossa in neonates: report of 3 cases]. / Tératome du cavum étendu à la fosse infratemporale du nouveau-né, à propos de 3 cas.

Teratomas are tumors which develop in childhood or early adulthood, generally in the gonads. More rarely these tumors may be found in an axial localization, notably in cervicofacial forms. We report three cases of teratomas observed in rhinopharynx of three neonates operated at the Clocheville General Hospital. We present the main anatomoclinical features of these tumors, focusing on the cervicofacial forms in neonates. All three cases occurred in female neonates presenting acute dyspnea within the first hours of life, requiring intubation in two cases. The first two tumors invaded the infratemoral region and the third was a pediculated tumor of the velum exteriorized via the mouth. In one case antenatal ultrasound had suggested the diagnosis of a right temporomaxillary tumor. Rapid excision of the rhinopharngyeal component allow extubation for the two intubated infants and pathology diagnosis. In the first infant operated at 2 months, the lateral route was adapted to age, with mandibulotomy with section of the coronoid process but preserving the mandibular condyle. The second infant was operated at the age of 3 weeks using a wide frontotemporoperitonial approach then at the age of 3.5 months for recurrence extending to the floor of the temporal fossa and the middle ear. A type C infratemporal approach was used with lost-bone temporal craniectomy. Per-buccal excision was possible in the third infant with resection at the base of implantation. No recurrence has been observed in the first two cases at 3.5 and 2.5 months follow-up in the first two cases. The third infant was lost to follow-up.

Predictive factors for complications in children with laryngeal damage at extubation.

OBJECTIVES: To determine which factors contribute to early complications when intubated children show macroscopic lesions at extubation. STUDY DESIGN: Retrospective review of 96 consecutive medical records of children aged 1 day to 15 years. Patients were divided into three groups depending on the extent of the subsequent treatment required: medical, reintubation, and surgical. METHODS: Age, sex, clinical history, and macroscopic features of the lesions were collected and data were compared in each group. RESULTS: Underlying noninfectious respiratory diseases and young age were found to be risk factors for higher incidence of complications, but not prolonged or multiple intubations. Edema, especially in the glottic area, was a risk factor for surgical treatment. Multiple lesions were risk factors for reintubation. CONCLUSIONS: History of intubation, its cause, and lesions discovered at extubation can provide the basis for definition of an "at risk" profile for intubated children.

Surgical removal of subglottic hemangiomas in children.

OBJECTIVE: To examine the indications and the results of surgical excision of severe subglottic hemangiomas. DESIGN: Retrospective study and case series. SETTING: Four academic tertiary care centers of pediatric otolaryngology. PATIENTS: Twenty children were included from 1991 to 1997. All presented with severe subglottic hemangiomas resistant to classical treatments such as corticosteroids and/or CO2 laser. INTERVENTION: Six children were operated on using laryngotracheal reconstruction and prolonged stenting by a reinforced Silastic roll and 14 children were operated on by a single-stage laryngotracheoplasty and postoperative intubation in a pediatric intensive care unit. RESULTS: All patients were successfully decannulated or extubated and have been free from recurrent hemangiomas. CONCLUSION: The surgery of severe subglottic hemangiomas is a reliable technique in selected patients and should be considered in corticoresistant or corticodependent, circular, or bilateral hemangiomas.

[Necessity of auditory and academic supervision in patients with unilateral hearing disorder. Retrospective study of 175 children]. / Nécessité d'un suivi audiologique et scolaire de l'enfant sourd unilatéral. Etude rétrospective de 175 enfants.

This report reviews a consecutive series of 175 children suffering from unilateral hearing loss of 20 dB or more evaluated at the Clocheville Hospital between 1980-1991. We found no numerical preponderance of gender nor of side impairment. The mean age of diagnosis was 6.9 years. Based on speech frequency threshold averages, the loss was profound in 49.7%. 32.8% of the children experienced a deterioration of hearing of 10 dB or more. 40.4% of the children had repeated a grade during primary school (versus 16.3% in normal hearing population, p < 0.001). Monaural deafness especially when more than 40 dB, or delayed identification is significantly associated with a grade failure. A concerted effort aimed at early identification and management strategies in cases of unilateral hearing loss in children is warranted.

[Epidemiology of otitis media with effusion]. / Epidémiologie des otites avec épanchement.

Acute otitis media (AOM) and otitis media with effusion (OME) are very common in the young children. The relation ship between these two pathologies has not been completely established. The AOM incidence ranges between 22 to 74%. The OME which persists after onset of AOM is more frequent (20% at 2 months) than the chronic OME which concern 4.4 to 10% of the child population before the age of five. The highest age specific incidence for all episodes of AOM is one year of age. AOM and OME are most likely to occur in the winter. The OME risk factors are: the first episode of OMA before 6 month of age, the males sex, no breastfeeding, day-care centers, low socio-economic conditions and familial genetic predisposition. Passive-smoke exposure and allergy are discussed. The epidemiology assesses the actual state of these pathologies to settle, with the family, the optimum choices for the prevention.

Deafness and Mondini dysplasia in Kabuki (Niikawa-Kuroki) syndrome. Report of a case and review of the literature.

Report of a case and review of the literature: We report the case of a seven-year-old female kabuki patient suffering from severe bilateral deafness related to Mondini dysplasia and ossicular anomalies. A review of the literature in English confirms that hearing loss is a major component of Kabuki Syndrome (KS) with a frequency at around 32%. However the possible mechanisms have not been fully described and hearing loss is often attributed to otitis media, but one reported case had severe ossicular malformations, two had sensorineural deafness and three others had mixed deafness. Our observation is the first reported case of Mondini dysplasia in KS. Awareness by physicians of this problem has a major practical consequence as diagnosis of Mondini dysplasia implies searching for and surgical prevention and treatment of perilymphatic fistula in order to prevent meningitis.

[Cervicofacial manifestations of tularemia. Apropos of a familial case]. / Manifestations cervico-faciales de la tularémie. A propos d'un cas familial.

Tularemia is a rare infectious disease, due to Francisella tularensis, a virulent bacterium transmitted by a carrier insect (essentially ticks) or by the meat of an infected animal (generally hares). We report 3 cases that occurred in the same family, showing the various symptoms of this disease. Revealing head and neck manifestations may mislead diagnosis.

Type III-IV laryngotracheoesophageal cleft: report of a successfully treated case.

This report presents a case of Stage III laryngotracheoesophageal cleft (LTEC). It is, to our knowledge, the fourth case in which the patient is still alive twenty months after surgery. We herein describe an initial symptomatology dominated by a bubbling hypersalivation, our surgical technique using a pleural shred of interposition and an endoscopic check during the operation and, finally, the clinical development dominated by a food intake refusal which was progressively improved through psychiatric help.

[Need for multidisciplinary care management in the treatment of type III laryngo-tracheo-esophageal cleft]. / La nécessité d'une prise en charge pluridisciplinaire dans le traitement des diastèmes laryngo-trachéo-cesophagiens de type III.

We report a case of type III laryngotracheoesophageal cletf. To our knowledge, this case represents the fourth case repaired. Survival was 22 months. The surgical repair we describe here is the first condition to survival. Close collaboration initially with anesthesiologists, then with the intensive careteam unit is required for post-operative management. Moreover, in addition to the surgical trauma, post-operative management is often long with tracheotomy and gastrostomy leading to a corporeal schema disorder in swallowing and respiration. Early psychologic assistance is indispensable to a good functioning of the aero-digestive region.

Gastroesophageal reflux and ENT disorders in childhood.

Among controversies in pediatric otorhinolaryngology, the role of gastroesophageal reflux (GER) in inflammatory disorders of the upper airway remains of major concern. A laryngeal involvement by GER was demonstrated in adults and a correlation with GER has been found in pediatric populations with recurrent croup. However, although considered statistically significant, these results concern a few patients only and are inconclusive for a causal relationship. In addition, pH monitoring, often considered as the gold standard for the diagnosis of GER disease, has failed in giving normal values in ENT disorders. Eventually, upper pharyngeal and nasal involvements by GER and GER-related otitis media or otalgia have been suggested by some authors. In the 6th International Congress on Pediatric Otolaryngology, the Symposium on GER was designed to help physicians in improving their knowledge of the data from the literature and their understanding of the involved mechanisms. Bearing in mind the potential severity of GER disease, the audience also heard and debated the most up-to-date methods of assessing GER and treating it in patients with possibly related otorhinolaryngological symptoms. Here is the summary of this symposium.

[Detection of beta-lactamase in samples obtained after tonsillectomy in children]. / Recherche de beta-lactamase sur les prélèvements d'amygdalectomie chez l'enfant.

Production of beta-lactamase was detected using a microbiological assay (Guts test) in samples of tonsils, and by in Haemophilus growing from the same samples of both tonsils obtained from 30 children aged 2 to 13 years (18 aged < 6 years and 12 aged > or = 6 years). Two pieces from each tonsil, core and superficial, were studied. The procedure included direct microscopic examination of smears, and culture to identify Haemophilus, beta-haemolytic streptococci and Streptococcus pneumoniae. Guts test was positive in tonsillar tissue obtained from 26 children (14 aged < 6 years and 2 aged > or = 6 years) (p < 0.01). In 10 of them (9 aged < 6 years and 1 aged > or = 6 years) (p < 0.05) grew beta-lactamase producer Haemophilus influenzae. One to three varieties of Haemophilus could be found in 28 children (11 with H. influenzae = 5 beta-lactamase +, 8 with Haemophilus parainfluenzae = 3 beta-lactamase +); Group A, C, or G streptococci in 5 children, but no strain of Streptococcus pneumoniae. No difference could be demonstrated between core and superficial samples: beta-lactamase activity was positive in superficial samples from 26 children and core samples from 24. Almost all bacteria described grew from superficial as well as (slightly but no significantly less) from core samples.

[Blue rubber bleb naevus syndrome. Diagnosis and management apropos of 2 cases]. / Blue Rubber Bleb Naevus Syndrome. Diagnostic et conduite à tenir à propos de deux cas.

Blue Rubber Bleb Naevus Syndrome is a rare pathology: 70 cases have been noted since the first description, by Gascoyen, in 1860. It is an acquired disease which usually appears before the age of ten. It is marked by angiomatic cutaneo-digestive tumours combined with chronic anaemia and iron deficiency. Its many and various complications, particularly cataclysmic haemorrhages, car jeopardize the vital prognosis throughout. This little known syndrome is rarely diagnosed at the time of its first manifestations. We recall, from two cases and a review of their literature, the clinical characteristics of the syndrome, its complications and its essentially symptomatic treatment. We therefore suggest an approach to its diagnosis.

[Pharyngeal obstruction caused by tonsil hypertrophy in children]. / L'obstruction pharyngée d'origine amygdalienne chez l'enfant.

Tonsillectomy for enlarged tonsils has been so soundly criticized that doctors no longer date to suggest the operation. If they do come to the conclusion that the procedure in inevitable, it is only after an expensive and sometimes aggressive work-up. In order to better establish the criteria which should determine this indication for amygdalectomy, we studied a series of 47 patients undergoing this procedure for enlarged tonsils. We conclude that it is most important to base decisions on a thorough physical examination which includes careful inspection of the pharynx and a complete history. Particular attention must be paid to symptoms, especially nocturnal, and to the failure to gain weight.

[Septic erosion of the internal carotid artery and retrostylian phlegmon. Apropos of a case]. / Erosion septique de l'artère carotide interne et phlégmon rétro-stylien. A propos d'un cas.

The vascular complications of peritonsillar phlegmons have become exceptional. On the basis of a recent case, the authors sum up the criteria of severity, including: white puncture sample, paralysis of the 9th, 10th, 11th, 12th cranial nerves and of the cervical sympathetic nerve. Computed tomography allows not only refining the topographic diagnosis, but even sometimes diagnosing a pseudoaneurysm before it is fissured. At this stage, intraoperative radiology may probably prevent the unavoidable secondary rupture. If it cannot be used, preventive ligation must be proposed. In the absence of cataclysmic hemorrhage, this easier procedure usually does not cause any irreversible neurological deficit. If performed in emergency, it may entail a major risk, not only a neurological risk, but a vital risk as well.