Inflammation and remodeling of the sinus mucosa in children and adults with chronic sinusitis.

OBJECTIVES/HYPOTHESIS: The sinus mucosal inflammatory response in adult patients with chronic sinusitis is well documented in the literature. In contrast, little is known about the pathogenesis of this condition in children. The objective of the study was to compare the inflammatory cell profile and the extent of tissue remodeling in the sinus mucosa of children and adults with chronic sinusitis. STUDY DESIGN: Prospective design. METHODS: Children (n = 7) and adult patients (n = 7) with chronic sinusitis undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no evidence of sinus disease (n = 6) were used as control subjects. Using immunohistochemical analysis, sinus mucosal specimens were assessed for the presence of T lymphocytes, eosinophils, basophils, mast cells, and neutrophils. The extent of submucosal collagen deposition was evaluated in histological sections using van Gieson stain. RESULTS: The number of T lymphocytes, eosinophils, and basophils and the amount of subepithelial collagen deposition are significantly higher in the mucosa of both adults and children with chronic sinusitis compared with normal control subjects (P <.01). The number of mast cells is significantly higher in the mucosa of children with chronic sinusitis compared with normal control subjects (P <.01). The number of eosinophils and neutrophils and the amount of subepithelial collagen deposition are significantly greater in adults compared with children with chronic sinusitis (P <.01). CONCLUSIONS: The sinus mucosal inflammatory profile is similar in adults and children with chronic sinusitis. However, the degree of tissue eosinophilia and remodeling is significantly greater in adult sinus specimens when compared with those of children with chronic sinusitis.

Computer-assisted voice analysis: establishing a pediatric database.

OBJECTIVES: To establish and characterize the first pediatric normative database for the Multi-Dimensional Voice Program, a computerized voice analysis system, and to compare the normative data with the vocal profiles of patients with vocal fold nodules. DESIGN: A cross-sectional, observational design was used to establish the normative database. The comparative study was completed using a case-control design. SETTING: University-based outpatient pediatric otolaryngology clinic. PARTICIPANTS: One hundred control subjects (50 boys and 50 girls) aged 4 to 18 years contributed to the normative database. The voices of 26 patients (19 boys and 7 girls) with bilateral vocal fold nodules were also analyzed. MAIN OUTCOME MEASURES: Demographic data, including sex, age, height, weight, body mass index, and cigarette smoke exposure, were obtained. The Multi-Dimensional Voice Program extracted up to 33 acoustic variables from each voice analysis. RESULTS: The mean (SEM) values of each of the acoustic variables are presented. At age 12 years, boys experience a dramatic decrease in fundamental frequency measurements. The voices of patients with vocal fold nodules had significantly elevated frequency perturbation measurements compared with control subjects (P<.001). CONCLUSIONS: The vocal profile of children is uniform across all girls and prepubescent boys. Patients with vocal fold nodules demonstrated a consistent acoustic profile characterized by an elevation in frequency perturbation measurements. Normal acoustic reference ranges may be used to detect various vocal fold pathologic abnormalities and to monitor the effects of voice therapy.

Cytokine profile of chronic sinusitis in patients with cystic fibrosis.

BACKGROUND: The inflammatory-cell and cytokine profiles of chronic sinusitis (CS) are well documented in the literature. In contrast, little is known about the pathogenesis of this condition in patients with cystic fibrosis (CF). OBJECTIVE: To determine whether patients with CF have inflammatory-cell and cytokine profiles that differ from other patients with CS. METHODS: Patients with CF (n = 7) and adults with CS (n = 7) undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no allergies or sinus disease (n = 6) were used as controls. Using immunohistochemical analysis, we assessed sinus mucosal specimens for the presence of T lymphocytes, eosinophils, macrophages, and neutrophils. Using in situ hybridization, we assessed the expression of interleukin (IL) 4, IL-5, IL-8, IL-10, and interferon gamma. RESULTS: There was a higher number of neutrophils, macrophages, and cells expressing messenger RNA for interferon gamma and IL-8 in patients with CF than in patients with CS or in controls (P<.01). The number of eosinophils and cells expressing messenger RNA for IL-4, IL-5, and IL-10 was higher in patients with CS than in those with CF and controls (P<.01). CONCLUSIONS: Sinus disease in patients with CF presents different inflammatory-cell and cytokine profiles than that seen in other patients with CS. These results may explain the difference in response to treatment in the CF group.

Chronic tympanic membrane perforation in an animal model.

OBJECTIVE: The aim of this study was to revalidate and reproduce a chronic tympanic membrane perforation animal model. STUDY DESIGN: Prospective, animal study. METHODS: Eight female chinchillas underwent bilateral thermal myringotomy. The edges of the perforation were folded inward using microflaps. The perforations were followed over time to monitor the course of closure. RESULTS: Two animals were excluded from the study because of ear infection. None of the other tympanic membrane perforations remained open. The closing time varied from 4 to 6 weeks. CONCLUSIONS: Our findings demonstrate that the thermal myringotomy combined with infolding technique is not a reliable and consistent method to create a chronic tympanic membrane perforation. The closing time is shorter than expected and varies among the study subjects. There is a clear need for developing a reliable chronic tympanic membrane perforation model.

Linking laryngopharyngeal reflux to otitis media with effusion: pepsinogen study of adenoid tissue and middle ear fluid.

HYPOTHESIS/OBJECTIVES: Laryngopharyngeal reflux (LPR) was recently implicated in the etiology of otitis media with effusion (OME). To study the hypothesis that gastric juice reaches the middle ear through the nasopharynx and eustachian tube, we evaluated the presence of pepsinogen in the adenoid tissues of children with otitis media with effusion (OME) and compared them with the tissues of a control group of children without OME. METHODS: In the study group, middle ear effusions (MEEs) and adenoidal tissue biopsies were obtained from patients undergoing simultaneous tympanostomy tube placement and adenoidectomy. In the control group, adenoid specimens were taken during adenoidectomy (+/- tonsillectomy) from children with no history of OME. The adenoid tissues were analyzed immunohistochemically to confirm the presence of pepsinogen. Normal gastric tissue was used as a positive control and lymphatic tissue as a negative control. Total pepsinogen levels of MEE were measured with enzyme-linked immunosorbent assay. RESULTS: Adenoid tissue of the OME group (n = 25) demonstrated significantly higher pepsinogen immunoreactivity when compared with the adenoid tissue of the control group (n = 29), specifically in staining of both the epithelia (p < .0001) and the subepithelia, (p < .001). The presence of pepsinogen was detected in 84% of MEEs from the OME group, at concentrations 1.86 to 12.5 times higher than that of serum. Pepsinogen messenger ribonucleic acid was not demonstrated in any of the adenoid tissues of the OME group. CONCLUSION: LPR plays an important role in the pathogenesis of OME as gastric reflux reaches the middle ear through the nasopharynx and eustachian tube to cause OME.

Complications of adenotonsillectomy revisited in a large pediatric case series.

OBJECTIVE: To document the most important postoperative adenotonsillectomy morbidities, with an emphasis on prolonged hospitalization and readmissions. DESIGN: Retrospective chart analysis. METHODS: We reviewed 2067 cases of adenotonsillectomies performed at our institution over a period of 6 years. RESULTS: Of these cases, 1927 patients had undergone tonsillectomy by electrocautery and adenoidectomy by suction-coagulator, of whom 9.3% required admission. The incidence of admissions owing to bleeding was 1.7%, whereas admissions owing to respiratory and gastrointestinal complications represented 3.7% and 5.2%, respectively. Compared with the literature and our institution's previous results, these morbidity values were found to be either comparable or significantly lower (p < .05). CONCLUSION: We attribute this improvement to our use of electrocautery-based techniques not only for tonsillectomy but also for adenoidectomy.

Hydrogen peroxide mouth rinse: an analgesic post-tonsillectomy.

OBJECTIVE: To compare the analgesic efficacy of hydrogen peroxide (H2O2) mouth rinse with control for post-tonsillectomy pain management. DESIGN: Double-blinded, prospective, randomized, controlled clinical trial. PATIENTS AND METHODS: Thirty-seven patients from 5 to 14 years old undergoing electrocautery tonsillectomy were randomized to either the H2O2 mouth rinse or the water rinse (control) group. For 14 days, patients recorded pain levels twice daily using a visual analogue scale. Analgesic uses, as well as any complications, were also noted by the patients. RESULTS: Thirty-seven patients completed the study, 21 in the treatment group and 16 in the control group. Mean postoperative days of pain were 10.3 and 8.3, respectively, and differed significantly (p = .008). Mean postoperative days of analgesic use were 9.0 and 6.7, respectively, and differed significantly (p = .005). Only one incidence of postoperative hemorrhage occurred in the study group. CONCLUSION: In our study, the H2O2 mouth rinse does not provide a better analgesic effect than the water rinse for post-tonsillectomy pain relief.

Orbital complications of sinusitis in children.

BACKGROUND: Orbital complications of sinusitis are uncommon but can result in significant morbidity if not appropriately managed. OBJECTIVE: This study was conducted to evaluate the clinical presentation, diagnosis, management, and outcome of orbital complications of sinusitis in children treated at our institution over a 10-year period. METHODS: The study retrospectively reviewed cases of 139 children with evidence of orbital complications of sinusitis admitted to the Montreal Children's Hospital between January 1990 and March 2000. Factors assessed included the clinical presentation, radiologic findings, management, and outcome (length of admission, complications). Complications were classified as preseptal if they did not penetrate the periorbita. Postseptal complications were defined as those penetrating the periorbita and were further subdivided into cellulitis and abscess categories. RESULTS: Seventy-two percent of patients presented with preseptal cellulitis, 19% with orbital cellulitis, and 9% with subperiosteal abscess. Ophthalmoplegia and proptosis at presentation were found to be predictors of postseptal disease, although computed tomography (CT) was necessary to differentiate between cellulitis and abscess. Preseptal disease resolved with antibiotics in all cases. Postseptal disease was treated medically and in some cases surgically, although surgery did not affect outcome. CONCLUSION: Preseptal complications of sinusitis can be diagnosed clinically without a CT scan and should be treated with an appropriate course of intravenous antibiotics. Postseptal complications of sinusitis can be diagnosed by the presence of ophthalmoplegia or proptosis and mandate a CT scan to differentiate abscess from orbital cellulitis. Management of these patients should include intravenous antibiotics, reserving surgery for selected cases.

Lateral neck radiography versus direct video rhinoscopy in assessing adenoid size.

OBJECTIVE: To evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhinoscopy in assessing adenoid size and the relationship of these methods to associated symptoms and thus the severity of the disease. METHODS: Children with suspected adenoid hypertrophy underwent standard lateral neck soft tissue radiographs: the percentage of airway occlusion, adenoid to nasopharynx (AN) ratio, airway to soft palate ratio, and adenoid thickness were assessed by a radiologist. The percentage of airway closure was assessed by direct fibre-optic rhinoscopy in an ear, nose, and throat clinic. Associated clinical symptoms were assessed by parents using a standardized questionnaire, evaluating the severity of symptoms (snoring, sleep apnea, mouth breathing, and otitis media) to give a total symptom score out of 16. RESULTS: Nonparametric statistical analysis using Spearman's correlation coefficients was performed on 32 patients. There was a weak correlation, which approaches significance, between the percentage of airway occlusion assessed by fibre-optic rhinoscopy and the total symptom score (r = .344, p = .054). However, this correlation becomes significant when the frequency of otitis media is omitted (r = .367, p = .039). There was also a significant correlation between airway occlusion assessed by rhinoscopy and the percentage of airway occlusion as determined by lateral neck radiography (r = .431, p = .014). There was no correlation between any of the measurements taken by lateral soft tissue neck radiography and total symptom score. CONCLUSION: Dynamic video rhinoscopy is more accurate at assessing adenoid hypertrophy, and the percentage of airway occlusion, as estimated by video rhinoscopy, is better correlated to the severity of symptoms than are values obtained by lateral neck radiography.

Similar allergic inflammation in the middle ear and the upper airway: evidence linking otitis media with effusion to the united airways concept.

BACKGROUND: Otitis media with effusion (OME) is a chronic inflammatory disease of the middle ear space characterized by the accumulation of fluid. Previous investigations have suggested that the immunopathologic mechanism underlying the development of middle ear effusion in patients with allergy is largely due to the effects of T(H)2 mediators. The composition of the inflammatory substrate in the effusions of allergic otitis media is similar to the late-phase allergic response seen elsewhere in the respiratory tract, such as in asthma and in allergic rhinitis. OBJECTIVE: To determine whether the middle ear compartment may be a component of the united airways in allergic disease by comparing the inflammatory profiles of the middle ear to the upper airway. METHODS: Middle ear effusions, torus tubaris (Eustachian tube mucosa at the nasopharyngeal orifice), and adenoidal tissue biopsies were obtained from 45 patients undergoing simultaneous tympanostomy tube placement for OME and adenoidectomy for adenoid hypertrophy. The cellular and cytokine profiles of each site were investigated by using immunocytochemistry (elastase, CD3, major basic protein) and in situ hybridization (IL-4, IL-5, IFN-gamma mRNA). Atopic status was determined for each patient by using skin prick testing. RESULTS: Eleven of the 45 patients with OME (24%) were atopic. The middle ear effusions of atopic patients had significantly higher levels of eosinophils, T lymphocytes, and IL-4 mRNA + cells ( P < .01) and significantly lower levels of neutrophils and IFN-gamma mRNA + cells ( P < .01) compared with nonatopic patients. The nasopharyngeal tissue biopsies revealed similar cellular and cytokine profiles. CONCLUSION: In atopic patients with OME, the allergic inflammation occurs on both sides of the Eustachian tube, both in the middle ear and in the nasopharynx. The results of this study support the concept that the middle ear may be part of the united airway in atopic individuals.

T(H)2 cytokine expression in atopic children with otitis media with effusion.

BACKGROUND: Otitis media with effusion (OME) is more common in atopic children. Few studies have looked for the presence of inflammatory mediators in the middle-ear effusions of this population. OBJECTIVE: We hypothesize that atopic children with OME have a different inflammatory cell and cytokine profile than nonatopic patients with the disease. METHODS: Twenty-six patients with OME undergoing myringotomy and ventilation tube placement were recruited at the McGill University Hospital Center. The atopic status was determined for each patient by using standard skin testing. By means of immunocytochemistry, fluid specimens were assessed for T lymphocytes (CD3), eosinophils (major basic protein), neutrophils (elastase), mast cells (tryptase), and basophils (BB1). By using in situ hybridization, the expression of IL-4, IL-5, and IFN-gamma was assessed. RESULTS: There is a higher percentage of eosinophils and T lymphocytes in atopic patients with OME (n = 8) compared with that seen in nonatopic patients (n = 18, P <.01). There is a higher percentage of neutrophils in nonatopic patients with OME compared with that seen in atopic patients (P <.01). In examining cytokine profiles, there is a higher percentage of cells expressing IL-4 and IL-5 in atopic patients with OME compared with that seen in nonatopic patients (P <.01). CONCLUSION: The predominance of eosinophils, T lymphocytes, and T(H)2 mediators in the middle-ear effusions of atopic children provides evidence that allergy might play a role in the pathogenesis of OME.

Evidence of allergic inflammation in the middle ear and nasopharynx in atopic children with otitis media with effusion.

BACKGROUND: Otitis media with effusion (OME) occurs in the setting of eustachian tube (ET) dysfunction. Previous studies have demonstrated a predominance of T helper 2 (Th2) mediators in the middle ear effusions (MEEs) of atopic children, suggesting that allergy plays a role in the pathogenesis of OME. Given that the middle ear is contiguous with the upper airway, the allergic inflammation seen in the middle ear of atopic patients with OME may also have been observed in the nasopharynx. OBJECTIVE: We hypothesize that atopic children have different cellular and cytokine profiles in MEE compared with nonatopic patients and that this allergic inflammation occurs in both the middle ear and the nasopharynx. METHODS: Forty-five patients undergoing both ventilation tube placement for OME and adenoidectomy for adenoid hypertrophy were recruited. The atopic status was determined for each patient using standard skin testing. The cellular and cytokine profiles of the MEEs and the torus tubarius and adenoid tissues were investigated using immunocytochemistry and in situ hybridization. RESULTS: Our results indicate that, within the atopic patient, there is a similar cellular and cytokine profile within the three regions sampled, with a predominant expression of interleukin-4 (a Th2 cytokine) and an increased infiltration of eosinophils compared with the nonatopic patient. CONCLUSION: These findings confirm the association of allergy with MEE and support the hypothesis that the middle ear may be an integral part of the United Airway Concept.