Acquired nasopharyngeal stenosis: a warning and review

OBJECTIVES

To present and discuss the clinical presentation and treatment planning in children with acquired nasopharyngeal stenosis (NPS) following tonsillectomy and adenoidectomy.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENTS AND OTHER PARTICIPANTS

Nine children identified over 2 years (1995-1996) with newly diagnosed NPS were evaluated. Seven of these children underwent adenoidectomy using a potassium titanyl phosphate laser technique at a neighboring facility. These children were aged 15.6 to 62.1 months at the time of original surgery, and all presented with nasal obstruction and mouth breathing beginning within 10 weeks after surgery. In addition, 5 had newly documented obstructive sleep apnea.

RESULTS

Of the 9 children, 1 required a tracheotomy. After undergoing an adenoidectomy, chronic rhinosinusitis developed and aggressive medical treatment failed in 4 children. Time from symptom onset to diagnosis of NPS ranged from 2 to 34 months. The diagnosis of NPS depends on obtaining a thorough medical history and conducting a physical examination that includes nasopharyngoscopy. Most children underwent a computed tomographic scan prior to repair. The scarring encountered in these patients involved the soft palate and the posterior pharyngeal wall and/or choanae bilaterally. Five children had no identifiable eustachian tube opening into the nasopharynx, and all 5 children had chronic otitis media with effusion or persistent otorrhea.

CONCLUSIONS

Nasopharyngeal stenosis following adenoidectomy and/or tonsillectomy is difficult to correct. Multiple surgeries may be required to relieve the obstruction. Standard operative techniques using the lateral pharyngeal flap and transpalatal or endoscopic intranasal approaches were adapted to the clinical situation. Prolonged use of nasal stents is mandatory to produce a nasopharyngeal opening. Adjunctive treatment may include pressure equalization tubes. However, the best treatment remains prevention.

Balance in children with otitis media with effusion

To determine the presence of balance disorders in young children who had otitis media with effusion (OME), 25 subjects, aged 13-57 months, diagnosed by pediatric otolaryngologists, were tested on the gross motor subtest of the Peabody Developmental Motor Scales, a standardized test of motor development with established norms. Parents also filled out questionnaires about their children's balance skills. Subjects with unilateral disease did not differ significantly from normals. Subjects with bilateral disease, however, were significantly impaired compared to normals on balance, locomotion and total score and they were significantly impaired compared to unilateral subjects on all scores. Parental perceptions of their children's balance correlated poorly with the test results. These data suggest that young children with bilateral otitis media with effusion are delayed in developing motor skills that require dynamic balance. Therefore, in spite of a negative history for balance problems physicians should consider balance performance when developing a treatment plan. Children with balance impairments might benefit from more aggressive intervention.

Modulation of immune cell function by the autonomic nervous system

This review discusses some of the major findings implicating the autonomic nervous system in the regulation of immune function. The sympathetic nervous system, the primary focus of this line of research, directly innervates the major lymphoid organs, and physiological release of sympathetic neurohormones at these sites has been documented. Leukocytes have been shown to express receptors for catecholamines, as well as neuropeptide Y, and studies in vitro and in vivo have indicated that occupation of these receptors by the appropriate ligands produces functional changes in immunological cells. Finally, altered sympathetic regulation may underlie some of the immunological abnormalities observed in chronic stress, clinical depression, and ageing.

Paranasal sinus development in chronic sinusitis, cystic fibrosis, and normal comparison population: a computerized tomography correlation study

Chronic sinus disease in patients with and without cystic fibrosis may have an impact on the pattern of paranasal sinus pneumatization. Arrest of pneumatization has been reported in both of these conditions. To assess the development of the paranasal sinuses in relationship to chronic sinusitis and cystic fibrosis (CF), a retrospective review of coronal CT scans of the age-matched patients with no previous sinus disease, patients with chronic sinusitis, and cystic fibrosis patients was conducted. The patients' ages ranged from 4 to 17 years. The maxillary sinus volume, anteroposterior diameter, and greatest transverse diameter and height were determined using image analysis software after the coronal CT scans were scanned into Macintosh computer. The size of the maxillary sinus increased with advancing age in the control and chronic sinusitis group, but not in the patients with cystic fibrosis. The patients with cystic fibrosis had a statistically significant smaller maxillary sinus size. Approximately 50% of the patients with chronic sinusitis had anatomic anomalies, the most common being paradoxical middle turbinates. The CT scans of CF patients were characterized by uncinate process demineralization and medial displacement of the lateral nasal wall in the middle meatus, and decreased maxillary sinus pneumatization.

Tenuous airway in children with trisomy 21

Multiple congenital anomalies are closely linked to Down syndrome (trisomy 21). Cardiac malformations are found in 40% of patients, a large number of whom will require a major surgical procedure. The importance of postextubation stridor in these children is frequently underestimated. A retrospective review of 99 trisomy 21 patients who underwent cardiovascular surgery revealed postextubation stridor in 24 (24.2%). Significant factors for the development of stridor included younger age (P=0.04), lower growth percentile for weight (P=0.03), and increased frequency of reintubation (P=0.04). Subglottic stenosis was found in 6 (6.1%). In 4 of these patients, an endotracheal tube of larger diameter than predicted for age was used. All 6 patients were less than the 10th percentile for weight. We conclude that Down syndrome patients deserve special considerations and modifications of standard intubation techniques for successful airway management.

Role of ultrasound in the assessment of vocal cord function in infants and children

The determination of the cause of stridor in the infant and child is an important directive for the otolaryngologist. The limitations of current clinical diagnostic techniques have provided the impetus for pursuing newer, more practical techniques to diagnose vocal cord paralysis in children. The purpose of this paper is to describe a new technique to image the larynx and determine its role in discerning vocal cord paralysis in children. This study began with an animal study (lamb model) demonstrating that computerized ultrasound can accurately delineate laryngeal anatomy and function. The human protocol included 27 patients (age 1 day to 14 years): 15 with normal larynges and 12 with vocal cord paralysis. Recorded ultrasound studies of these subjects were compiled in a randomly ordered videotape and presented twice and viewed in a blinded manner by four expert raters. Statistical analysis of their readings revealed that ultrasound is a highly accurate technique to document vocal cord paralysis, with a high degree of interrater and intrarater reliability. Beyond the accuracy and consistency of computerized ultrasound, there are many other aspects of this technique that make it clinically attractive. Laryngeal ultrasound is noninvasive, painless, and widely accepted. It is relatively safe, with no radiation exposure and no need for sedation or anesthesia. It is well tolerated by patients and their families. The results are easily displayed and recorded and available for hard copy storage. This investigation should not be interpreted as an endorsement for laryngeal ultrasound as a replacement for endoscopy in children. This work does indicate, however, that ultrasound is a technique that can accurately address the special issue of vocal cord mobility in infants and children. At present, this is the primary use for laryngeal ultrasound, although with additional investigation and sophistication it is likely that ultrasound of the larynx may become useful for other purposes.

Natural and cellular immune responses in Flinders sensitive and resistant line rats

Major depression is associated with impairments in natural and cellular immune responses. This study characterized baseline natural and cellular immune function in the Flinders Sensitive Line (FSL) genetic animal model of depression and in Flinders Resistant Line (FRL) controls. Splenic natural cytotoxicity per natural killer (NK) cell was significantly lower in the FSL rats, suggesting that NK cells are less activated at rest in the FSL rats than in the FRL controls. Neither lymphocyte proliferative responses nor interleukin-2 production differed between the two strains. Resting baseline concentrations of plasma adrenocorticotropic hormone and corticosterone were similar between the FSL and FRL rats, indicating that hypothalamo-pituitary adrenal axis activation did not mediate immunological differences. FSL rats show abnormalities in natural immunity similar to those found in clinically depressed human beings, indicating that this animal model may be useful in understanding the neural and neuroendocrine mechanisms associated with immune alterations in depression.

Context-dependent behavioral effects of interleukin-1 in the rhesus monkey (Macaca mulatta)

The behavioral effects of recombinant human interleukin-1 alpha (IL-1) in rhesus monkeys (Macaca mulatta) were assessed in 3 experimental paradigms: (1) a testing situation in which an initial quiescent period was followed by a challenge designed to evoke agitation; (2) a novel environment with a social partner; and (3) a working memory-dependent nonspatial cognitive task. In the first two experiments we replicated our previous observations that a high IL-1 dose (25 micrograms) induces somnolence in a quiet setting within 1 h. A lower IL-1 dose (1 ng) did not have these sedative properties, but both IL-1 doses significantly reduced the number of vocalizations made by the monkeys. In contrast, when the monkeys were challenged through direct eye contact with a human experimenter, the 25 micrograms IL-1 dose significantly increased agonistic behavior. Finally, performance on a working memory-dependent task (delayed non-matching-to-sample) was unaffected by doses of IL-1 ranging from 1 to 25 micrograms, possibly because the monkeys were tested after learning the task rather than during the acquisition phase. These results demonstrate that high levels of IL-1 in peripheral circulation can have potent behavioral effects in the nonhuman primate, but that the nature of the influence will depend on the context in which the animal is evaluated. Manifestation of cytokine-induced 'sickness behavior' appears to require a permissive environment.

Surgical management of macroglossia in children

Congenital macroglossia is associated with a variety of syndromes, most commonly Down syndrome and Beckwith-Widemann syndrome. Clinically, macroglossia may result in respiratory compromise, dysphagia, and poor cosmesis. A variety of treatments have been proposed, with surgical resection being the most common. We review management and describe a new surgical technique, consisting of a keyhole resection to decrease the width and length of the tongue. Between 1990 and 1992, five keyhole resections for congenital macroglossia were performed on four consecutive children at Texas Children's Hospital, Baylor College of Medicine, Houston. Patients had improved cosmesis and improved function of the oropharyngeal airway, with no change in speech and feeding. Keyhole resection is an effective treatment for macroglossia.

A role for CRH and the sympathetic nervous system in stress-induced immunosuppression

Central CRH coordination of the behavioral and physiologic sequelae of stress has been well established, and so it is parsimonious to suggest that CRH might also coordinate the immunologic sequelae. The studies presented here lend support to this suggestion. CRH administration into the brain was shown to modulate aspects of both cellular and humoral immune function, and the inhibition of CRH release in the brain following stress inhibited stress-associated immunosuppression. The effects of CRH appear to be mediated by the sympathetic branch of the autonomic nervous system, as chemical sympathectomy and pharmacological blockade of beta-adrenergic receptors both reversed the effects of CRH on immune function. In contrast, removal of the adrenal glands did not alter the immunologic effects of CRH. These links among CRH in the brain, sympathetic activation, and immune function suggest the possibility that immune function may be altered in other conditions characterized by elevated sympathetic tone, such as depression and aging, and that these alterations may be attributed to CRH dysregulation in the brain. These studies shed light on the intricate relationship between the brain and the immune system, and also illuminate its complexity. The differential regulation of CRH in the brain and the periphery is one example of the latter. These findings also set the stage for potential clinical intervention with CRH antagonists, for example, to treat compromised immune function associated with chronic stress, depression, or aging.

Neuropeptide Y inhibits in vivo specific antibody production in rats

The sympathetic neurotransmitter neuropeptide-Y (NPY) is hypothesized to play a role in the in vivo modulation of immune responses. This study examined the effects of intraperitoneal administration of NPY on specific antibody responses to keyhole limpet hemocyanin (KLH) in rats. Antibody levels were repeatedly measured by enzyme-linked immunosorbent assay before and after intraperitoneal immunization with KLH. NPY induced a dose-dependent inhibition of IgM and IgG antibody responses following immunization with either physiologic or supraphysiologic doses of antigen. These in vivo results suggests that NPY may be involved in endogenous modulation of immune responses.

Avoiding Complications in Pediatric Otolaryngology

Educational objectives: To avoid specific complications associated with common procedures in pediatric otolaryngology and to manage complications effectively when they arise after certain procedures in pediatric otolaryngology.

Head and neck manifestations of erythema multiforme in children

Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis are related disorders of skin and mucous membranes, which are typically associated with antecedent medication use or infection. We review 108 cases of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis from Texas Children's Hospital, Houston, Texas, from 1981 to 1991, and illustrate the characteristic skin and mucosal lesions. In addition, we describe in detail two unusual cases requiring intensive airway management. Head and neck manifestations were present in 4 of 79 patients (5%) with erythema multiforme and 26 of 28 patients (93%) with Stevens-Johnson syndrome. In Stevens-Johnson syndrome, mucosal involvement of the lip (93%), conjunctiva (82%), oral cavity (79%), and nose (36%) were most common. Antecedent medication use was identified in 59% of erythema multiforme patients and 68% of Stevens-Johnson syndrome patients. We note a striking increase in the number of cases in our series caused by cephalosporins. Fifty percent of Stevens-Johnson syndrome patients required supplemental hydration or alimentation because of the severity of the oral cavity involvement. The head and neck mucosal manifestations largely respond to local care, and the routine use of prophylactic antibiotics or systemic steroids is not recommended.

Bidirectional effects of interleukin-1 on immune responses in rhesus monkeys

Physiological and pharmacological doses of recombinant human interleukin-1 (IL-1) were administered intravenously to juvenile rhesus monkeys in order to evaluate its effects on immune and endocrine activity. Mitogen-induced lymphocyte proliferation was increased following 1-ng and 1-microgram doses of IL-1, but decreased following 10- and 50-micrograms doses. Natural killer cell cytotoxicity was also significantly reduced at the 10-micrograms dose and tended to be below baseline at the 50-micrograms dose. These changes were associated with marked neutrophilia observed after administration of IL-1. These results indicate that peripheral administration of IL-1 can either enhance or inhibit the numbers and responses of immune cells in rhesus monkeys depending on the dose administered. These responses may have been the result of differential activation of the endocrine system, because levels of pituitary hormones in plasma increased progressively with increasing doses of IL-1. Thus, the extent to which a particular dose of IL-1 induces the release of pituitary-adrenal hormones may be related to the direction and magnitude of the resulting changes in immune activity.

Pain, disability, and psychological functioning in chronic low back pain subgroups: myofascial versus herniated disc syndrome

A series of patients with chronic low back pain evaluated at a tertiary referral center were the subjects for this study. Of 250 consecutive patients, 94 were diagnosed as having myofascial pain and 57 as having herniated disc syndrome. Before evaluation and diagnosis, all patients completed the McGill Pain Questionnaire, ratings of pain and disability, and the Symptom Checklist 90-R. Patients were also grouped on the basis of previous surgical history and workers' compensation benefits. Patients suffering from myofascial pain were significantly less likely to report periods of pain relief than patients with herniated disc syndrome. Those receiving workers' compensation benefits reported significantly greater levels of pain, disability, and psychological distress than those not receiving benefits, irrespective of diagnosis. Patients who underwent previous surgery did not differ significantly from those who never underwent surgery. All patients had elevated scores on the Somatization subscale of the Symptom Checklist 90-R. Patients with myofascial pain and workers' compensation benefits demonstrated the highest levels of somatization and phobia. These findings suggest that the effects of low back pain of myofascial origin have comparable, if not worse, consequences than disc herniation. These findings also reaffirm the importance of workers' compensation in understanding the differences in patients with chronic low back pain.

Vincristine-induced recurrent laryngeal nerve paralysis

Vincristine-sulfate-related vocal cord paralysis has been reported infrequently in the literature. The neurotoxicity of the vinca alkaloids is well-known; however, the potential for cranial nerve involvement is not widely recognized. Given the complexity of the typical patient receiving such a chemotherapeutic agent, the potential for misdiagnosis is high. Many patients have primary tumors or metastatic lesions in sites that could cause the clinician to overlook this reversible cause of neurologic dysfunction. This study describes the first three reported pediatric cases of vincristine-induced vocal cord paralysis. Two patients developed increasing stridor secondary to bilateral vocal cord paralysis; the third developed a unilateral vocal cord paralysis. All resolved spontaneously upon withdrawal of the vincristine. Vinca-alkaloid-induced vocal cord paralysis is a potentially dangerous but reversible lesion. Otolaryngologists should be aware of the association between these agents and cranial nerve neuropathies.

Laser therapy for lymphatic malformations of the upper aerodigestive tract. An evolving experience

Lymphatic malformations of the upper aerodigestive tract can present therapeutic challenges. Symptoms associated with these lesions include bleeding, dysphagia, changes in speech, and dyspnea. Surgical therapy is recommended, which often leads to functional interference and cosmetic deformities. Laser photocoagulation of these malformations can control symptoms and may be repeated as necessary, preserving tissue and function. The results in four patients treated with the carbon dioxide laser and in five patients treated with the neodymium-YAG laser were reviewed. Reduction of bulk and improvement of symptoms were achieved in all patients, most of whom required multiple treatments. The average duration of each procedure was 30 minutes. All patients were discharged from the hospital on the same day or 1 day after laser therapy with minimal morbidity. The indications, evolving technique, and results of laser therapy are discussed.

Thyroglossal duct remnants. Preoperative evaluation and management

Midline cervical cysts arising from the thyroglossal duct are one of the most common causes of anterior neck swelling in children. The potential for confusion between the thyroglossal duct cyst and the ectopic thyroid gland is well documented and may result in serious complications. A retrospective chart analysis was therefore undertaken to determine the relative importance of clinical evaluation, thyroid function testing, and radioisotope scanning in distinguishing these two entities preoperatively. A combined study was carried out by The Children's Hospital, Boston, Mass, and Rainbow Babies Hospital, Cleveland, Ohio. The hospital records, including nuclear scans, were reviewed. A total of 229 patients were taken to the operating room between January 1, 1978, and December 31, 1987. Nuclear scanning was performed in 30% of these patients. This subgroup of patients forms the basis for our guidelines of preoperative assessment. The absolute need for a preoperative scan is reexamined.

Congenital cholesteatoma of the middle ear in children: a clinical and histopathological report

Forty-one children with congenital cholesteatoma of the middle ear seen from 1978 through 1989 are reviewed. The most common presentation was that of an asymptomatic white mass behind a normal intact tympanic membrane. Computed tomography (CT) scan was useful in documenting extension beyond the mesotympanum. Surgical removal was performed using an extended tympanotomy for lesions in the middle ear and tympanomastoidectomy for those that had extended into attic and mastoid air cells. Observation over an average 3.1-year period indicated that 80% of children were free of disease after initial surgery. Residual disease that required further surgery was present in 20%. The importance of early diagnosis of congenital cholesteatoma is strongly advocated. The prognosis is better when the cholesteatoma is confined to the anterosuperior quadrant of the middle ear. Seventeen patients in this study had such a lesion, and extended tympanotomy allowed removal of an encapsulated closed cholesteatoma with normal postoperative hearing and no residual cholesteatoma. The average age was 2.3 years. Temporal bone histopathological studies of three cases of congenital cholesteatoma demonstrate two distinct pathological types of congenital cholesteatoma. A "closed" keratotic cyst in the anterior mesotympanum, which is easily removed, and an "open" infiltrative type in which there is no containment of the keratotic debris and the cholesteatoma matrix is in direct continuity with middle ear mucosa. Surgical extirpation of the "open" type is difficult and more likely to be associated with residual disease.

Time-dependent effects of peer separation on lymphocyte proliferation responses in juvenile squirrel monkeys

This study evaluated the immunological, hormonal, and behavioral responses of juvenile squirrel monkeys to repeated social separations of varying length. Following a 3-hr separation, lymphocyte responses to stimulation with the mitogen concanavalin A (Con A) declined significantly, and these alterations were sustained after a 24-hr separation period. The responses to Con A and to a second mitogen, phytohemagglutinin (PHA), were suppressed after 2 days. At the end of a 7-day separation period, immune responses were not significantly different from basal values. Plasma cortisol levels were elevated above basal levels in all animals after the 3-hr, 24-hr, and 2-day separations, but were not elevated after the 7-day separation. While we observed no statistically significant changes in locomotor activity or calling behavior during any of the separations, the monkeys tended to be most active and to call most immediately following separation. Our findings concur with earlier reports indicating that social stressors can influence lymphocyte proliferation in nonhuman primates and that certain cell types might be differentially sensitive to stress, but also indicate that these influences are transient.

Airway complications in CHARGE association

The association between catastrophic airway events and developmental delay was examined in patients with CHARGE (coloboma, heart disease, atresia choanae, retarded growth and/or development, genital hypoplasia, and ear anomalies and/or deafness) association. A retrospective chart analysis was performed from The Children's Hospital in Boston, Mass. Sixteen patients were identified with CHARGE association. Nine patients had at least one respiratory arrest, and 7 had no airway difficulties. Some degree of developmental delay was seen in 14 patients, but was most severe in those patients who suffered a respiratory arrest. We conclude that children with CHARGE association have a propensity for airway instability and that cerebral hypoxia contributed to the developmental delay in some of our patients. We recommend early tracheotomy rather than early choanal atresia repair in these patients to protect the central nervous system.

Chronic pediatric stridor: etiology and outcome

Stridor in children is usually acute. This paper represents a chart review and telephone survey of 60 patients with chronic pediatric stridor. The most common etiology was laryngomalacia, which required airway intervention in 22% of the patients. The symptoms persisted beyond 18 months of age in 17% of the patients. Twelve percent of the patients had multiple lesions; 65% of the second lesions were below the vocal cords. It appears that the presence of cyanosis should increase physician suspicion of multiple lesions. There was not a higher risk of recurrent upper respiratory infections with any of the diagnoses.

Central nervous system complications associated with acute otitis media in children

The purpose of this article is to review a subset of pediatric patients with otitis media occurring simultaneously with meningitis and other central nervous system diseases. Of the 92 cases reviewed, 61.3% involved patients under 12 months of age. Meningitis associated with otitis media involved 91% of the patients; the remainder had nonmeningitic central involvement. The most striking finding was the high incidence of Haemophilus influenza type-B, a relatively uncommon pathogen of the middle ear. This finding highlights the need to select antibiotic coverage to adequately treat Haemophilus influenza type-B.