Imaging studies in the diagnostic workup of neonatal nasal obstruction

Twelve neonates presenting with nasal obstruction after birth were evaluated by imaging studies for diagnostic reasons. Four groups were recognized: Group I: choanal atresia (n = 5) and choanal stenosis (n = 1); Group II: congenital nasal pyriform aperture stenosis (CNPAS) (n = 3) and holoprosencephaly (n = 1); Group III: nasolacrimal duct mucocele (n = 1); Group IV: nasal hypoplasia (n = 1). Associated anomalies were found in eight patients. Four patients with choanal atresia showed manifestations of the CHARGE (coloboma, congenital heart defect, atretic choanae, retarded physical and neuromotor development associated with central nervous system anomalies, genital hypoplasia, and ear anomaly and/or deafness) association. In the fifth patient with choanal atresia, the diagnosis of amnion disruption sequence was made. One patient with CNPAS had a solitary maxillary central incisor (SMCI), a mild form of holoprosencephaly. Besides proboscis and synophthalmos, SMCI was also present in the holoprosencephaly case. The patient with severe nasal hypoplasia had warfarin embryopathy. This review emphasizes the need for performing imaging studies in the diagnostic workup of neonates born with nasal obstruction.

Turnover of Haemophilus influenzae isolates in otitis-prone children

Arbitrarily primed PCR with primer ERIC2 and RAPD Ready-to-Go beads was applied to study the epidemiology of non-typable Haemophilus influenzae (NTHI) isolated from the nasopharynx of children with recurrent otitis media (otitis-prone children). Thirty-five otitis-prone children (OP-children) were included. Three pairs of siblings were identified in the study population. This study is part of a large prospective multicentric trial investigating the efficacy of a new conjugated pneumococcal vaccine in OP-children (OMAVAX trial). During a 2-year study period, NTHI strains were isolated from nasopharyngeal swabs and, when possible, middle ear aspirates were collected in OP-children between 1 and 6 years of age. In 20 out of the 35 children, 48 H. influenzae isolates were obtained simultaneously from different sites (left and/or right ear and/or nasopharynx) of the same child as well as from siblings or during initial and follow-up visits of the same child. Subsequent genotyping indicated substantial genetic diversity among the H. influenzae isolates studied, since for a total of 48 isolates in 20 OP-children, 29 different genotypes were observed. Simultaneous isolation for different sampling sites (ear or nasopharynx) as well as for siblings resulted mostly in identical fingerprints. Longitudinal follow-up of H. influenzae isolates in the nasopharynx almost always resulted in different genotypes. We can therefore conclude that both cross colonization (between sampling sites within the same patient and between siblings) and turnover of H. influenzae isolates are high in OP-children.

Congenital CMV-infection and hearing loss

CMV (cytomegalovirus) is one of the Herpesviridae, known for their potential for latency and reactivation. The sequelae of fetal infection are diverse: chronic stage of early fetal infection with brain anomalies, symptomatic late fetal infection with hepatitis and thrombocytopenia and asymptomatic infection. With any of these clinical phenotypes, permanent hearing loss is possible. CMV-infection is the only relevant viral cause of perinatal hearing loss because rubella, measles and mumps have become rare due to vaccination. Recent studies have suggested beneficial effects on outcome of i.v. ganciclovir treatment in symptomatic cases. We have recently taken the challenge of treating asymptomatic newborns on the basis of active sonographic brain lesions in order to prevent labyrinth destruction. We would also like to stress the importance of suspecting children with congenital hearing loss, or hearing loss that develops in the first year of life, of having an asymptomatic congenital CMV-infection. Follow up in the first years of life is necessary in these children because further progression of hearing loss is possible.

Turnover of Haemophilus influenzae isolates in otitis-prone children

INTRODUCTION

Previous studies have suggested a direct relationship between the nasopharyngeal carriage of potential middle ear pathogens and the development of middle ear disease. It has been shown that otitis-prone (OP) children tend to be colonized more often than non-OP children. To study the turnover of nontypeable Haemophilus influenzae (NTHI) in the nasopharynx of OP children, arbitrarily primed PCR was applied to NTHI strains isolated nasopharyngeal swabs collected prospectively during a 2-year study period from 35 OP children under 4 years of age at fixed intervals. METHODOLOGY/MATERIALS: In 20 patients, H. influenzae could be isolated from different sites (left and/or right ear and/or nasopharynx) or at different occasions during follow-up. Forty-eight H. influenzae isolates of different sites (left and/or right ear and/or nasopharynx) of the same patient as well as from siblings were typed using arbitrarily primed PCR with primer ERIC2 and RAPD Ready-to-Go beads (Pharmacia Biotech, Uppsala, Sweden).

RESULTS

Typing with arbitrarily primed PCR enabled to differentiate 29 genotypes among the 48 H. influenzae isolates. Sixteen of these fingerprints were observed only once. Thirteen of these fingerprints appeared on two or more occasions. In the three pairs of siblings the same strain was identified at one moment. Genetically identical NTHI strains from unrelated individuals were never identified. In 11 of 14 cases for which isolates were obtained simultaneously from different sites (throat and/or left ear and/or right ear) or from three pairs of siblings, identical fingerprints were observed. In nine cases whereby isolation was separated by a period of more than 4 weeks (maximum 28 weeks) the fingerprints of the isolates were different from the original isolate.

CONCLUSION

Typing with arbitrarily primed PCR indicated substantial genetic diversity among the H. influenzae isolates studied, since for a total of 48 isolates of 20 different patients, 29 different genotypes were observed. Since simultaneous isolation for different sampling sites (ear or nasopharynx) as well as for both of siblings, resulted mostly in identical fingerprints, and since sampling of the same site of the same patient, separated by an interval of more than 1 month, almost always resulted in different genotypes, one could conclude that both cross colonization (between sampling sites within the same patient and between siblings) and turnover are high. The relation between acquisition and development of disease needs further attention.

Communication problems in Turner syndrome: a sample survey

Turner syndrome is a condition first recognized in 1938 with an incidence estimated at 1/2500 female births. It is known to result from a missing X chromosome and has as its main features a short stature, ovarian dysgenesis, neck webbing, congenital peripheral lymphedema, coarctation of the aorta, cubitus valgus, dysplastic nails, and pigmented nevi. In addition, psychosocial difficulties including communication disorders may occur. While the physical characteristics of Turner syndrome have been well documented, information on the communication problems in Turner syndrome is scarce. This study reports the results of a sample survey in 128 girls with Turner syndrome ranging in age from 2.4 to 58.8 years. Results are presented on the occurrence and nature of speech and language problems (voice disorders, articulation problems, stuttering, and delayed language development), on the presence of learning disabilities, and on educational history.

Uncommon and unusual complications of otitis media with effusion

Some complications of otitis media with effusion (OME) are not obvious and not always associated with otitis media by physicians and patients; the authors propose to call them 'unusual complications', although they may be quite frequent. Complications such as dizziness, clumsiness and behavioural disorders are classified in this group. Other complications are rare and uncommon such as sensorineural hearing loss and cholesteatoma. Some of these sequelae are structural, others more functional. The impact of OME on complex functions such as language, learning or behaviour is still controversial but seems to have been underestimated until now. Not only withholding treatment in children with OME may cause complications but also the treatment of OME may lead to sequelae, although serious side effects caused by the treatment of OME are rare. In this literature review, the epidemiology, importance and diagnosis of the uncommon and unusual complications of OME will be discussed.

Role of nasopharyngeal bacterial flora in the evaluation of recurrent middle ear infections in children

OBJECTIVE: To study the nasopharyngeal colonization in otitis-prone children before and after adenoidectomy. METHODS: The study population consisted of 35 children between 11 months and 4 years of age, undergoing adenoidectomy and tube placement for recurrent acute otitis media. All these children were otitis prone (OP). During general anesthesia, bacteriologic samples were obtained from the nasopharynx and the middle ear fluid, if present. During the follow-up visit, a new nasopharyngeal culture was taken. The control population consisted of 35 children undergoing surgery for non-ear-nose-throat pathology. These children had no history of recurrent upper respiratory tract infections. RESULTS: Colonization of the nasopharynx with potential pathogens (Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae) occurred significantly more in the OP children than in the non-OP children. Adenoidectomy resulted in a substantial decrease of potential middle ear pathogens in the nasopharynx and an increase of normal commensal flora. In about half of the patients, middle ear fluid was still present at the time of tube placement; in most instances, H. influenzae was cultured. Typing with arbitrarily primed PCR indicated substantial genetic diversity among the H. influenzae isolates studied. CONCLUSIONS: Both cross-colonization (between sampling sites within the same patient and between siblings) and turnover appeared to be high.

Otological manifestations of CHARGE association

The combined findings of abnormalities of the incus and stapes, absence of the oval window, absence of the stapedius muscle (with absent pyramidal eminence and tympanic sinus in most cases), and abnormalities of different parts of the inner ear (dysplastic cochlea, hypoplastic or dysplastic vestibule, and absent semicircular canals) are characteristic of the CHARGE association. Computed tomography and magnetic resonance imaging using 1-mm-thick contiguous slices proved useful in demonstrating the broad spectrum of temporal bone abnormalities in patients with the CHARGE association.

CT of the temporal bone in the CHARGE association

We reviewed the CT examinations of the temporal bone, performed with 1-mm-thick contiguous sections, of seven patients with the CHARGE association. We found abnormalities of the incus and stapes, with ossicular chain fixation, absence of the stapedius muscle and oval window, hypoplasia or dysplasia of the vestibule and absence of the semicircular canals in all ears. The pyramidal eminence and tympanic sinus were absent and there were anomalies of the cochlea in 13 of 14 ears. Absence of the semicircular canals is the most specific change in patients with the CHARGE association.

Secondary superficial siderosis of the central nervous system in a patient presenting with sensorineural hearing loss

We present a 50-year-old man who was investigated for sensorineural hearing loss. On MRI of the brain superficial siderosis of the central nervous system was seen, while MRI of the spine revealed an ependymoma of the cauda equina. This case illustrates the importance of performing T2-weighted imaging of the brain and posterior fossa when sensorineural hearing loss is present. Spine imaging is mandatory when superficial siderosis of the brain is diagnosed without identification of a bleeding source in the brain.

Value of rigid bronchoscopy and cytodiagnosis of bronchial washings in detecting bronchial carcinoma in the presence of a carcinoma of the upper aerodigestive tract

OBJECTIVE

To assess the usefulness of rigid bronchoscopy and bronchial washings in detecting primary lung carcinomas.

SETTING

Department of Otolaryngology, University Hospital of Ghent, Belgium.

DESIGN

Prospective analysis of patient investigations.

METHOD

The results of 127 rigid bronchoscopies with bronchial washings in patients with a new, untreated head and neck tumour and a normal chest radiograph were analyzed for their usefulness in detecting simultaneous primary lung carcinomas. All patients were followed for a minimum of 2 years or till death.

RESULTS

We found positive bronchial washings in 19 cases (21%). Unilateral positive bronchial washings were found in 8 patients (9%). In only one patient was a simultaneous primary lung tumour found. One patient was found to have a pulmonary metastasis. The remaining 6 patients with positive unilateral cytology (6/8) had normal chest roentgenograms and/or CT scans, and did not develop a lung tumour in the course of follow up. Of the 19 positive bronchial washings, 10 patients had a carcinoma of the larynx and two had a large hypopharyngeal carcinoma.

CONCLUSIONS

Contamination of bronchial washings with tumour cells from head and neck neoplasms limited seriously the usefulness of positive bronchial cytology. The sensitivity and specificity of the rigid bronchoscopy with bronchial washing is too low to justify its cost.

Diagnostic and therapeutic management of atypical mycobacterial infections in children

A series of 12 children (9 girls, 3 boys) with non-tuberculous mycobacterial lymphadenitis was reviewed to define the most frequent presenting features, helpful diagnostic measures and optimal management. The mean age at diagnosis was 42 months and cervical nodes in the submandibular region were most commonly affected. In most of the children the diagnosis was made on the basis of a positive intradermal skin test with specific antigens for atypical mycobacteria. The diagnosis was confirmed in all but one case by histopathologic examination. Total excision of the affected gland was recommended as the therapy of choice in the patients treated.