Relationship between the clinical course and HPV typing of recurrent laryngeal papillomatosis. The Red Cross War Memorial Children's Hospital experience 1982-1988

During the period 1982-1988, 20 new cases of laryngeal papillomatosis in children were seen at The Red Cross War Memorial Children's Hospital. HPV typing of biopsy specimens was performed. Their clinical course was reviewed and age at presentation ranged from 1 to 10 years. There was no correlation between age and either aggression or a prolonged clinical course. HPV DNA was identified in all 20 cases (100%). Fifteen (75%) were HPV Type 11 and 5 (25%) were HPV Type 6. There were no mixed infections. HPV Type 6 infection was more clinically aggressive than HPV Type 11 infection. The intensity of the virus signal in the biopsy specimens was not in general indicative of the clinical behavior of the disease, although two children with particularly strong intensity exhibited aggressive disease. It is suggested that identification of HPV type 6 infection has prognostic significance.

Ascariasis and acute otitis media

Ascaris lumbricoides has rarely been implicated in the causation of middle ear disease. An infant who developed acute suppurative otitis media while on antibiotics for an upper respiratory tract infection and who extruded an ascaris worm from the ear is presented. The otitis media subsequently resolved. Our understanding of the pathophysiology of ascariasis in the eustachian tube and middle ear is discussed.

Age-based construct validation using structural equation modeling

In this paper we describe some mathematical and statistical models based on structural equation modeling (SEM) using computer programs like LISREL. We focus on SEM methodology for the simultaneous examination of the internal validity of psychological constructs and the external validity represented by age relations. To illustrate these ideas we use a latent variable path model to examine the organization of intellectual abilities measured by the WAIS-R in the standardization sample. We also examine different ways in which age can be used to structure this organization. This is primarily a methodological paper, but we try to integrate conceptual principles of modeling with some substantive issues of research on the psychology of aging.

Adenoids: comparison of radiological assessment methods with clinical and endoscopic findings

Methods of evaluating adenoidal size pre-operatively are controversial. Symptoms and clinical evaluation have been both advocated and condemned. Depending on the methodology, measurement of the radiological adenoidal shadow has been difficult to correlate with the clinical patency of the nasopharyngeal airway and to the actual size of the removed adenoid. Four different methods were used to measure the adenoidal size on 74 radiographs. The methods were evaluated against the degree to which the adenoids obstructed the nasopharynx on flexible endoscopy of the postnasal space. Obstructive symptomatology was also evaluated against the degree of obstruction. The radiological method that best correlated to the endoscopic findings was that of Cohen and Konak (1985). However, obstructive symptomatology had the overall highest correlation to endoscopic findings.

Peristomal complications of paediatric tracheostomy

Failure of decannulation after paediatric tracheostomy, once the underlying disorder has resolved, is almost always due to peristomal complications. Granulation tissue formation in the raw tissue of the stoma and its subsequent fibrosis requires removal (50 of the 293 tracheostomies from the Red Cross War Memorial Children's Hospital). It is suggested that this can be avoided by creating a formal skin-to-trachea stoma at the time of tracheostomy. Suprastomal depression of the anterior wall of the trachea (52/293) appears to be unavoidable when using standard tracheostomy tubes. Localised stomal site tracheomalacia and stenosis (numbers of this complication are unknown) results from damage to cartilage of the trachea either by incision or by necrosis from pressure of the tracheostomy tube. Trauma to the cartilage needs to be minimised by careful design of the tracheal incision. It is suggested that consideration should be given to creating a formal tracheostomy stoma for any paediatric tracheostomy that is likely to be required for more than a short period of time.

The effect of experimental infection with Rhodococcus equi on immunodeficient mice

To investigate the pathogenesis of respiratory lesions caused by the facultative intracellular pathogen, Rhodococcus equi, pulmonary clearance was compared in four groups of genetically defined mice, chosen for their specific deficits in immune and inflammatory responses. Complement-deficient A/J, immunodeficient nu/nu (nude), scid/scid.bg/bg (SCID/beige), C57BI/6J.bg/bg (beige) and normal Swiss mice (SW) received approximately 10(7) R. equi intranasally on day 0. Bacterial clearance was assessed in lung, liver and spleen on days 1, 4, 7 and 14. Pulmonary clearance was not significantly different between SW and A/J mice. Beige mice cleared R. equi more rapidly and completely than A/J and SW, indicating that deficits in phagocytic and NK cell function associated with the bg/bg gene did not compromise clearance. Pulmonary clearance in immunodeficient SCID/beige mice paralleled that of the SW and A/J mice initially but bacterial proliferation produced significant differences from SW mice at day 14. Nude mice were unable to clear R. equi from day 1, resulting in the death of two nude mice at day 11. Both SCID/beige and nude mice developed severe pyogranulomatous bronchopneumonia, whereas A/J and SW mice developed transient pulmonary lesions. Beige mice developed minimal lung lesions. Significant systemic bacterial proliferation occurred only in nude and SCID/beige mice. We conclude that deficiencies in complement components, phagocytic and NK cells do not impair the pulmonary clearance of R. equi but that a competent cellular immune system is required to prevent pneumonia and death. The difference in early phase pulmonary clearance in nude and SCID/beige mice indicates two phases are important for clearance. An acapsular mutant of R. equi was completely cleared from the lungs of SCID/beige mice suggesting an important role for the capsule in virulence for mice.

The current status of corrective surgery for laryngomalacia

When the airway obstruction related to laryngomalacia becomes significant, surgical correction of the underlying laryngeal deformity is indicated. The three elements of the supraglottic soft tissue that prolapses, namely, the corniculate mounds on the arytenoid cartilages, the shortened ary-epiglottic folds, and the omega shaped epiglottis, can all be appropriately "trimmed" using either conventional instruments or the surgical laser. Relief of symptoms is dramatic and, provided surgery is performed precisely and not during episodes of infection, complications should not occur. The aid of specialized, skillful anesthesia is required for this type of surgery. We present a series of 40 children with significant obstruction: 30% had neuromuscular disorders, 68% had an infantile epiglottis, seven required airway support prior to surgery, all had laser "supraglottic trimming," and 13 required airway support after surgery. Relief of stridor and airway obstruction was generally rapid. There was only one complication: croup developing 4 days after surgery.

Mastoid surgery at the Red Cross War Memorial Children's Hospital 1986-1988

Eighty-three children between ages 0-12 years had mastoid surgery in the three year period 1986-88. The indications were acute mastoiditis (30 children), uncontrolled chronic suppurative otitis media (CSOM) (24 children), cholesteatoma (22 children) and a miscellaneous group (7 children). Forty-seven per cent of those with acute mastoiditis were under one year but the 27 per cent with cholesteatoma as the precipitating cause were 4-12 years. Twenty-three per cent had significant complications. Typmano-mastoid surgery was employed to resolve uncontrolled CSOM. Children were between 2-12 years and 62 per cent were below the 25th centile for weight. Seventy-nine per cent of the tympanic membrane grafts were successful. The children with cholesteatoma were between 3-12 years and 76 per cent were below the 25th centile for weight. Eight of them only presented after the onset of acute mastoiditis. One child had a definite congenital cholesteatoma. Only one had a pars flaccida origin of the cholesteatoma sac and only eight an origin from the postero-superior pars tensa. All had open cavity surgery. When the cavity was lined by temporalis fascia, healing was improved markedly.

Tympanoplasty surgery at the Red Cross War Memorial Children's Hospital 1986-1988

Results of tympanoplasty surgery over a 3 year period in 96 children aged 2-12 years were analysed to better define indications for surgery and prognostic factors. Nineteen percent had a hearing loss associated with a dry perforation--grafts were successful in 84% and 71% improved hearing to less than 20 dB. Forty-two percent had a hearing loss but also troublesome recurrent infection--grafts were successful in 88% but only 65% improved hearing to less than 20 dB. Thirteen percent had troublesome recurrent infection--grafts were successful in 79%. Twenty-two percent had uncontrolled infection, a cortical mastoidectomy together with myringoplasty produced a 75% take rate. Graft take was not affected by age, type of surgery, infection status or perforation size. Poor nutritional status and postoperative infection both had negative tendencies. In this small series there was a 10% re-perforation rate.

Ear and hearing disorders in rural grade 2 (Sub B) schoolchildren in the western Cape

Four hundred and one children living in rural areas with a high level of poverty were assessed for ear and hearing disorders in their second year of schooling. Overall, only 40.3% of these children had both normal-appearing ear drums and normal hearing thresholds bilaterally; 14% had obstructing wax plugs; 17% had evidence of past acute otitis media with scarring or progression to chronicity--6% having perforations; 31% had middle-ear effusions and/or their sequelae; and 33% had some impairment of hearing but, if the effect of testing in the classroom environment is considered, there was probably only significant impairment in 9%. It is suggested that the prevalence of chronic ear disorders is a useful marker of the quality of primary care in rural communities.

Tracheostomy in the management of laryngotracheobronchitis. Red Cross War Memorial Children's Hospital experience, 1980-1985

In the 6-year period 1980-1985 162 children required tracheostomy during treatment of laryngotracheobronchitis at Red Cross War Memorial Children's Hospital, Cape Town. This represents 4.6% of 3,500 children with this disorder and 28% of those requiring airway intervention. Fifty-eight percent of the children were decannulated within 4 weeks and 75% within 10 weeks. Fifty-four per cent of the children required one or more further procedures before decannulation, including 7 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 24 children and suprastomal collapse was a cause of decannulation failure in 29 children. Use of an expiratory valve as an aid to decannulation is discussed. Three children died of tracheostomy airway complications and 6 of a medical disorder. Another complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration.

Tracheostomy in children--the Red Cross War Memorial Children's Hospital experience 1980-1985

During the 6 years (1980-1985) at The Red Cross Children's Hospital 293 children required a tracheostomy during treatment of a variety of disorders. Of these children 44% were under 1 year of age. Indications are discussed of which the commonest was LTB. Of the 3500 children seen with laryngotracheobronchitis (LTB) 4.6% had a tracheostomy--28% of those requiring airway intervention. Overall 67% of the children were decannulated within 10 weeks and 92% within a year. For 56% one or more further procedures prior to decannulation were required, including 34 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 51 children and suprastomal collapse was a cause of decannulation failure in 52 children. Use of an expiratory valve as an aid to decannulation is discussed. Five children died of tracheostomy airway complications and 25 children of a medical disorder. One complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration. Staphylococcus aureus and Hemophilus influenzae were the main organisms cultured in the early weeks, with Pseudomonas and Streptococcus species predominating later.

Protocol for management of the interposition cartilage graft laryngotracheoplasty

This report presents the results of laryngotracheoplasty surgery using both the Evans and Cotton techniques on 27 children with congenital or acquired subglottic stenosis. Failure to obtain early decannulation after surgery has resulted in the formulation of a new protocol for the operative and postoperative management of infants undergoing cartilage graft tracheoplasty. Excision and closure of the tracheostoma at surgery, with postoperative nasoendotracheal intubation providing the necessary support for the graft, now has reduced this period to approximately 2 weeks. A series of six infants for whom this protocol was followed is presented.

Idiopathic facial nerve palsy (the effect of treatment with steroids)

Eight hundred and seventy-nine patients with Bell's Palsy were seen over a 10-year period. There was a distinct female preponderance and the peak incidence occurred in the second to fourth decades. There did not appear to be an increased incidence of either hypertension or diabetes but there was a definite increased risk during pregnancy. Half of the patients had an incomplete palsy and they all recovered within a few weeks of onset. Those patients with complete palsy but without evidence of degeneration also all recovered but took longer to do so. If degeneration was evident the chance of recovery was only 50 per cent. Steroids did not appear to influence the outcome of Bell's Palsy.

An unusual complication of epistaxis

Ten days after left-sided external carotid artery ligation for control of profuse epistaxis a complete left-sided facial nerve palsy developed in a 25-year-old male. Abnormal bleeding or clotting disorders had been excluded. It is postulated that either thrombosis or embolus obstructed the petrosal branch from the middle meningeal artery on the same side with subsequent ischaemia resulting in nerve degeneration of the intratemporal portion of the facial nerve.

Idiopathic facial nerve palsy in children and the effect of treatment with steroids

During a 10-year period 228 children were seen with Bell's Palsy. In half of them the palsy was incomplete. Overall the recovery rate was 96%. There was a strong female preponderance but no difference in incidence between right of left sides. Twenty-eight reported a previous episode of facial palsy. When separated into categories based on clinical assessment and evidence of nerve fibre degeneration it was evident that all children without degeneration recovered. Those with incomplete palsies recovered in about half the time taken by those with complete palsies. Only two thirds of those children in whom degeneration was evident recovered. One hundred children were treated with a course of high dose steroid. This did not influence recovery either by improving recovery rate or by decreasing the time period to recovery.

Laryngomalacia. A review and the surgical management for severe cases

Laryngomalacia with its characteristic inspiratory collapse of lax supraglottic tissues into the laryngeal inlet may on occasion cause obstruction of such severity as to require airway intervention. The anatomy of the condition and the physiological explanation for its clinical presentation are examined and the pathological changes that precipitate a life-threatening situation discussed. Surgical correction of the abnormal tissue represents an acceptable alternative to tracheostomy in this situation. Simply 'trimming' the lax tissue over the arytenoid mounds may suffice in some cases but complications can occur and stabilisation of the epiglottis should be attempted as well. A series of 11 infants on whom such surgery was performed is presented with discussion of the surgical procedures performed and the complications experienced. The current uniformly successful surgical management of severe laryngomalacia by 'supraglottic trimming' combined with 'anterior epiglottopexy' is advocated for correction of severe laryngomalacia.

Span of apprehension deficits in schizophrenia and mania

Reduced perceptual span has been suggested to be a cognitive marker of vulnerability to schizophrenia. However, the specificity of this impairment in visual information processing to schizophrenia is not well established. This preliminary study examined perceptual span in schizophrenic and manic patients divided into subgroups with and without active symptomatology. Symptomatic patients had reduced span in comparison with less symptomatic groups, but there were no differences between schizophrenic and manic patients.

Experience with bilateral congenital atresia of the posterior nasal choanae

Atresia of the posterior nasal choanae is an unusual congenital condition. The embryological explanation is uncertain, that felt to be the most probable being presented here. Bilateral choanal atresia tends to be associated with neonatal airways obstruction and steps to be taken in its diagnosis and management are outlined. The definitive treatment of the condition is surgical excision, by either a trans-nasal or a trans-palatal approach. The conclusions arrived at as to the most effective method of management of these cases from a personal series of fourteen cases are detailed. A preference for the trans-nasal surgical approach is indicated and surgical details for this method are given, some aspects of which have not been previously reported.

Possible implication of an efferent neuropathy in vestibular upset

This essay examines two possible mechanisms whereby a neuropathy affecting the efferent vestibular innervation may cause incoordination of vestibular afferent input to the Vestibular Integrating Centres: firstly, by loss of the normal fine control of afferent impulses; secondly, by a disruption of the sodium-potassium pump mechanism that maintains the ionic stability of the inner ear fluids.

Test-retest reliability of information-processing measures among chronic schizophrenics

Evidence of task reliability is critical for use of measures of attention in studies of individual differences among members of clinical populations. Test-retest reliability of several measures of attention and information processing was studied in 14 chronic schizophrenics. Performance was stable over a 6-month period, except for decreases in reaction time.