Effectiveness of bismuth subgallate for preventing bleeding following adenotonsillectomy: A multicentre study

BACKGROUND

Tonsillectomy and adenotonsillectomy are surgical procedures routinely performed worldwide, with various complications, including postoperative bleeding (PTH). Among haemostatic agents, bismuth subgallate (BS) has been employed in the past decades, but its use is controversial in children.

OBJECTIVE

This retrospective, multicentre study aims to evaluate the effectiveness and safety of BS in preventing PTH following tonsillectomy and adenotonsillectomy.

MATERIALS AND METHODS

Two cohorts of children between 0 and 18 years of age were compared in two different hospitals. The first (active) group of patients included children who underwent tonsillectomy/adenotonsillectomy performed using BS added to gauze swabs, whereas this agent was not administered to the second (control) group. The following variables were analysed: age, gender, degree of tonsillar hyperplasia, length of hospital stay, acute complications (including bleeding and infection), further admissions to the Paediatric Emergency Department (PED), and further hospital admissions in the 30 days postoperatively.

RESULTS

Four-thousand- seven hundred forty-four children were included in the study, 2598 in the active group and 2146 in the control group. The cases included in the active treatment group displayed a significantly reduced PTH prevalence, 1.4 versus 2.6 % (p < 0.05). No cases of neurological complications or aspiration pneumonia were detected.

CONCLUSIONS

This study supports BS as a safe and reliable option for preventing severe PTH following tonsillectomy/adenotonsillectomy.

Proteomic Study Identifies Glycolytic and Inflammation Pathways Involved in Recurrent Otitis Media

Recurrent acute otitis media (RAOM) in children is clinically defined as the occurrence of at least three episodes of acute otitis media over a course of 6 months. A further common pathological condition of interest in the context of pediatric otolaryngology is adenotonsillar hypertrophy (ATH), a common cause of obstructive sleep apnea syndrome. Aimed at unraveling the differential modulation of proteins in the two pathologies and at understanding the possible pathways involved in their onset, we analyzed the proteomic profile of the adenoids from 14 RAOM and ATH patients by using two-dimensional gel electrophoresis (2-DE) and mass spectrometry (MS). The 2-DE coupled with MS allowed us to identify 23 spots with significant (p-value < 0.05) changes in protein amount, recognizing proteins involved in neutrophil degranulation and glycolysis pathways.

Copy number variation, gene expression and histological localization of human beta-defensin 2 in patients with adeno-tonsillar hypertrophy

Both bacterial infections and innate oral immunity response participate in development of adeno-tonsillar hypertrophy (ATH). ATH can lead to obstructive sleep apnea. We investigated the beta-defensin 2 (hBD-2) encoding gene, DEFB4, by analyzing the copy number variations (CNVs) of the defensin gene cluster in patients with ATH and by correlating CNV with DEFB4 gene expression. We enrolled 79 patients with ATH, 21 of whom presented with only adenoid hypertrophy, while 58 exhibited hypertrophy of both adenoid and tonsil. CNVs of the defensin gene cluster, DEFB4 mRNA, and hBD-2 protein expression were assessed. Also, beta-defensin 2 was localized histologically using immunohistochemistry. The distribution of defensin gene cluster CNV was similar among the 79 subjects. DEFB4 expression analysis exhibited considerable inter-individual variability, but with neither specific differences among subjects nor correlation with the CNV number. Immunohistochemistry enabled localization of hBD-2 in the tonsil and adenoid epithelium. No differences in localization between the two ATH presentations were found. Inducible antimicrobial defensin peptides exhibited great inter-individual variability in terms of both CNV and gene expression, but no correlation with presentation of ATH was found.

Human beta defensin-1 is involved in the susceptibility to adeno-tonsillar hypertrophy

INTRODUCTION

Innate immunity molecules are known to play a pivotal role in the homeostasis of the oral mucosa, permitting the presence of commensal microflora and, at the same time, providing a first line of defense against pathogens attempting to invade the oral cavity. Tonsils represent the local immune tissue in oral cavity, being able to provide a non-specific response to pathogens; however, in the presence of microbes or foreign materials present in the mouth tonsils could became infected and develop chronic inflammation, thus leading to hypertrophy. The etiology of the disease is multifactorial depending upon environmental and host factors, the latter including molecules of mucosal innate immunity.

METHODS

Ninety-five children with adeno-tonsillar hypertrophy subjected to adeno-tonsillectomy were recruited at the pediatric otorhinolaryngology service of the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste (Italy). The specimen discarded from the surgery were used for genomic DNA extraction and genotyping, for mRNA extraction and gene expression analysis, finally the samples were cut and used to prepare slides to perform immunohistochemistry.

RESULTS

Functional polymorphisms within DEFB1 gene, encoding the human beta defensin-1 (hBD-1), were analyzed finding association between DEFB1 rare haplotypes and susceptibility to adeno-tonsillar hypertrophy. DEFB1 mRNA expression was detected in the tonsils and the hBD-1 protein was localized at the epithelia of tonsils mainly in the proximity of the basal lamina.

CONCLUSION

Our findings lead us to hypothesize an involvement of hBD-1 mediated innate immunity in the modulation of the susceptibility towards adeno-tonsillar hypertrophy development.

Neither hereditary periodic fever nor periodic fever, aphthae, pharingitis, adenitis: Undifferentiated periodic fever in a tertiary pediatric center

AIM

To describe the frequency and clinical characteristics of patients with undifferentiated periodic fever (UPF) and to investigate whether a clinical classification of UPF based on the PRINTO-Eurofever score can help predicting the response to treatment and the outcome at follow-up.

METHODS

Clinical and therapeutic information of patients with recurrent fever who presented at a single pediatric rheumatology center from January 2006 through April 2016 were retrospectively collected. Patients with a clinical suspicion of hereditary periodic fever (HPF) syndrome and patients with clinical picture of periodic fever, aphthae, pharingitis, adenitis (PFAPA) who were refractory to tonsillectomy underwent molecular analysis of five HPF-related genes: MEFV (NM_000243.2), MVK (NM_000431.3), TNFRSF1A (NM_001065.3), NLRP3 (NM_001079821.2), NLRP12 (NM_001277126.1). All patients who had a negative genetic result were defined as UPF and further investigated. PRINTO-Eurofever score for clinical diagnosis of HPF was calculated in all cases.

RESULTS

Of the 221 patients evaluated for periodic fever, twelve subjects with a clinical picture of PFAPA who were refractory to tonsillectomy and 22 subjects with a clinical suspicion of HPF underwent genetic analysis. Twenty-three patients (10.4%) resulted negative and were classified as UPF. The median age at presentation of patients with UPF was 9.5 mo (IQR 4-24). Patients with UPF had a higher frequency of aphthae (52.2% vs 0%, P = 0.0026) and musculoskeletal pain (65.2% vs 18.2%, P = 0.0255) than patients with genetic confirmed HPF. Also, patients with UPF had a higher frequency of aphthous stomatitis (52.2% vs 10.7%, P < 0.0001), musculoskeletal pain (65.2% vs 8,0%, P < 0.0001), and abdominal pain (52.2% vs 4.8%, P < 0.0001) and a lower frequency of pharyngitis (56.6% vs 81.3%, P = 0.0127) compared with typical PFAPA in the same cohort. Twenty-one of 23 patients with UPF (91.3%) received steroids, being effective in 16; 13 (56.2%) were given colchicine, which was effective in 6. Symptoms resolution occurred in 2 patients with UPF at last follow-up. Classification according to the PRINTO-Eurofever score did not correlate with treatment response and prognosis.

CONCLUSION

UPF is not a rare diagnosis among patients with periodic fever. Clinical presentation place UPF half way on a clinical spectrum between PFAPA and HPF. The PRINTO-Eurofever score is not useful to predict clinical outcome and treatment response in these patients.

DEFB1 polymorphisms and susceptibility to recurrent tonsillitis in Italian children

INTRODUCTION

The tonsils are secondary lymphoid organs fundamental for immune system response against pathogens within the oral cavity. Tonsillitis refers to inflammation of the pharyngeal tonsils that may include the adenoids and the lingual tonsils and that can be acute, recurrent, and chronic. Viral or bacterial infections, as well as immunologic factors are the main trigger to tonsillitis and disease's chronicity: the host immune responses, especially the innate one, could play an important role in susceptibility to the disease.

OBJECTIVES

The current study aims at investigating the role of functional polymorphisms in the 5'UTR (c.-52G>A, c.-44G>C and c.-20G>A) of DEFB1 gene, encoding for the antimicrobial peptide human beta-defensin 1, in the predisposition to recurrent tonsillitis in children from North Eastern Italy.

RESULTS

No significant correlation was found between DEFB1 allele, genotype and haplotype frequencies and recurrent tonsillitis susceptibility with the exception of an increased risk to disease development in patients carrying DEFB1 rare haplotypes.

CONCLUSION

Our results may suggest that DEFB1 polymorphisms alone may not influence pathology susceptibility, however they could possibly concur, together with other factors involved in the genetic control of innate immune system, in the predisposition towards recurrent tonsillitis.

Ear nose throat manifestations in hypoidrotic ectodermal dysplasia

The ectodermal dysplasias (EDs) are a large and complex group of inherited disorders. In various combinations, they all share anomalies in ectodermal derived structures: hair, teeth, nails and sweat gland function. Clinical overlap is present among EDs. Few causative genes have been identified, to date. Altered gene expression is not limited to the ectoderm but a concomitant effect on developing mesenchymal structures, with modification of ectodermal-mesenchymal signaling, takes place. The two major categories of ED include the hidrotic and hypohidrotic form, the latter more frequent; they differentiate each other for the presence or absence of sweat glands. We report Ear Nose Throat manifestations of ED, linked to the reduction of mucous glands in the nasal fossae with reduced ciliar function, and decrease salivary glands function. Often patients report an increased rate of infections of the upper respiratory tract and of the ear. Nasal obstruction due to the presence of nasal crusting, hearing loss and throat hoarseness are the most represented symptoms. Environmental measures, including a correct air temperature and humidification, is mandatory above all in subjects affected by hypohidrotic form.

Bilateral orbital preseptal cellulitis after combined adenotonsillectomy and strabismus surgery--case report and pathogenetic hypothesis

The first case of bilateral orbital preseptal cellulitis complicating combined adenotonsillectomy and strabismus surgery is reported. The issues of antimicrobial prophylaxis are discussed. The authors speculate about the possible routes of surgical site infection. Transient bacteraemia secondary to adenotonsillectomy may be theoretically a source of distant surgical site infection to the orbit, raising the issue of distant surgical site contamination during multidisciplinary surgery. Combined adenotonsillectomy and eye surgery might benefit from prophylactic systemic antibiotic administration.

Age-related hearing loss in four Italian genetic isolates: an epidemiological study

The objective of this study was to estimate the prevalence of hearing impairment in four genetically isolated Italian villages (Carlantino, Campora, Gioi-Cardile, and Stoccareddo), 1682 subjects were recruited from all the individuals participating in a multidisciplinary study. They underwent otoscopy and pure-tone audiometry and completed a questionnaire. The audiological data show that the percentage of impaired people increases with age and in particular becomes relevant aged over 40. For this reason we decided to compare the PTA values of individuals aged 40 or older. The PTA values of Stoccareddo and Carlantino are statistically different from PTAs of the other villages. Campora and Gioi-Cardile, both located within the Cilento National Park, have similar middle-low frequency PTA values while some differences are present at high frequencies. Using pedigrees it was possible to calculate the heritability of the trait. For Carlantino and Gioi-Cardile the percentage of the phenotype variation attributable to genetic variation is not significant, while for Campora the heritability value is 0.49 (p = 0.01) suggesting that genetic factors may have an important role.

MBL expression in patients with recurrent tonsillitis

OBJECTIVE

We evaluated mannose binding lectin (MBL) protein production and histological localization, MBL2 gene expression and genotypes distribution in patients characterized by recurrent tonsillitis, with the aim of verifying the innate immune response to the infection and inflammation occurring in the tonsils.

METHODS

MBL2 exon 1 and promoter polymorphims were detected by PCR amplification and subsequent direct sequencing of the amplicons. Monoclonal antibodies to MBL were used on frozen sections of tonsils for the immunohistochemical localization of MBL protein. MBL Oligomer ELISA kit was used to quantify the level of MBL in the serum of the 30 patients with recurrent tonsillitis. Quantitative RT PCR for the evaluation of MBL2 expression of MBL high producers (HP), low producers (LP) and deficient producers (DP) was performed using the Hs00175093 gene-expression Assay on Demand.

RESULTS

The distribution of the MBL2 combined genotypes was as follows: 21 HP (70%; 15 HYA/HYA, 6 HYA/LXA), 6 LP (20%; 5 HYA/0, 1 LXA/LXA) and 3 DP (10%, all 0/0). MBL levels were directly correlated to the MBL2 combined genotypes: HP patients showed higher mean MBL concentration of 4044 ng/mL, LP patients were characterized by a mean of 905 ng/mL whereas those with DP combined genotype presented extremely low levels of MBL (mean value of 74 ng/mL) (p=0.0005). Immunohistochemistry performed on tonsils sections demonstrated that MBL was widely distributed throughout the surface of the basal lamina of all the 21 HP subjects. MBL was undetectable in situ in both LP and DP patients. MBL2 expression, although at very low levels, was found for the HP group, the LP and the DP group as well.

CONCLUSIONS

We confirmed the genotype-phenotype correlation of MBL2 gene exon 1 and promoter polymorphisms with the quantitative production of serum MBL, we reported a very low MBL2 expression at local level in tonsils and we determined the in situ localization of MBL in the basal lamina of the tonsils of patients who underwent to tonsillectomy. Our findings suggest an important role of MBL protein in the innate immune response of the tonsil to pathogens, as in recurrent infection and inflammation.

Role of the "rooming-in" on efficacy of universal neonatal hearing screening programmes

Sensorineural hearing loss is one of the most common congenital abnormalities in infants and it affects approximately one to two neonates in every 1000 births. Early identification of hearing loss in the newborn is the first step for a successful rehabilitation programme. The introduction of Otoacoustic Emission responses as a useful tool in hearing screening programmes, allowed the identification of hearing loss in the well-baby nursery and in targeted populations of the neonatal intensive care unit. Recently, a new concept of breastfeeding during hospitalization after birth has been developed. Indeed, the so-called "rooming-in" allows a mother to stay with her child in the same room, located in the nursery. This new trend has been developed to avoid any psychological adverse consequences of birth on the child-mother relationship. To enhance how "rooming-in" could affect the Universal Neonatal Hearing Screening (UNHS) programmes, an analysis has been made of the data coming from two maternity wards using different breastfeeding protocols. Data obtained demonstrate a worse performance on obtaining essential benchmark in the UNHS in the maternity ward where rooming-in is adopted (60% of newborns tested). UNHS programme efficacy could be affected by the wider adoption of the "rooming-in" regimen in the maternity wards and early detection of hearing loss revealed by UNHS could be vanished by dispersion of patients. In fact, more data are necessary to evaluate the impact of rooming, even though our data show a worsening in the UNHS results.

Lateral sinus thrombosis as a complication of acute mastoiditis

Lateral sinus thrombosis is a rare complication of middle ear diseases: in children, it is usually related to acute otitis media, but it is also found in adults with chronic otitis. It was more frequent in the pre-antibiotic era and mortality was high. The Authors present a paediatric case of lateral sinus thrombosis in which they describe the clinical approach and related literature.

Lymphangiomas of the head and neck in children

Lymphangiomas are rare benign congenital tumours, involving both the head and the neck and causing obstructing symptoms in the upper airways as well as aesthetic anomalies. In recent years, sclerosing therapy with OK-432 has become the treatment of choice in the management of these lymphatic malformations. Nonetheless, surgery still seems to be the therapy advocated for resolution of symptoms. Herein, three cases of lymphangiomas involving the head and the neck are described and a review of the English scientific literature is outlined.

Non tuberculous mycobacteria infection of the parotid region: two familiar cases

OBJECTIVE

We review two cases of non tuberculous mycobacteria infections of the parotid region in members of the same family. The parotid region represents a peculiar location for the disease and it is exceptional to discover cases in members of the same family.

METHODS

Two unusual case reports of non tuberculous mycobacteria infections in two members of the same family are presented. We discuss the diagnostic criteria and review pertinent recent literature. To our knowledge, these are the first English language reports of NTM infections in member of the same family.

RESULTS

We performed surgical exeresis of the lesions in parotid region together with the skin affected by the fistula; regular check-ups for 24 months after surgery.

CONCLUSIONS

Surgical exeresis of regional structures is the treatment for non tuberculous mycobacteria infections non responsive to antibiotic therapy.

MBL2 genetic polymorphisms in Italian children with adenotonsillar hypertrophy

We investigated the role of the polymorphisms in the first exon of MBL2 gene in the susceptibility to recurrent tonsillitis in a selected group of Italian children and healthy controls. Significant difference has been observed in MBL2 genotype and allelic frequencies between children with recurrent tonsillitis and healthy controls matched for sex and age. Children characterized by a "low MBL" producer genotype, namely 00, are more prone to recurrent tonsillitis when compared to the healthy controls. To our knowledge this is the first report on the role of MBL2 polymorphisms in adenotonsillar hypertrophy and our results shown that presence of MBL2 00 genotype could be used as a prognostic marker in subjects with adenotonsillar hypertrophy.

Pneumocephalus and meningitis as a complication of acute otitis media: case report

Otogenic pneumocephalus is a rare condition. The case is described of pneumocephalus and meningitis secondary to acute otitis media. Although the rate of intracranial complications related to middle ear disease is only 0.5 to 4%, mortality still ranges between 5 and 15%.

Mucoceles of the frontal sinus. Clinical and therapeutical considerations

BACKGROUND

Mucocele is an epithelial lined mucus-containing sac completely filling a paranasal sinus and capable of expansion by virtue of a dynamic process of bone resorption and new bone formation. It is the most common lesion causing expansion of the paranasal sinuses. Even though mucoceles of paranasal sinuses are increasingly treated by endoscopic surgery, the external approach with or without the obliteration of the sinus still remains a useful and sometimes the only tool in the treatment of this disease.

METHODS

The results obtained in seven patients observed at the ENT Department of the University of Ferrara (Italy) in the period ranging from 1989 to 1999 are presented; they were affected by massive fronto-ethmoidal mucoceles and treated with the external approach alone or combined with an endonasal approach and osteoplastic flap. They were five males and two females, with a mean age of 56.5 years. Locations were bilateral in one mucocele, while in six patients only one side was involved, with a prevalence of the left frontal sinus (4:2).

RESULTS

No patient showed any local or general complication in the postoperative period. The follow-up showed no recurrence of the disease.

CONCLUSIONS

Since the osteoplastic flap was introduced one hundred years ago, it still remains the optimal surgical treatment for fronto-ethmoidal mucoceles. Even though, today, endoscopic surgery represents the new horizon in the management of the sinonasal disease, mucoceles need a surgical treatment which allows the total vision of the cavity to obtain radical treatment and any recurrence of disease.

Malignant myoepithelioma of the tongue base: case report and literature review

Malignant myoepithelioma is a rare tumor of salivary origin, preferentially located in the parotid and submandibular glands and in the palate. We report the first case involving the tongue base in a 30-year-old man. The histopathological and clinical features and therapeutic options are discussed.

Schwannoma of the parapharyngeal space

A schwannoma (or neurilemmoma) of the parapharyngeal space is a rare tumor in the head and neck region arising from the sheath of cranial nerves and/or the sympathetic chain. In the early stages of growth, there is usually a lack of symptoms because of the anatomical localization and slow growth of the tumor. The large dimension of the mass at presentation makes it difficult to perform a functional surgery, and in many cases the operation worsens the nerve status. The choice of surgical approach is of paramount importance in both preserving nerve function and achieving vascular control. The authors report a case and discuss the English literature.

Normal and altered cytoarchitecture of the inner ear

Scanning electron microscope gave new insights into real morphology of the inner ear and has enhanced basic research. In fact, during the last twenty years, the cellular system that composes the organ of Corti and the vestibular apparatus has been clearly described by many authors. We now have a better understanding of each cell type and that they have a physiological functioning as ear and vestibular system. In addition, new insights into the damage caused by many drugs, such as aminoglucosides, can be investigated by studying the morphological changes and the reparative process following the injury. Animals such as guinea pigs can be used as ideal models to investigate the alterations in the sensory epithelium of the cochlear and vestibular receptors following ototoxic poisoning.