Depressive symptoms in children after tonsillectomy

OBJECTIVE

Several cases of severe depression after tonsillectomy have been described in children, indicating psychological trauma after surgery and hospitalization. The actual prevalence of depressive symptoms after tonsillectomy is unknown and possibly underestimated. This study aims to quantify this problem by employing current diagnostic methods.

METHODS

This is a prospective study of 159 children who underwent tonsillectomy in a major Pediatric University Hospital. All patients stayed in the hospital overnight. Parents were sent questionnaires based on diagnostic criteria for depression (ICD-10) 3 weeks postoperatively. Whenever the criteria for a depressive episode were met, a telephone interview with the parents followed 3 months after the operation.

RESULTS

Some 89 questionnaires were returned (56%), revealing that 15 patients (17%), 4-16 years old, developed depressive symptomatology compared with a 4% prevalence of depression in the general child population and 10-20% in the pediatric hospital populations. No children had persisting symptoms 3 months later.

CONCLUSIONS

These results suggest that post-tonsillectomy morbidity can occasionally manifest with depressive symptoms, usually resolving spontaneously. A high index of suspicion is required by the otolaryngologist, nurses and primary care physician for early diagnosis and referral of persisting cases to a specialist. Emphasis is given to a structured preoperative psychological preparation of pediatric patients.

The distribution of the calcium buffer calbindin in the cochlea of the guinea-pig

INTRODUCTION: Ca2+ is involved in many important functions in the inner ear and its intracellular levels are controlled by extrusion mechanisms and stores, and also by buffers such as calbindin. The latter has been demonstrated previously in hair cells of the organ of Corti using immunofluorescence at the light microscopic level, although its precise intracellular distribution has yet to be determined. One postulated role for calbindin in the brain is protection against hypoxic cell injury and degeneration, in which Ca2+ overload has been implicated. METHODS: We have therefore performed postembedding immunogold labelling for electron microscopy on ultrathin sections of apical and basal turns of the guinea-pig cochlea with anticalbindin (Swant), followed by appropriated gold conjugated secondary antibodies. This technique allows quantitative analysis of the distribution of labelling by counting gold particle densities. RESULTS: Outer hair cells in the apical turn were significantly more heavily labelled than those in the base (P < 0. 001). In addition, at the apex there was a progressive reduction across the three rows of outer hair cells towards the modiolus (P < 0.005) although at the base no radial gradient was detected. CONCLUSIONS: These results confirm previous reports of gradients of calbindin distribution in the organ of Corti. This distribution corresponds with the pattern of hair cell loss that occurs, e.g. after some forms of ototoxicity and it may therefore contribute to the diffential susceptibility of hair cells to damage. ACKNOWLEDGEMENT: This work was supported by the Wellcome Trust.

Cranial nerve dysfunction following carotid endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is the most common surgical procedure performed for the treatment of symptomatic carotid stenosis greater than 70%. Among the recognised complications, such as stroke and myocardial infarction, is injury to cranial nerves.

METHODS

We report the incidence and follow-up of cranial nerve injury in 269 patients who underwent carotid endarterectomy between January 1994 and December 1997 at the Royal Liverpool University Hospital.

RESULTS

Fifteen cranial nerve injuries were documented (5.6%). Seven patients (2.6%) had unilateral vocal cord paralysis, nine (3.3%) hypoglossal palsy, two (0.7%) glossopharyngeal nerve injury and one (0.4%) facial nerve palsy (marginal mandibular nerve). All patients showed improvement within a few weeks and none had residual disability at the last follow-up (two weeks to 14 months).

CONCLUSIONS

Patients manifesting symptoms of cranial nerve dysfunction should undergo a thorough otolaryngological evaluation and long-term follow-up. Most cranial nerve injuries are transient and result from trauma during dissection, retraction or carotid clamping. Knowledge of cranial nerve anatomy is essential if the surgeon is to avoid such injuries.

Ballooned trachea caused by cuffed tracheostomy tube

Despite the dramatic decrease in cuff-related complications with the introduction of high-volume low-pressure devices for intubation and tracheostomy, notable problems can still occur. A case is reported of a patient who developed persistent dilatation of the trachea after prolonged mechanical ventilation. This is an under-recognized, life threatening clinical entity occurring after cuffed intubation for prolonged time. At present there is no definitive treatment regarding the management of a dilated trachea on a ventilator-dependent patient and therefore emphasis is directed at prevention. The patient presented was managed with periodical alterations of the cuff level which although not achieving any reversal of the dilatation, have prevented further progression of tracheal damage. During the follow-up period, regular assessment with flexible endoscopy has provided more reliable information on the condition of the trachea than computed tomography (CT) scanning.

Pleomorphic adenoma causing acute airway obstruction

A case is reported of a pleomorphic adenoma of the minor salivary glands of the oral cavity presenting with acute airway obstruction. This is the first reported case to our knowledge of a mixed salivary tumour of the upper respiratory tract causing upper airway obstruction and acute respiratory failure. The patient had to be intubated and transferred to the intensive care unit. After an elective tracheostomy was performed, the adenoma was excised from its fibrous capsule. It was found to originate from the soft palate and occupied the parapharyngeal space. A high index of suspicion should be kept in order to diagnose tumours of the parapharyngeal space with unusual presentation. These tumours which are usually benign should be considered in the differential diagnosis from more common infectious or traumatic conditions and surgical morbidity should be minimal.

Treatment of experimental osteomyelitis caused by methicillin-resistant Staphylococcus aureus with a biodegradable system of lactic acid polymer releasing pefloxacin

A novel biodegradable system of D-,L-dilactide delivering pefloxacin was implanted in 104 rabbits with experimental osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA), 26 serving as controls. Animals were killed on each third day and viable bacterial counts and levels of pefloxacin in bone tissue were determined. A 99. 9% decrease in viable count of bacteria was achieved by day 12 and complete bacterial eradication on day 33. Pefloxacin was released gradually, reaching its peak on day 15 at levels 100 times the MIC of pefloxacin for MRSA. The biodegradable system described may have a future role in the therapeutic approach to osteomyelitis.

An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease)

Stridor is a noisy breathing caused by compromised airway in the larynx and trachea. The causes can either be due to intrinsic or extrinsic compression. Stridor resulting from extrinsic compression due to anterior cervical osteophytes is rare. We report an unusual case of acute stridor due to an osteophytic mass in the cervical vertebrae resulting in a mechanical upper airway obstruction. The underlying pathology was Forestier's disease or diffuse idiopathic skeletal hyperostosis (DISH). Stridor is a rare manifestation of DISH and it certainly represents the most life-threatening one. Only a few cases have been reported in the English literature and are mainly secondary to impaired function of the vocal folds, or postcricoid ulceration and oedema. We present such a case, in that stridor was the result of direct airway obstruction by the osteophytic mass and an emergency tracheostomy had to be performed to establish an airway.

Efficacy of external fixation following nasal manipulation under local anaesthesia

Nasal fractures are one of the commonest reasons for patients being referred to ENT departments, but few studies have been published about the management of this condition. In particular, the efficacy of external splintage following manipulation has not been assessed. This was a prospective randomized study, which examined the results of manipulation under local anaesthetic and the benefit to be gained from external fixation with Plaster of Paris (POP) following this procedure. Accurate measurements of the degree of deviation of the nose pre- and post-manipulation were obtained using a camera mounted on a specially designed frame. Thirty-three out of 241 consecutive patients seen at a research clinic over the course of 12 months were included in the study. The mean deviation of the nasal bridge at presentation was 4.12 mm. Manipulation under local anaesthetic significantly improved the degree of deviation (mean 2.47 mm, P = 0.0011, 90% CI, 1-2 mm). Randomization of the patients, following manipulation, into POP/none-POP groups showed that external splintage of the nose appeared to be of little practical benefit.

Hypersensitivity reactions during hemodialysis related to the use of acetate dialysate. A case report

A patient developed a hypersensitivity reaction two weeks after being put on hemodialysis with acetate dialysate. The reactions appeared exclusively during hemodialysis and were relieved immediately after its termination. These allergic manifestations disappeared with substitution of bicarbonate for acetate dialysate and reappeared upon rechallenge with acetate dialysate. The rest of the dialysis materials were excluded as possible causes of allergy by scheduled dialysis sessions with varying materials. Acetate dialysate is implicated as the cause of allergy reaction in this case.