Surgical management of retropharyngeal space infections in children

OBJECTIVE

To study the perioperative management strategies in a large group of pediatric patients undergoing surgical therapy for suppurative adenitis of the parapharyngeal and retropharyngeal spaces.

STUDY DESIGN

Retrospective analysis of all patients treated surgically from January 1, 1989, to December 31, 1998, in a tertiary care pediatric hospital.

METHODS

Charts were reviewed for demographic data, duration and nature of symptoms, radiological workup, surgical approach, complications, duration of medical therapy and antibiotic choice, and bacteriological findings. Computed tomography (CT) results were correlated to surgical findings.

RESULTS

A dramatic increase in the incidence of deep neck space infection was seen during the study period; this increase was congruent with the increase in culture-positive group A beta-hemolytic streptococcal abscesses. More than two-thirds of the patients were boys with the peak incidence being in the 3- to 5-year-old group. The duration of symptoms before presentation was less than might be expected, especially in the younger age groups. Seventy of 73 children were treated with a transoral approach. Sixty-eight of 73 were successfully treated with one operative intervention. Irregularity of the abscess wall was found to be a stronger predictor of the presence of pus than the presence of ring enhancement.

CONCLUSIONS

The current study represents the largest series of pediatric retropharyngeal abscesses in the modern medical literature. Changes in the disease process and in management from the first half of the century to today are reviewed, and recommendations for optimal management presented. The data in this series support a transoral approach to these abscesses unless there is extension lateral to the great vessels.

The relationship between dental overbite and eustachian tube dysfunction

OBJECTIVE

The purpose of this study was to investigate the association between deep dental overbite and eustachian tube dysfunction (ETD).

DESIGN

Case-control study.

SETTING

Tertiary care pediatric otolaryngology outpatient clinic at the Children's Hospital, Boston, Massachusetts.

PATIENTS

105 patients between the ages of 2 and 6 years. STUDY MEASUREMENTS: Dental overbite, overjet, and occlusal relationships were measured by an observer who was unaware of ETD status. ETD was defined as having ventilation tubes in place or having the recommendation for ventilation tube placement by an attending pediatric otolaryngologist. In addition, demographic information and medical and social histories were prospectively recorded.

RESULTS

In a multivariate logistic regression model, children with deep bites were 2.8 times more likely to have ETD than those without deep bites (P = .03). Other independent risk factors for ETD identified in this model were family history of otitis media (OM) and age less than 3 years.

CONCLUSIONS

Children with deep dental overbites are at a significantly increased risk for developing ETD.

Endotracheal isoflurane anesthesia for chick auditory surgery

Survival surgeries upon chicks are commonly used in auditory research. Appropriate anesthesia is usually obtained with intramuscular or intraperitoneal injections of systemic agents. These techniques have several drawbacks, including delayed onset of anesthesia, difficulty in adjusting the dosage to accomodate individual animals' different responses, prolonged recovery times, and in some cases substantial mortality. We present a technique of administering inhaled isoflurane via an endotracheal tube which we have used for over a year with excellent results. With this agent, onset of deep anesthesia is very rapid, dosage can be titrated readily, overdosage is survivable, complete recovery occurs within a few minutes and mortality is rare. This technique may be valuable for other auditory scientists performing survival surgery in avian species.

Effect of violation of the labyrinth on the sensory epithelium in the chick cochlea

Models in which a single large systemic dose of gentamicin is used to cause near-synchronous hair cell (HC) loss in the basal end of the chick cochlea have proven increasingly useful in the study of HC regeneration. We quantified the amount of HC death, as a percentage of the length of the basilar papilla, following single doses of 200 mg/kg and 300 mg/kg of gentamicin in 23-day-old chicks. Following 200 mg/kg of gentamicin, there was total HC loss in the basal 18.0% of the sensory epithelium and partial HC loss in the basal 26.3%. Following 300 mg/kg of gentamicin, there was total HC loss in the basal 30.5% of the epithelium and partial HC loss in the basal 40.9%. The second goal of this study was to determine whether cannula implantation in the inner ear, and infusion of bromodeoxyuridine causes HC damage. We found that creation of a fistula in the labyrinth is not associated with HC damage, but that cannula implantation can cause HC death, and can also cause potentiation of gentamicin-induced HC death. Revision of the cannula and surgical technique to ensure minimal penetration into the labyrinth almost entirely eliminated these effects. We conclude that surgical technique is critical in experimental models in which the labyrinth is violated.

Necrotizing fasciitis of the pharynx following adenotonsillectomy

Necrotizing fasciitis is a rare clinical entity in the head and neck region. We report a case of necrotizing fasciitis following adenotonsillectomy in a previously healthy 2-year-old girl. The child presented in a septic state with impending airway compromise. Computed tomography (CT) showed massive soft tissue widening with air in the retropharyngeal, parapharyngeal and retromandibular spaces. Intraoperative exploration showed necrosis of the posterior pharyngeal wall from the skull base to the cricoid, with extension into the parapharyngeal and retropharyngeal spaces. Cultures from the debrided tissues grew two aerobes and three anaerobes. Management involved airway support, surgical debridement, broad spectrum antibiotic coverage and nutritional support. The patient ultimately developed nasopharyngeal and oropharyngeal stenosis requiring tracheostomy and gastrostomy tube placement. This case report highlights an extremely rare complication of adenotonsillectomy.

Extensive facial nerve tumor with atypical histology: case report

Primary facial nerve tumours are uncommon; most are benign schwannomas. Rare cases of malignant schwannomas and cellular schwannomas have been reported. The report describes a multicentric facial nerve tumor that did not fit well into any of these histopathologic categories. The tumor was removed in two stages and the patient has no clinical or radiographic evidence of recurrence 2 years after the initial procedure.

Cell division in the gerbil cochlea after acoustic trauma

The recent discovery of hair cell regeneration in the avian inner ear raises the possibility that hair cell regeneration might occur in the mammalian cochlea as well. The authors used 3H-thymidine labeling to detect mitotic activity in the cochleas of normal 3-week old gerbils exposed to acoustic trauma. Following an acoustic insult that caused progressively more severe damage in an apical to basal progression, 3H-thymidine was injected for 5 days. Control animals were not exposed to the acoustic insult. The gerbils' cochleas were sectioned and processed for autoradiography. In the control cochleas, there were extremely rare labeled cells in the stria, the spiral ligament, and the glial cells around the acoustic nerve fibers. In the damaged cochleas, no evidence of hair cell regeneration or of any cell division within the normal sensory epithelial structures was seen. Three labeled cells were seen in intercellular spaces within the sensory epithelium; they appeared to be macrophages. Frequent cell division was seen in numerous other regions of the damaged cochleas and among glial cells adjacent to the acoustic nerve fibers. It is concluded that there is no evidence for hair cell regeneration following acoustic trauma in the gerbil, but acoustic trauma does induce cell division in numerous other areas of the cochlea.

Parotid cancer: treatment and results

The records of 74 consecutive patients with primary parotid malignancy were reviewed. The age and sex incidence was comparable to that described in previous studies; we observed a high incidence of adenocarcinoma not reported by other investigators. Stage at the time of examination and histologic grade of tumor were independent statistically significant predictors of clinical outcome. Long survival with low grade disease and late recurrence were common. Radiation therapy has been shown to increase survival in a number of studies; however, it had no demonstrable benefit in our series. Parotid cancer should be managed aggressively and early surgery is indicated for all parotid neoplasms. Neck dissection is indicated for clinically positive nodes and high grade cancers; radiation therapy is indicated for high grade cancers and residual disease.

A paradoxical effect of antibody concentration on vWF-dependent platelet agglutination distinguishes between botrocetin and ristocetin-induced agglutination

Several heterologous antisera directed against either human or porcine von Willebrand factor (vWF), inhibited botrocetin-induced vWF-dependent agglutination at high concentrations but were found to enhance this reaction at low concentrations. Purified IgG from these immune sera also potentiated botrocetin-induced agglutination as did its F(ab)'2 fragments. However, monovalent Fab fragments of the purified IgG did not. The requirement for a divalent antigen combining region suggests that one possible mechanism of enhanced agglutination may involve intra or inter-molecular cross-linking of vWF multimers by the antibody. Another possible mechanism could be a conformational change in the vWF molecule induced by antibody binding. Such a conformational change may provide additional active sites on the vWF molecule that, in the presence of botrocetin, lead to enhancement of the agglutination reaction. Antisera to human vWF that showed this paradoxical inhibitory/enhancing effect on botrocetin-induced agglutination also inhibited ristocetin-induced platelet agglutination at high concentrations, but failed to enhance agglutination at any concentration. The different effects of these antisera on botrocetin and ristocetin-induced platelet agglutination suggest that no single mechanism can explain the action of both of these mediators.