Volumetric brain magnetic resonance imaging analysis in children with obstructive sleep apnea

OBJECTIVES

Pediatric Obstructive Sleep Apnea (OSA) is associated with neurocognitive deficits. Cerebral structural alterations in the frontal cortex, cerebellum, and hippocampus have been reported in adult OSA patients. These brain areas are important for executive functioning, motor regulation of breathing, and memory function, respectively. Corresponding evidence comparing cerebral structures in pediatric OSA patients is limited. The objective of this study is to investigate MRI differences in cortical thickness and cortical volume in children with and without OSA.

STUDY DESIGN

Prospective, single institutional case-control study.

METHODS

Forty-five children were recruited at a pediatric tertiary care center (27 with OSA; mean age 9.9 ± 1.9 years, and 18 controls; mean age 10.5 ± 1.0 years). The OSA group underwent magnetic resonance imaging (MRI), polysomnography (PSG) and completed the Pediatric Daytime Sleepiness Scale (PDSS) and the Child's Sleep Habits Questionnaire (CSHQ). High-resolution T1-weighted MRI was utilized to examine cortical thickness and gray and white matter volume in children with OSA compared to a healthy group of demographically-comparable children without OSA selected from a pre-existing MRI dataset.

RESULTS

Children with OSA showed multiple regions of cortical thinning primarily in the left hemisphere. Reduced gray matter (GM) volume was noted in the OSA group in multiple frontal regions of the left hemisphere (superior frontal, rostral medial frontal, and caudal medial frontal regions). Reduced white matter (WM) volume in both the left and right hemisphere was observed in regions of the frontal, parietal, and occipital lobes in children with OSA.

CONCLUSION

This study noted differences in cortical thickness and GM and WM regional brain volumes in children with OSA. These findings are consistent with other pediatric studies, which also report differences between healthy children and those with OSA. We found that the severity of OSA does not correlate with the extent of MRI alterations.

Optimizing Performance by Preventing Disruptive Behavior in Radiology

Disruptive behaviors impede delivery of high-value health care by negatively impacting patient outcomes and increasing costs. Health care is brimming with potential triggers of disruptive behavior. Given omnipresent environmental and cultural factors such as constrained resources, stressful environments, commercialization, fatigue, unrealistic expectation of perfectionism, and burdensome documentation, a burnout epidemic is raging, and medical providers are understandably at tremendous risk to succumb and manifest these unprofessional behaviors. Each medical specialty has its own unique challenges. Radiology is not exempt; these issues do not respect specialty or professional boundaries. Unfortunately, preventive measures are too frequently overlooked, provider support programs rarely exist, and often organizations either tolerate or ineffectively manage the downstream disruptive behaviors. This review summarizes the background, key definitions, contributing factors, impact, prevention, and management of disruptive behavior. Every member of the health care team can gain from an improved understanding and awareness of the contributing factors and preventive measures. Application of these principles can foster a just culture of understanding, trust, support, respect, and teamwork balanced with accountability. The authors discuss these general topics along with specific issues for radiologists in the current medical environment. Patients, providers, health care organizations, and society all stand to benefit from better prevention of these behaviors. There is a strong moral, ethical, and business case to address this issue head-on. ^©RSNA, 2018.

Twelve tips for the introduction of emotional intelligence in medical education

Emotional intelligence (EI) is the ability to recognize, understand, and manage emotions in yourself and in others. EI has long been recognized as a critical component for individual and organizational success within the business realm, and there is emerging evidence that enhancing EI is equally important in the medical setting. EI can improve interpersonal communications, enable constructive conflict resolution, and promote a culture of professionalism. As healthcare becomes increasingly team-based, proficiency in EI will be required to build consensus among multidisciplinary stakeholders, and effect change in attitudes and behaviors that result in improved patient safety and clinical outcomes. Based on the existing literature and the authors' experiences, these 12 tips provide practical suggestions on how to introduce EI into a medical curriculum. These tips have broad applicability, and can be implemented in courses on topics such as professionalism, leadership development, empathy, patient safety, or wellness.

A Five-Year Analysis of Airway Foreign Body Management

Objective:

To identify characteristics in patients who undergo positive and negative bronchoscopy for a suspected airway foreign body (AFB).

Methods:

Review medical records between 2008 and 2012.

Results:

There were 145 patients who went to the operating room with the pre-bronchoscopy diagnosis of suspected AFB during the study period. There was an overall negative bronchoscopy rate of an average of 37%, with an annual range between 21% and 50%. The findings of history or suspicion of choking, asymmetric breath sounds, and wheezing were statistically more common in patients with an AFB. Chest roentograms (CXR) had a sensitivity and specificity of 62% and 57%. Twenty patients had a chest computed tomography (CT) scan, and 100% were clinically significant. Four CT scans were diagnostic of an AFB, and 16 patients avoided bronchoscopy after negative CT.

Conclusions:

In current clinical practice, it is difficult to identify patients with an AFB without performing bronchoscopy. This results in a significant number of negative bronchoscopes. Certain elements in the history and physical exam were more common in patients who were found to have an AFB. Our preliminary data suggest that chest CT scans may be useful to decrease the number of negative bronchoscopies.

Outcomes variability in non-emergent esophageal foreign body removal: Is daytime removal better?

OBJECTIVE

The objective of this study is to investigate differences between esophageal foreign body removal performed during standard operating room hours and those performed after-hours in asymptomatic patients.

METHODS

A retrospective chart review at a tertiary children's hospital identified 264 cases of patients with non-emergent esophageal foreign bodies between 2006 and 2011. Variables pertaining to procedure and recovery times, hospital charges, complications, length of stay, American Society of Anesthesiology (ASA) classification, and presence of mucosal injury were summarized and compared between cases performed during standard operating hours and those performed after-hours.

RESULTS

Cases performed during standard hours had significantly longer average wait times compared with after-hours cases (13.1h versus 9.0h, p<0.001). No other clinical characteristics or outcomes were significantly different between groups. Longer wait times are not associated with mucosal injury or postoperative complications.

CONCLUSION

There were no significant differences in procedure time, charges, or safety in after-hours removal of non-emergent esophageal foreign bodies compared to removal during standard operating hours. OR wait time was about 4h longer during standard hours compared with after-hours. This study could not assess the factors to determine the impact in differences in hospital resource utilization or work force, which may be significant between these two groups.

A cooperative approach to diagnosis of rare diseases: primitive myxoid mesenchymal tumor of infancy

Primitive Myxoid Mesenchymal Tumor of Infancy (PMMTI) is a recently recognized locally aggressive myofibroblastic tumor. It is a low- to intermediate-grade fibroblastic malignancy with a high local recurrence rate but low metastatic potential and is composed of primitive spindled cells in a myxoid background. We present the eleventh reported case of PMMTI, occurring in the sinonasal tract of a 3-year old child. This case is novel in both the relatively older age of the child, the location of the tumor, and the role that immunohistochemical stains, and cytogenetic analysis played in differentiating it from similar diagnoses that differ considerably in their chemosensitivity and recurrence rates. Close collaboration between the pathologist and surgeon was crucial as different diagnoses would have led to vastly different treatment strategies for the patient.

Potocki-Lupski syndrome: a microduplication syndrome associated with oropharyngeal dysphagia and failure to thrive

OBJECTIVE

Failure to thrive (FTT) is a feature of children with Potocki-Lupski syndrome (PTLS) [duplication 17p11.2]. This study was designed to describe the growth characteristics of 24 subjects with PTLS from birth through age 5 years in conjunction with relevant physical features and swallow function studies.

STUDY DESIGN

We evaluated 24 individuals with PTLS who were ascertained by chromosome analysis and/or array comparative genome hybridization. Clinical assessments included review of medical records, physical examination, otolaryngological examination, and swallow function studies. Measures of height and weight were converted to Z-scores.

RESULTS

The mean weight-for-age and weight-for-length Z-scores at birth were lower (P < .01) than the reference standard and did not change with age. A history of poor feeding, hypotonia, and FTT were reported in 92%, 88%, and 71%, respectively. Individuals with hypotonia had lower weight-for-age and body mass index-for-age Z-scores (P = .01). Swallow function studies demonstrated at least one abnormality in all subjects.

CONCLUSIONS

FTT is common in children with PTLS. We hypothesize that oropharyngeal dysphagia and hypotonia likely contribute to FTT in patients with PTLS and recommend that once a diagnosis is established, the individual be assessed for feeding and growth issues and be availed of oromotor therapy and nutritional services.

Differential diagnosis of pediatric tumors of the nasal cavity and paranasal sinuses: a 45-year multi-institutional review

We conducted a retrospective case-series review to identify the various diagnoses of neoplasms of the nasal cavity and paranasal sinuses in a pediatric population. Our study group was made up of 54 children-23 boys and 31 girls, aged 8 months to 16 years (mean: 9 yr). All patients had been diagnosed with a tumor of the nasal cavity or paranasal sinuses between Jan. 1, 1955, and Dec. 31, 1999, at one of four university-based, tertiary care referral centers. We compiled data on tumoral characteristics (location, size, and histopathology), morbidity and mortality, and rates of recurrence. Lesions included adnexal neoplasm, ameloblastic fibro-odontoma, basal cell carcinoma, benign fibrous histiocytoma, blue nevus, chondrosarcoma, compound nevus, epithelioma adenoides cysticum, esthesioneuroblastoma, Ewing sarcoma, fibrosarcoma, giant cell granuloma, granulocytic sarcoma, hemangioma, hemangiopericytoma, Langerhans cell histiocytosis, lymphangioma, lymphoma, melanoma, neuroblastoma, neurofibroma, ossifying osteofibroma, osteochondroma, osteosarcoma, port wine stain, rhabdomyosarcoma, Spitz nevus, and xanthogranuloma. To the best of our knowledge, this is the largest such study of its kind to date. We believe that the large size of this study and the data on disease incidence will allow clinicians to be better informed of the differential diagnosis of neoplasms of the nasal cavity and paranasal sinuses in the pediatric population.

Nasal and sinus disease in cystic fibrosis

Paranasal and sinus disease is present in almost every patient with cystic fibrosis. However, symptoms are rarely reported. Some aspects including polyposis and microbial flora change with patient age. Endoscopy and computerised tomography have broadened our understanding of how this disease affects the sinuses, including an increased recognition of polyposis than previously thought and identification of several disease specific entities such as abnormalities of the lateral nasal wall and uncinate process. Few randomised, controlled trials evaluating medical or surgical treatments of CF sinus disease exist. Sinus surgery may provide some benefit, though there are no established selection criteria for appropriate candidates. A link between sinus disease and lower respiratory tract function may contribute to general health and survival following lung transplantation. Complications of sinonasal disease in CF are rare and include mucoceles and periorbital abscesses.

The usefulness of computed tomography scans in cystic fibrosis patients with chronic sinusitis

BACKGROUND

This study was performed to evaluate the usefulness of computed tomography (CT) scans of the sinuses in children with cystic fibrosis (CF) as an outcomes measurement for medical and surgically treated chronic rhinosinusitis.

METHODS

Patients with CF who had sinus scans performed at the study institution from January 1999 to September 2003 were identified. The scans and any available prior scans were scored according to the Lund-MacKay system. A retrospective chart review determined if hospitalization with i.v. antibiotic therapy or operative intervention had occurred between scans and if the scans showed improvement secondary to the intervention.

RESULTS

One hundred thirty-four patients were identified who met inclusion criteria. A total of 290 scans were reviewed, with the average number of CT scans per patient of 2.24 (range, 1-10). The average Lund-MacKay score for scans closest in time to the first sinus surgery was 14.5. (range, 7-24), and for the first postoperative scans, the score was 14.7 (8-24). There was no significant difference between the preoperative and postoperative Lund-MacKay score after initial surgery (p = 0.99) or in subsequent scans despite medical or surgical interventions (p = 0.90).

CONCLUSION

CT scanning of the sinuses does not appear to be useful in determining outcomes of intervention in CF patients.

Characterization of Potocki-Lupski syndrome (dup(17)(p11.2p11.2)) and delineation of a dosage-sensitive critical interval that can convey an autism phenotype

The duplication 17p11.2 syndrome, associated with dup(17)(p11.2p11.2), is a recently recognized syndrome of multiple congenital anomalies and mental retardation and is the first predicted reciprocal microduplication syndrome described--the homologous recombination reciprocal of the Smith-Magenis syndrome (SMS) microdeletion (del(17)(p11.2p11.2)). We previously described seven subjects with dup(17)(p11.2p11.2) and noted their relatively mild phenotype compared with that of individuals with SMS. Here, we molecularly analyzed 28 additional patients, using multiple independent assays, and also report the phenotypic characteristics obtained from extensive multidisciplinary clinical study of a subset of these patients. Whereas the majority of subjects (22 of 35) harbor the homologous recombination reciprocal product of the common SMS microdeletion (~3.7 Mb), 13 subjects (~37%) have nonrecurrent duplications ranging in size from 1.3 to 15.2 Mb. Molecular studies suggest potential mechanistic differences between nonrecurrent duplications and nonrecurrent genomic deletions. Clinical features observed in patients with the common dup(17)(p11.2p11.2) are distinct from those seen with SMS and include infantile hypotonia, failure to thrive, mental retardation, autistic features, sleep apnea, and structural cardiovascular anomalies. We narrow the critical region to a 1.3-Mb genomic interval that contains the dosage-sensitive RAI1 gene. Our results refine the critical region for Potocki-Lupski syndrome, provide information to assist in clinical diagnosis and management, and lend further support for the concept that genomic architecture incites genomic instability.

An assessment of sinus quality of life and pulmonary function in children with cystic fibrosis

BACKGROUND

Treatment of patents with cystic fibrosis (CF) is primarily directed at the lungs. However, there is a growing feeling that the status of the sinuses may have a profound influence on the status of the lungs in these patients. A number of investigators have demonstrated a relationship among coexisting rhinitis, sinusitis, other upper airway conditions, and lung disease. Several studies have shown that treatment and resolution of sinusitis results in an improvement in a number of pulmonary conditions. We hypothesize that pulmonary function test scores will be lower in patients with CF with more severe sinusitis.

METHODS

Consecutive CF patients were asked to complete a sinus-specific quality-of-life instrument, the 16-item Sino-Nasal Outcome Test (SNOT-16), and these scores, were compared to FEV, scores.

RESULTS

Univariate analysis revealed a significant correlation between SNOT-16 and FEV1 in patients under the age of 12. There was a trend toward significance in the older children and evaluation of the raw data shows that children with the highest FEV, had the lowest SNOT-16.

CONCLUSION

This study indicates that the severity of sinus disease correlates with the severity of pulmonary disease in CF patients under the age of 12. We plan to use the SNOT-16 to assess sinus interventions on pulmonary status.

Surgical indications and outcomes of tympanostomy tube removal

OBJECTIVE

To evaluate factors affecting perforation healing in children with surgical removal of retained tympanostomy tubes.

METHODS

We conducted a retrospective chart review of 82 pediatric patients (111 ears) who underwent surgical tube removal at a tertiary care pediatric hospital from 1/1/1999 to 12/31/2001. Patients included 47 males and 35 females with an age range of 2-15 years (average age, 6.8 years and median, 6 years). The length of intubation ranged from 12 months to 108 months (average, 44.6 months). The indications for removal included: prolonged intubation (61.3%), otorrhea or recurrent infection (21.6%), obstruction (7.2%), tube in middle ear (6.3%), enlarging perforation (2.7%), and in preparation for future cochlear implant surgery (9.9%). Interventions included removal of tympanostomy tubes and techniques for encouraging perforation closure. Seventy-six percent of the ears had a technique used to encourage healing. These techniques included freshen edges (11.8%), Gelfoam or Gelfilm (14.1%), Gelfoam and/or Gelfilm with freshened edges (50.6%). The main outcome measure was perforation healing. Chi-square statistical analysis were used to determine the statistical significant of observations.

RESULTS

Overall closure rate for all patients available for follow up was 87.0%, regardless of technique used to encourage healing. There was no statistically significant difference between the average intubation time in ears that healed (44 months), versus those with persistent perforation after removal (42 months). There was no statistical significant difference in closure rate based on patient age. When tubes were removed for prolonged intubation, 87.0% closed. If the indication was otorrhea or recurrent infections, 93.0% healed.

CONCLUSIONS

The overwhelming majority of patients who undergo surgical removal of tubes will show complete tympanic membrane healing independent of technique at time of removal, duration of intubation, patient age, or indication for removal.

Quality of Life and Sleep Study Findings After Adenotonsillectomy in Children With Obstructive Sleep Apnea

OBJECTIVES

To assess polysomnogram (PSG) results and global and disease-specific quality of life (QOL) in children with obstructive sleep apnea (OSA), before and after adenotonsillectomy, and to assess the association between PSG findings and QOL.

DESIGN

Prospective observational study. We performed overnight PSG using standardized techniques and assessed disease-specific and global QOL using validated instruments. Follow-up was assessed at 1 year. We compared QOL outcomes between children who underwent adenotonsillectomy and children who did not.

SETTING

A large tertiary care children's hospital.

PATIENTS

Children with sleep-disordered breathing who were suspected of having OSA.

INTERVENTION

Adenotonsillectomy.

MAIN OUTCOME MEASURES

We evaluated PSG parameters, disease-specific QOL, and global QOL.

RESULTS

We enrolled 47 children, 31 of whom met PSG criteria for OSA. Disease-specific and global QOL were not significantly different between children with OSA and children without. Global QOL was significantly worse for children with OSA than healthy children on several subscales: general health perception, behavior, and parental impact-emotional. Children who underwent adenotonsillectomy had significant improvements in QOL scores and PSG parameters (apnea-hypopnea index, P = .004; minimum saturation, P = .004). We found significantly larger QOL changes in children who underwent surgery compared with children without surgery (subscales: infections, P = .01; airway, P = .002; swallowing, P = .02; and behavior, P = .03). No strong association was identified between QOL scores and PSG parameters.

CONCLUSIONS

Children with OSA and sleep-disordered breathing have significantly worse QOL than healthy children. However, the association between PSG findings and QOL was only moderate. Children with OSA treated with adenotonsillectomy demonstrated large improvements in disease-specific and global QOL as well as PSG parameters.

Cell adhesion molecules and cytokines in middle ear effusions in children with or without recent acute otitis media

OBJECTIVES

We sought to compare the levels of cytokines and cell adhesion molecules in middle ear effusions (MEEs) of children with (group 1) or without (group 2) acute otitis media (AOM) within 3 months of obtaining MEE and to correlate these levels with hearing loss.

DESIGN AND SUBJECTS

MEE were collected from children (49 and 51 children composed groups 1 and 2, respectively) with otitis media with effusion (OME) undergoing tube placement who had an audiogram performed preoperatively. MEE was assessed as serous or mucoid. Cytokines and cell adhesion molecules were measured by enzyme-linked immunosorbent assay. Data were analyzed with the Student t test, chi(2) test, and the Pearson correlation test.

RESULTS

Concentrations of interleukin (IL)-1, IL-6, and vascular cell adhesion molecules (VCAM) were greater in the MEE of the children in group 1 compared with those of group 2 children. (P < 0.001 for IL-1 and IL-6; P < 0.05 for VCAM). The concentrations of IL-1, IL-6, VCAM, and E-selectin were greater in serous than in mucoid MEE. (P < 0.05). Concentrations of IL-6 correlated with the concentrations of the other 2 cytokines and the 3 cell adhesion molecules. Only concentrations of IL-6 in MEE correlated with the degree of hearing loss (P < 0.002).

CONCLUSIONS

The inflammatory response leading to OME involves multiple cytokines regardless of an AOM episode in the 3 months before obtaining MEE. IL-6 is an important cytokine in the pathogenesis of OME.

Quantitation and prevalence of tympanosclerosis in a pediatric otolaryngology clinic

OBJECTIVE

To determine the incidence and prevalence of tympanosclerosis (TS) in patients seen in a pediatric otolaryngology clinic.

DESIGN

Prospective observational study.

SETTING

Tertiary care, ambulatory care clinic.

PATIENTS AND OTHER PARTICIPANTS

We conducted a prospective observational study to determine the incidence of TS in 218 patients seen consecutively in a pediatric otolaryngology clinic for otologic and nonotologic reasons. The patient age range was 3 weeks to 30 years; 63% were male and 37% female. Of the 218 patients, 37% (81) had undergone bilateral myringotomy and tube placement (BM&T), and 35% (21) of the 81 showed signs of TS; 63% (137) of the 218 patients had no history of otologic surgery, but 12% (15) of the 137 showed signs of TS.

METHOD

The area of the tympanic membrane affected by TS was determined by otoscopy performed by one viewer, who drew the otoscopic findings on a standardized tympanic membrane template. The area of TS was quantified in terms of percentages by digital image analysis of the scaled drawings.

RESULTS

There was a range of 0.5-59.9% involvement of the tympanic membrane with TS, with the median percentage of involvement being 4.95%. There was an increased percentage of TS with repeat BM&T.

CONCLUSION

This observational study shows that patients who have had BM&T have a higher incidence of TS than those who have not had the surgery. However our findings also show that 38% of the patients in this study who had TS had never undergone BM&T.

Pediatric bilateral vocal fold immobility: the role of carbon dioxide laser posterior transverse partial cordectomy

Vocal fold paralysis in children has been estimated to be the second most common congenital abnormality of the pediatric airway. Most commonly, children present with the vocal folds in the midline or adducted position. Pediatric patients usually have a good voice or cry and a poor airway. In these cases, the surgical goal will be improving the airway, usually by lateralizing a vocal fold, while maintaining a normal voice and intact swallowing. The focus of this article is a modification of a technique for use in adults that was introduced by Dennis and Kashima in 1989. The procedure is intended to separate the vocal ligament and vocalis muscle from the arytenoid cartilage with removal of significant tissue mass with the CO2 laser. The demographics and results of 5 pediatric patients who underwent this procedure are discussed. The preoperative goals of airway enlargement, voice preservation, and normal deglutition were achieved in all 5 patients.

The role of postoperative chest radiography in pediatric tracheotomy

A postoperative chest radiograph has traditionally been obtained after tracheotomies to evaluate for the presence of a pneumothorax and to assess tube position. Several recent studies in adults have questioned the usefulness of routine postoperative chest radiography in uncomplicated cases, but the role of post-operative chest radiography in pediatric patients has not been previously reviewed. We performed this study to examine the clinical utility of post-tracheotomy chest radiography in pediatric patients and determine if this routine practice impacts patient management enough to merit continued usage. A retrospective review was performed of 200 consecutive pediatric patients who underwent tracheotomies by the otolaryngology service in a tertiary care pediatric hospital from January 1994 to June 1999. All patients received postoperative chest radiographs. Five of 200 patients had a new postoperative radiographic finding, with three requiring interventions. Two patients required chest tube placement for pneumothorax, and one patient required tracheostomy tube change for repositioning. Fifty-one patients, including both pneumothoraces, exhibited clinical signs of pneumothorax (decreased breath sounds or oxygen saturation) in the immediate postoperative period. Chest X-ray ruled out a pneumothorax in the remaining 49 patients. The majority of these 51 patients were less than 2 years old (94%, P=0.002) or weighed less than 17 kg (89%, P=0.004). Postoperative chest X-rays yielded clinically relevant information in 168 patients that fell into one or more of four high risk categories: age less than 2, weight less than 17 kg, emergent procedures, or concomitant central line placement. Avoiding chest X-rays in the remaining 32 patients would have resulted in potential savings of $5000, which does not reflect the actuarial cost of a missed complication. Since the majority of our patients (84%) fell into a high-risk category, we feel it would be prudent to continue obtaining postoperative chest radiographs following all pediatric tracheotomies.

Central CRH suppresses specific antibody responses: effects of beta-adrenoceptor antagonism and adrenalectomy

Central corticotropin releasing hormone (CRH)-induced activation of the sympathetic nervous system and/or the pituitary-adrenal axis is hypothesized to mediate suppression of in vivo specific antibody responses. To test whether beta-adrenergic receptor activation is involved in the immunosuppressive effects of central CRH, rats were pretreated with propranolol or saline before intracerebroventricular infusion of CRH and immunization with keyhole limpet hemocyanin (KLH). KLH (3 microg/kg) immunization induced significant increases in circulating levels of antigen-specific IgM and IgG. Central infusion of CRH (200 pmol) suppressed both IgM and IgG responses. Pretreatment with propranolol (20 mg/kg IP) reversed CRH-induced suppression of IgG responses but had no effect on IgM levels. To test whether adrenal activation also plays a role in the effects of KLH on specific antibody responses, a separate group of animals underwent adrenalectomy prior to CRH infusion and immunization with KLH. As compared to nonadrenalectomized control rats, adrenalectomized rats showed a reduction of antibody responses, and CRH failed to induce a further suppression of IgM or IgG responses in adrenalectomized animals. Collectively, these data suggest that beta-adrenoceptors mediate the suppression of primary antibody responses induced by central CRH. Moreover, the adrenals may promote optimal primary antibody responses after exposure to physiological levels of antigen.

Validation of an outcomes instrument for tonsil and adenoid disease

OBJECTIVE

To design and validate a disease-specific health status instrument-the Tonsil and Adenoid Health Status Instrument-for use in children with tonsil and adenoid disease.

DESIGN

Prospective psychometric and clinimetric instrument validation in 3 stages.

SETTINGS

A tertiary academic pediatric specialty hospital and a tertiary academic hospital, in 2 different cities. PATIENTS/OTHER PARTICIPANTS: Children with tonsil and adenoid disease presenting for evaluation and treatment (n = 224). INTERVENTION/METHOD: Prospective instrument validation. Stage 1 consisted of initial item testing, reduction, and subscale construction; stage 2, reliability and validity testing, factor analysis, and final item reduction; and stage 3, responsiveness analysis.

MAIN OUTCOME MEASURES

Test-retest and internal consistency reliability; content, construct, and criterion validity; orthogonal principal components factor analysis; and response sensitivity analysis.

RESULTS

Factor analysis and item analysis confirmed 6 distinct subscales measuring different constructs (aspects) of disease-specific health status that are affected by tonsil and adenoid disease: eating and swallowing, airway and breathing, infections, health care utilization, cost of care, and behavior. For each subscale, the Tonsil and Adenoid Health Status Instrument demonstrated excellent test-retest reliability (r = 0.72-0.88) and internal consistency reliability (Cronbach alpha = .73-.87). Content validity was ensured during the design process. Construct validity was demonstrated by means of convergent and divergent validity with a global quality-of-life instrument (the Child Health Questionnaire, version PF28). Criterion validity was also satisfactory. Finally, the instrument was appropriately sensitive, with high standardized response means and effect sizes.

CONCLUSIONS

The Tonsil and Adenoid Health Status Instrument is a valid, reliable, and sensitive instrument with 6 distinct subscales. This instrument has significant utility for outcomes research in children with tonsil and adenoid disease.

Intracranial complications of acute mastoiditis

OBJECTIVE

Oral antibiotic use may have changed the incidence and microbiology of otitic intracranial complications. We reviewed cases of acute mastoiditis to document: (1) incidence of intracranial complications; (2) risk factors; and (3) identify pathologic organisms.

METHODS

A retrospective study of children at a tertiary care children's hospital with acute mastoiditis from July, 1986 through June, 1998.

RESULTS

118 children with acute mastoiditis were identified. Eight patients (6.8%), ages 20 months to 14 years, had intracranial complications related to acute mastoiditis. Three children had a sigmoid sinus thrombosis, two children had an epidural abscess, and two children had both complications of sigmoid sinus thrombosis and epidural abscess, and a sigmoid sinus thrombosis and meningitis was present in one child. Pre-admission oral antibiotics were administered for an average of 10 days in seven of the eight patients. Persistent otorrhea and/or otalgia were present in all patients. Intraoperative cultures were negative in four cases (50%). Organisms isolated included: Streptococcus pneumoniae (2); Proteus mirabilis (1); Pseudomonas aeruginosa (1); and coagulase negative Staphylococcus (1). Multi-drug resistant organisms were documented in only one case. All patients underwent a contrast enhanced CT of the temporal bones and brain. Surgical management included complete mastoidectomy in all patients and a pressure equalization tube in seven of the eight cases.

CONCLUSIONS

Our review did not document an increase in the incidence of otitic intracranial complications. Persistent otalgia or otorrhea while on oral antibiotics with associated neurologic symptoms are ominous signs suggestive of a complication. Multi-drug resistant organisms are uncommon whereas negative intraoperative cultures are common.

Tracheobronchial foreign bodies

Aspirated and ingested foreign bodies continue to present challenges to otolaryngologists. The major issues involve the accurate diagnosis and speedy, safe retrieval of the foreign body. The accurate diagnosis may allude physicians because often the initial choking incidents are not witnessed and the delayed residual symptoms may mimic other common conditions. The retrieval of foreign bodies has been facilitated by technical improvements with the rod lens telescope, video endoscopy, a broad range of a variety of sized forceps, and safer anesthesia. This article reviews the clinical presentation, diagnostic work-up, and appropriate management of foreign bodies in the aerodigestive tract.

Vocal cord paralysis in infants and children

Vocal cord paralysis is the second most common cause of neonatal stridor. Recognition of laryngeal paralysis warrants further evaluation for an underlying etiology as it is frequently a manifestation of a multisystem anomaly. Initial intervention must concentrate on airway stabilization and treatment of any underlying conditions. Management strategies should be individualized and focus on maintenance of a safe and stable airway, acquisition of intelligible speech, and deglutition without aspiration.

Quality of life and health status in pediatric tonsil and adenoid disease

OBJECTIVE

To assess the baseline global health status and quality of life (QOL) in children with tonsil and adenoid disease.

DESIGN

Cross-sectional multicenter survey series.

SETTINGS

A tertiary academic pediatric specialty hospital and a tertiary academic hospital in 2 different cities.

PATIENTS AND OTHER PARTICIPANTS

Consecutive series of 55 parents of children who were seen for tonsil and adenoid disease. INTERVENTION AND METHOD: Cross-sectional survey of the health status of affected children to assess their QOL and its relationship to tonsil and adenoid disease.

MAIN OUTCOME MEASURES

Quality-of-life subscale scores of affected children on the Child Health Questionnaire version PF28 (CHQ-PF28); comparisons of population data from healthy normal children and children with asthma and juvenile rheumatoid arthritis.

RESULTS

The overall health status and QOL of children with tonsil and adenoid disease is significantly worse than those of healthy normal children, as demonstrated by lower mean scores on several CHQ-PF28 subscales, including general health, physical functioning, behavior, bodily pain, and parental impact (emotional). In addition, the general health perception of children with tonsil and adenoid disease is similar to the perceptions of children with asthma and juvenile rheumatoid arthritis, but several aspects of health status, as measured by CHQ-PF28 subscale scores, were significantly worse in children with tonsil and adenoid disease.

CONCLUSION

The health status impact of tonsil and adenoid disease appears to be quite significant, particularly in aspects related to the parental impact of the child's disease.

Recurrent meningitis in the pediatric patient--the otolaryngologist's role

OBJECTIVE

To assess the etiology of recurrent meningitis in the pediatric patient.

DESIGN

Retrospective case series and literature review.

SETTING

Tertiary-care pediatric hospital.

PATIENTS

Children (< 17-years-old) with recurrent meningitis, treated at Texas Children's Hospital (TCH) between 1984 and 1995.

RESULTS

A review of 463 cases of bacterial meningitis over an 11 year period revealed six children aged 3 months to 15 years with the diagnosis of recurrent meningitis. The patient's age, number of episodes of meningitis, diagnostic investigations performed and etiologies of recurrent meningitis were recorded. Fifteen episodes of meningitis were identified in these six patients; Streptococcus pneumoniae represented the bacteriology in 73% of the cases. Two patients were diagnosed with temporal bone abnormalities, two children with immunological deficiencies and no underlying etiology for the recurrent meningitis was identified in the remaining two patients. In this series, one-third of patients had an otolaryngologic etiology for their recurrent meningitis. These six patients, along with a review of the recent literature, will highlight the need for otolaryngological assessment and the importance of considering immunological investigations when managing recurrent meningitis in the pediatric patient.

CONCLUSION

We propose that children with recurrent meningitis of unknown etiology undergo: (1) an audiological evaluation; (2) a CT scan of the temporal bones, skull base and paranasal sinuses; and (3) an immunological evaluation.

Is parental perception an accurate predictor of childhood hearing loss? A prospective study

OBJECTIVE

We performed this study to assess whether parental perception of hearing loss predicted the results of audiometric testing in children with recurrent otitis media or persistent otitis media with effusion.

METHODS

As part of a larger prospective observational outcomes study of children undergoing tympanostomy tube placement, the child's parent completed a standardized questionnaire before and after tube placement. In addition, patients underwent age-appropriate audiologic threshold and tympanometry testing before and after tube placement.

RESULTS

We enrolled 113 patients (median age, 2 years), and 93 (82%) completed follow-up. Before treatment, parental perception of hearing loss did not predict hearing threshold level. After tube placement, parental perception of hearing loss was also poorly correlated with change in threshold.

CONCLUSIONS

Parental perception of their child's hearing loss is a poor predictor of objective audiologic findings both before and after treatment with tympanostomy tubes. These findings have important implications concerning the importance of screening for hearing loss in children with otitis media with effusion.

A retrospective analysis of airway endoscopy in patients less than 1-month old

OBJECTIVES

To review the authors' experience with neonates who underwent endoscopy over an 8-year period.

STUDY DESIGN

Retrospective review in a tertiary care children's hospital.

METHODS

Sixty-two neonates who underwent endoscopy were reviewed.

RESULTS

Common indications for endoscopy were stridor (56%), apnea/cyanotic episodes (30%), and feeding difficulty (23%). Laryngeal abnormalities were the most frequent finding, including laryngomalacia (19%), glottic edema (19%), and vocal cord paralysis (13%). Pierre Robin sequence was the most common associated anomaly. Forty-eight neonates (77.4%) had more than one endoscopic finding. Gastroesophageal reflux diagnosed by barium swallow or esophageal pH monitoring was found in 34%. Gastroesophageal reflux was the only identified etiologic factor in four cases. Computed tomography and magnetic resonance imaging provided less information than endoscopy.

CONCLUSIONS

Endoscopy in symptomatic neonates can determine etiology of distress most of the time. Multiple diagnoses were found in 77.4% of the neonates, emphasizing the need for a thorough aerodigestive tract examination. Concomitant diagnoses including gastroesophageal reflux, congenital heart disease, and pulmonary disease were found in 87.1% of neonates. Neonates have a higher likelihood of having multiple lesions in the aerodigestive tract as compared with older infants or children.

Childhood pseudohypacusis in patients with high risk for actual hearing loss

OBJECTIVE

While pseudohypacusis or nonorganic hearing loss is a well-recognized phenomenon in adults, it is the aim of this report to heighten the physician's awareness of the occurrence of nonorganic hearing loss in pediatric patients. The medical and otologic histories of 18 cases identified consecutively between 1983 and 1991 at The Children's Hospital, Boston, Massachusetts, were retrospectively reviewed. In these selected cases an analysis of the audiometric configuration, age range, and sex distribution is undertaken. This review highlights the need to rule out pseudohypacusis even in pediatric cases where suspicion is low. A precedent trauma was the presenting complaint in a high percentage of our patient population. This association has not been previously reported in the pediatric literature. While the severity of the traumatic incident was often minor, extensive medical and surgical investigations had been considered before the identification of nonorganic hearing loss.

STUDY DESIGN

A retrospective chart analysis of patients identified with pseudohypacusis over a 7-year period.

METHODS

A tertiary care children's hospital in an urban community. Eighteen consecutively identified patients examined by a staff audiologists at a tertiary care children's hospital. A specific battery of standard audiologic testing with the goal of detecting pseudohypacusis in children.

RESULTS

Successful if additional interventions such as exploratory tympanotomy were avoided.

CONCLUSIONS

Pseudohypacusis was identified in 18 patients with a majority having an antecedent history of trauma. Additional interventions were canceled upon the detection of true threshold values. A high index of suspicion of pseudohypacusis in children and an organized standardized battery of audiologic testing will facilitate early identification of these patients and will avert inappropriate interventions.

Intracranial complications of sinusitis: a pediatric series

Intracranial complications of sinusitis (ICS) (cerebral, epidural, and subdural abscesses, meningitis, and dural sinus thrombophlebitis) remain a challenging and contemporary topic. The progressive pneumatization and continued development of the sinuses after birth and the late appearance of the frontal and sphenoid sinuses imply that some infections would not appear until later childhood. We reviewed the records at a large pediatric hospital between 1986 and 1995 and found 10 children with 13 ICS (cerebral abscess, 5; extra-axial empyema, 5; and meningitis, 3). Of 43 children with cerebral abscess and 16 with extra-axial abscesses treated in this period, 12% of cerebral and 63% of extra axial abscesses were due to a sinogenic source. Multiple intracranial and extracranial complications of sinusitis in a single patient were common. The average age of children with ICS was 12.2 years old. We present these 10 cases and discuss their presentation, microbiology, and clinical course. Although the majority presented with a classic picture of headache, altered mental status, and fever, a few had symptoms that were more subtle. One child had recurrent meningitis, believed to be due to skull base dehiscence after endoscopic sinus surgery (ESS). He has required multiple otolaryngologic and neurosurgical procedures in an effort to prevent further episodes of meningitis. Ultimately, nine of 10 patients survived with an average hospital stay of 27.8 days (median of 17 days). The diagnosis of ICS requires a high index of suspicion, imaging of the brain and paranasal sinuses, and aggressive intervention.

Gastroesophageal reflux association with laryngomalacia: a prospective study

OBJECTIVE

To identify the incidence and clinical role of gastroesophageal reflux (GER) in patients with laryngomalacia.

DESIGN

Prospective evaluation of consecutive infants with a new diagnosis of laryngomalacia with an initial questionnaire, a barium esophagram or 24 h pH probe and record of their subsequent clinical course.

SETTING

A large, tertiary pediatric referral center and its associated outpatient clinic.

PATIENTS

New diagnosis of laryngomalacia in 33 consecutive infants were evaluated by questionnaire and 27 of these were evaluated for GER.

RESULTS

GER was observed in 64% of patients and was significantly associated with severe symptoms and complicated clinical course (P = 0.0163). The presence of smokers in the infant's household negatively impacted his or her clinical course and symptomatology (P = 0.013) as did the presence of other major, concurrent medical problems (P = 0.065).

CONCLUSIONS

In patients with laryngomalacia, GER was significantly associated with severe symptoms (a complicated clinical course), as was smoking in an infant's household and other significant medical problems.