[Association of hypertension and antihypertensive agents and the severity of COVID-19 pneumonia. A monocentric French prospective study]

BACKGROUND AND AIM

Angiotensin converting enzyme (ACE) type 2 is the receptor of SARSCoV-2 for cell entry into lung cells. Because ACE-2 may be modulated by ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), there are concern that patients treated with ACEIs and ARBs are at higher risk for COVID-19 infection or severity. This study sought to analyse the association of severe forms of COVID-19 and mortality with hypertension and a previous treatment with ACEI and ARB.

METHODS

Prospective follow-up of 433 consecutive patients hospitalised for COVID-19 pneumonia confirmed by PCR or highly probable on clinical, biological, and radiological findings, and included in the COVHYP study. Mortality and severe COVID-19 (criteria: death, intensive care unit, or hospitalisation >30 days) were compared in patients receiving or not ACEIs and ARBs. Follow-up was 100% at hospital discharge, and 96.5% at >1month.

RESULTS

Age was 63.6±18.7 years, and 40%) were female. At follow-up (mean 78±50 days), 136 (31%) patients had severity criteria (death, 64 ; intensive care unit, 73; hospital stay >30 days, 49). Hypertension (55.1% vs 36.7%, P<0.001) and antihypertensive treatment were associated with severe COVID-19 and mortality. The association between ACEI/ARB treatment and COVID-19 severity criteria found in univariate analysis (Odds Ratio 1.74, 95%CI [1.14-2.64], P=0.01) was not confirmed when adjusted on age, gender, and hypertension (adjusted OR1.13 [0.59-2.15], P=0.72). Diabetes and hypothyroidism were associated with severe COVID-19, whereas history of asthma was not.

CONCLUSION

This study suggests that previous treatment with ACEI and ARB is not associated with hospital mortality, 1- and 2-month mortality, and severity criteria in patients hospitalised for COVID-19. No protective effect of ACEIs and ARBs on severe pneumonia related to COVID-19 was demonstrated.

Childhood cholesteatoma

Although cholesteatoma was first described in 1683, its etiopathogeny remains unexplained. In children, there are two forms: acquired cholesteatoma, resembling the adult form, and congenital cholesteatoma. The acquired form has become less frequent in recent years, thanks to progress in the treatment of childhood otitic pathology. Diagnosis of congenital cholesteatoma, on the contrary, is increasing, due to improvements in information to health care professionals and in diagnostic tools. Clinical and histological evidence points to greater aggressiveness in childhood forms, although this difference cannot, at present, be precisely explained. Diagnosis is clinical, but CT and MR imaging is indispensable for preoperative assessment and postoperative follow-up. New delayed gadolinium-enhanced T1-weighted and diffusion-weighted MRI sequences have recently been developed and provide more precise radiological diagnosis. Treatment is surgical; alternatives, notably by laser, have proved unsuccessful. Complications concern involvement of neighbouring structures, and are mainly infectious; some can be life-threatening, and should be systematically screened.

[Cervical Castleman disease in childhood: a report of two cases and a review of the literature]

Castleman disease (CD) is a benign lymphoproliferative disorder, rare in children. Head and neck localizations are found only in 14 % of the cases. Two forms have been described: a hyaline vascular type and a plasma cell type. It can also be monocentric or multicentric. Both young patients were affected with an isolated neck localization of Castleman disease. Preoperative diagnosis can be difficult with a thymoma or a lymphoma. CT and MRI can help in the diagnosis, which is confirmed by histopathological assessment. The pathological features and the therapeutic management of CD are discussed. While surgery is the treatment for localized lesions, steroids and chemotherapy are indicated in the multicentric type. Because of the risk of relapse and malignant transformation, long-term follow-up is mandatory.

Cochlear implant in the carotid canal. Case report and literature review

BACKGROUND

Numerous complications have been described following cochlear implantation. Most of them are post-operative and benign, but some are intra-operative and can be more difficult to manage.

METHODS

Case report of a pediatric case of misplaced cochlear electrode in the carotid canal and literature review.

RESULTS AND CONCLUSIONS

Post-operative CT-scan allowed the diagnosis. The misplaced cochlear implant in the carotid canal was successfully removed and a successful re-implantation followed immediately. Anatomy of the interval between the cochlea and the carotid canal is reviewed, together with information regarding the neural telemetry response. In each case, specific anatomical landmarks must be identified to perform the cochleostomy in the right position. If not, or if surgery proves itself difficult, the surgeon should intra-operatively control the position of the electrode.

A 20-year experience of electron microscopy in the diagnosis of primary ciliary dyskinesia

Transmission electron microscopy (TEM) analysis of ciliary ultrastructure is classically used for the diagnosis of primary ciliary dyskinesia (PCD). We report our extensive experience of TEM analysis in a large series of patients in order to evaluate its feasibility and results. TEM analysis performed in 1,149 patients with suspected PCD was retrospectively reviewed. Biopsies (1,450) were obtained from nasal (44%) or bronchial (56%) mucosa in children (66.5%) and adults (33.5%). TEM analysis was feasible in 71.4% of patients and showed a main defect suggestive of PCD in 29.9%. TEM was more feasible in adults than in children, regardless of the biopsy site. Main defects suggestive of PCD were found in 76.9% of patients with sinopulmonary symptoms and in only 0.4% of patients with isolated upper and 0.4% with isolated lower respiratory tract infections. The defect pattern was similar in children and adults, involving dynein arms (81.2%) or central complex (CC) (18.8%). Situs inversus was never observed in PCD patients with CC defect. Kartagener syndrome with normal ciliary ultrastructure was not an exceptional condition (10.2% of PCD). In conclusion, TEM analysis is feasible in most patients and is particularly useful for PCD diagnosis in cases of sinopulmonary syndrome of unknown origin.

Childhood granular cell tumors: two case reports

Granular cell tumors (GCT), also known as Abrikossoff tumors, are rare tumors found largely in children, with few reports of laryngo-tracheal involvement. Two childhood cases of laryngo-tracheal GCT are reported here, of which one case had multifocal lesions. The histopathological features and the therapeutic management of GCT are also discussed.

Three-dimensional time-resolved fluorescence imaging by multifocal multiphoton microscopy for a photosensitizer study in living cells

Two-photon fluorescence microscopy is widely applied to biology and medicine to study both the structure and dynamic processes in living cells. The main issue is the slow acquisition rate due to the point scanning approach limiting the multimodal detection (x, y, z, t). To extend the performances of this powerful technique, we present a time-resolved multifocal multiphoton microscope (MMM) based on laser amplitude splitting. An array of 8 x 8 foci is created on the sample that gives a direct insight of the fluorescence localization. Four-dimensional (4D) imaging is obtained by combining simultaneous foci scanning, time-gated detection, and z displacement. We illustrate time-resolved MMM capabilities for 4D imaging of a photosensitizer inside living colon cancer cells. The aim of this study is to have a better understanding of the photophysical processes implied in the photosensitizer reactivity.

[Slide tracheoplasty in congenital tracheal stenosis]

OBJECTIVES

Slide Tracheoplasty has progressively become the gold standard in the management of long-segment tracheal stenosis in children and infants. However, in certain situations this operation might become difficult and others techniques might be preferred.

MATERIAL AND METHODS

Five patients, 1 to 6 month old had surgery by our team, for complex tracheal stenosis between 2001 and 2005. Tracheal hypoplasia was considered complex because it was associated to either: an acquired critical stenosis, a cricoid stenosis, a bronchial stenosis, a tracheal bronchus or associated to oesophageal atresia and severe tracheomalacia. All of them have been treated by a modified slide tracheoplasty.

RESULTS

The postoperative status required an average of 15 days in ICU, including 8 days of ventilation. Two patients had laryngeal nerve injury. Medium term follow up (27 months) demonstrated no need for re-intervention, good potential growth and normal child activity.

CONCLUSIONS

Slide tracheoplasty can provide good results in certain cases of severe and complex tracheal hypoplasia in infants.

[Current management of acute pediatric rhinosinusitis in France]

Un groupe de médecins généralistes et multidisciplinaire de spécialistes contribue à définir les différentes formes de sinusites ou rhinosinusites aiguës de l'enfant à partir des principaux symptômes et signes cliniques. Le rôle des pathologies associées telles que l'allergie, les troubles immunitaires est envisagé. L'incidence, la présentation clinique et la prise en charge des complications sont présentées. Les indications des examens radiologiques et biologiques sont analysées. La prise en charge médicale en particulier, la place et le type des antibiotiques sont discutés. Des propositions de prise en charge selon des situations cliniques rencontrées en pratique sont présentées.

Calcium phosphate fibres synthesized from a simulated body fluid

The biomimetic coating method was used for fabricating calcium phosphate fibres for biomedical applications such as bone defect fillers. Natural cotton substrate was pre-treated with phosphorylation and a Ca(OH)2 saturated solution. The pre-treated samples were then soaked in simulated body fluid (SBF) of two different concentrations, 1.5 times and 5.0 times the ion concentration of blood plasma. The cotton was then burnt out via sintering of the ceramic coating at 950 degrees C, 1050 degrees C, 1150 degrees C, and 1250 degrees C. The results demonstrated that osteoblastic cells were able to cover the entire surface cotton fibres, and the cell coverage appeared to be independent of surface roughness and Ca/P ratio of fibres.

[Middle ear cholesteatoma]

Cholesteatoma is a serious form of chronic otitis media. The aim of this paper is to present the state of the art of disease management, including recent data from the literature and the authors' derived from their Mentors' teaching, Professor Pierre Roulleau (Paris, France) and Professor Robert Charachon (Grenoble, France). The main recent advances concern the use of cartilage grafts to reconstruct the canal wall and/or tympanic membrane (allowing a significant reduction in residual cholesteatoma) and progress in medical imaging allowing more acute preoperative determination of extension of the cholesteatoma (in order to propose an optimally designed surgical technique) and a less invasive postoperative follow-up.

[Nasal glial heterotopia: embryological and clinical approaches]

INTRODUCTION

Nasal gliomas or heterotopia are nonhereditary congenital malformations composed of heterotopic neuroglial tissue. They usually present in infancy. Evaluation should include preoperative imaging with CT scan and/or MRI to rule out intracranial extension. There have been several cases reported in which nasal gliomas were misdiagnosed as capillary hemangiomas. The differential diagnosis includes prenasal space developmental impairment, which are nasoethmoidal meningoencephaloceles, nasal dermoid and epidermoid cysts.

CASE REPORT

We describe the case of a newborn male infant presenting at birth with a paramedial nasal glioma. An embryological and clinical analysis of nasal gliomas is proposed.

DISCUSSION

Nasal glioma is an uncommon congenital lesion presenting as a large panel of midline craniofacial anomalies. The embryological and anatomical origins of nasal gliomas are reviewed. The most known embryological theory was described by Grünwald in 1910 and is called the "prenasal space" theory. This theory is very attractive because of the embryopathogenic continuum proposed among dermoids, gliomas, and encephaloceles. In this article, we discuss major embryological theories on nasal gliomas pathogenesis and propose that while the prenasal space theory can explain the occurrence and the continuum between basal anterior or prenasal encephaloceles and gliomas, it cannot explain the occurrence of craniofacial demoids of the same topography. Better knowledge of embryological mechanisms implicated in the pathogenesis of nasal gliomas can help clinical management of this kind of malformations.

Cochlear implantation in children with internal ear malformations

OBJECTIVE

To evaluate surgical aspects and results of cochlear implantation in inner ear malformations.

STUDY DESIGN

Retrospective cohort study.

SETTING

Ear, nose, and throat department of a tertiary referral hospital.

PATIENTS

Out of 260 implanted children, 18 (6.9%) had inner ear malformations: complex cochleovestibular malformation (n = 11), common cavity (n = 1), and enlarged vestibular aqueduct (EVA) (n = 6). Deafness was progressive in 12 cases (G1) and congenital in 6 cases (G2). Genetics lead to diagnosis in 12 of 13 cases: PSD mutation (n = 11), Waardenburg syndrome (n = 1), negative (1). Mean age at implant was 7.8 years. Mean follow-up period was 48 months.

MAIN OUTCOME MEASURES

Medical and surgical outcomes were reported. Closed (CSW) and open (OSW) set word perception and level of speech production were evaluated each year. The results were compared pre- and postoperatively and between the two groups.

RESULTS

Gusher at surgery was observed in 50% of cases, with a persistent leak in one case. No facial injury or infectious complications were observed. At 12 months, 83% of the population had achieved more than 75% recognition in CSW, versus 16% before implant (p = 0.001). After 2 years, 64% of patients had more than 50% recognition in OSW. Good oral language was seen in 76% at 2 years and 100% at 3 years, versus 55% before implant (respectively, p > 0.05 and p = 0.03). At 1 year after implant, 83% of the G1 and 20% of the G2 achieved more than 50% recognition in OSW (p = 0.02). After 24 months, 83% of G1 and 40% of G2 had more than 50% in OSW (p > 0.05). Before implant, 75% in G1 and 0% in G2 had good oral language (p = 0.01). At 1 year, 83% in G1 and 16% in G2 had good oral language (p = 0.02). At 2 years, 100% in G1 and 20% in G2 had good oral language (p = 0.02). One child in G1 had no improvement after implantation.

CONCLUSIONS

No major complication was seen. Perceptive and linguistic results were variable and depended on the type of the deafness. In progressive deafness, the perceptive and linguistic result are expected to be good. In congenital deafness, the results are more variable.

RPGR is mutated in patients with a complex X linked phenotype combining primary ciliary dyskinesia and retinitis pigmentosa

INTRODUCTION

Primary ciliary dyskinesia (PCD) is a rare disease classically transmitted as an autosomal recessive trait and characterised by recurrent airway infections due to abnormal ciliary structure and function. To date, only two autosomal genes, DNAI1 and DNAH5 encoding axonemal dynein chains, have been shown to cause PCD with defective outer dynein arms. Here, we investigated one non-consanguineous family in which a woman with retinitis pigmentosa (RP) gave birth to two boys with a complex phenotype combining PCD, discovered in early childhood and characterised by partial dynein arm defects, and RP that occurred secondarily. The family history prompted us to search for an X linked gene that could account for both conditions.

RESULTS

We found perfect segregation of the disease phenotype with RP3 associated markers (Xp21.1). Analysis of the retinitis pigmentosa GTPase regulator gene (RPGR) located at this locus revealed a mutation (631_IVS6+9del) in the two boys and their mother. As shown by study of RPGR transcripts expressed in nasal epithelial cells, this intragenic deletion, which leads to activation of a cryptic donor splice site, predicts a severely truncated protein.

CONCLUSION

These data provide the first clear demonstration of X linked transmission of PCD. This unusual mode of inheritance of PCD in patients with particular phenotypic features (that is, partial dynein arm defects and association with RP), which should modify the current management of families affected by PCD or RP, unveils the importance of RPGR in the proper development of both respiratory ciliary structures and connecting cilia of photoreceptors.

Fluorescence-lifetime imaging with a multifocal two-photon microscope

Two-photon microscopy is a powerful tool for imaging of cells or tissues. However, it presents the drawback of being a laser-scanning technique that involves a long acquisition time for fluorescence-lifetime imaging. Thus it is commonly limited to intensity images that give only indications of the location of fluorophores but do not identify the physicochemical properties and interactions between cells' components. To protect biological samples from experiments that are too long and to provide a more comprehensive spectroscopic tool we have developed a time-resolved multifocal multiphoton microscope. This setup allows us to speed up the acquisition while retaining the possibility of measuring both intensity and lifetime images of the sample.

[Nasal ciliary investigations for the diagnosis of primary ciliary dyskinesia in children]

Primary ciliary dyskinesia (PCD) is an autosomal recessive disorder, characterized by chronic infections of the upper and lower airways, associated in 50% of cases with situs inversus, therefore, corresponding to Kartagener's syndrome. PCD is suspected on clinical features, including bronchitis, rhinosinusitis and chronic otitis media beginning in early childhood. The recurring infections eventually lead to bronchiectasis. The clinical features of PCD have been ascribed to primary defects in cilia, which lead to impairment of mucociliary clearance. Ciliary investigations looking for abnormalities in ciliary motion and ultrastructure can be easily performed at nasal level. Quantitative ultrastructural study of cilia is performed in cases of abnormal ciliary motion and/or clinical symptoms highly suggestive of PCD. In PCD, all or most of the cilia are abnormal, all bearing the same ultrastructural defects, mainly concerning dynein arms. In older children, the detection of a very low nasal NO output could also be useful for the diagnosis of PCD. As soon as the ciliary investigations are easy to perform at the nasal level, they could help for a better detection of PCD. This strategy could be especially useful in cases of atypical presentations, which are underestimated as a cause of recurrent airway infections. Diagnosis of PCD is important in order to prevent the development of bronchiectasis and to avoid any unnecessary procedure.

Radiosynthesis and pharmacological evaluation of [11C]EMD-95885: a high affinity ligand for NR2B-containing NMDA receptors

EMD-95885, 6-[3-[4-(4-fluorobenzyl)piperidino]propionyl]-3H-benzoxazol-2-one (1) has been described as a selective antagonist for the NMDA receptors containing NR2B subunits, displaying an IC50 of 3.9 nM for this subtype. EMD-95885 (1) has been synthesized in good overall yield and labelled with carbon-11 ( T1/2 : 20.4 min) at its benzoxazolinone moiety using [11C]phosgene. The pharmacological profile of [11C]EMD-95885 ([11C]-1) was evaluated in vivo in rats with biodistribution studies and brain radioactivity monitored with intracerebral radiosensitive beta-microprobes. The brain uptake of [11C]-1 was homogeneous (0.4-0.6%ID/mL) across the different brain structures studied. This in vivo brain regional distribution of [11C]-1 was not consistent with the known distribution of NR2B subunits. Also as a measure of specificity the hippocampus/cerebellum ratio reached 0.8 throughout the time course of the experiment supporting the lack of specificity. Competition studies with the NR2B prototypic ligand ifenprodil and EMD-95885 (1), 30 min before the radioligand injection, displayed homogeneous reduction of [11C]-1 uptake of 40-60%. Pre-treatment of rats with DTG (sigma ligand), MDL105519 (glycine site antagonist) and MK801 (ion channel blocker) had no inhibitory effect on [11C]-1 uptake. Use of haloperidol as a blocking drug also resulted in a homogeneous inhibition of [11C]-1 uptake by 66-60%, which does not reflect binding to dopamine or sigma receptors. Due to the homogeneous radioligand uptake and inhibition and no measure of cerebral blood flow effects during these blocking studies it is uncertain whether any specific binding is observed. In view of these results, [11C]EMD-95885 ([11C]-1) does not have the required properties for imaging NR2B containing NMDA receptors using positron emission tomography.

Traitement par vincristine des hémangiomes graves du nourrisson

AIM

To evaluate the efficacy of vincristine treatment for function- and life-threatening hemangiomas.

PATIENTS AND METHOD

Nine infants, eight girls and one boy, received vincristine treatment (VCR) for endangering hemangiomas. In six cases, the hemangiomas involved head and neck in a segmental unilateral or bilateral distribution (3/6 also had laryngeal and 2/6 tracheal location causing respiratory distress, 5/6 had eyelid and orbital involvement); one infant had disseminated neonatal hemangiomatosis (skin, liver, kidney); two infants had liver hemangiomas with cardiac failure. VCR was prescribed after failure of high-dosage corticosteroid treatment in six, and of both corticosteroids and interferon alpha 2b (5 months) in one; two infants received VCR as first line treatment.

RESULTS

A dosage of 1 mg/m(2) IV injection was delivered, with weekly injections first, and then tapering, increasing the interval between injections, depending on the clinical response. The nine infants received from 5 to 25 injections (average: 16), for a length of treatment of 1.5-8 months (average: 5.5 months). In seven patients a clear clinical response was observed at the end of the first month of treatment, while a slow protracted response was noted in two. Transient mild side effects were present in four patients.

DISCUSSION

Corticosteroid treatment, although a worldwide recognized treatment of problematic hemangiomas, cannot always control the growth of alarming hemangiomas. Interferon alpha 2a and 2b have proven a 90% effectiveness: treatment for cortico-resistant, function- and life-threatening, hemangiomas.

Chronic stridor caused by laryngomalacia in children: work of breathing and effects of noninvasive ventilatory assistance

Breathing pattern, gas exchange, and respiratory effort were assessed in five awake children with chronic stridor caused by laryngomalacia during spontaneous breathing (SB) and noninvasive mechanical ventilation (NIMV). During SB, the youngest children were able to maintain normal gas exchange at the expense of an increased work of breathing as assessed by calculated diaphragmatic pressure-time product (PTPdi), whereas the opposite was observed in the older children. NIMV increased tidal volume, from 8.77 +/- 2.04 ml/kg during SB to 11.67 +/- 2.52 ml/kg during NIMV, p = 0.04, and decreased respiratory rate, from 24.4 +/- 5.6 breaths/ min during SB to 16.6 +/- 0.9 breaths/min during NIMV, p = 0.04. NIMV unloaded the respiratory muscles as reflected by the significant reduction in PTPdi, from a mean value of 541.0 +/- 196.6 cm H(2)O x s x min(-1) during SB to 214.8 +/- 116.0 cm H(2)O x s x min(-1) during NIMV, p = 0.04. Therefore, NIMV successfully relieves the additional load imposed on the respiratory muscles. Long-term home NIMV was provided to a total of 12 children with laryngomalacia (including these five) and was associated with clinical improvement in sleep and growth.

Abnormal central complex is a marker of severity in the presence of partial ciliary defect

BACKGROUND

Ciliary ultrastructural defects with total lack of dynein arms (DA) cause abnormal mucociliary function leading to the chronic infections observed in primary ciliary dyskinesia. The role of partial ciliary ultrastructural defects, especially those involving the central complex, and their relationship with respiratory symptoms have been less thoroughly investigated.

OBJECTIVE

In a pediatric population with partial ciliary defects, we determined the relationship(s) between ultrastructural findings, ciliary motility, and clinical and functional features, and evaluated the outcome of this population.

DESIGN

We analyzed the clinical presentation and pulmonary function of 43 children with chronic bronchitis and partial ultrastructural defects (from 15% to 90%) of their respiratory cilia demonstrated on bronchial biopsies. The study population was divided into 3 groups according to ciliary ultrastructure: the main ultrastructural defect concerned the central complex in 23 patients (CC group), peripheral microtubules in 8 patients (PMT group), and DA in 12 patients (DA group).

RESULTS

The percentage of ciliary defects was lower in the PMT group than in the CC and DA groups. Patients in the PMT group had less severe disease with frequent normal ciliary motility. Patients in the CC group had initially a higher incidence of respiratory tract infections, extensive bronchiectasis frequently requiring surgery, and arguments in favor of a congenital origin (high proportion of sibling form). Partial absence of DA, although of congenital origin, was associated with a good prognosis. In all groups, follow-up showed that the functional prognosis remained good with appropriate treatment.

CONCLUSIONS

In children with chronic respiratory infections, presence of situs inversus, sibling form, obstructive pulmonary syndrome, or bronchiectasis required ultrastructural analysis, regardless of ciliary motility. Detection of CC abnormalities is a marker of severity and required intensive therapy and close follow-up.

[Episodic laryngeal dysfunction]

Episodic laryngeal dysfunction (ELD), also known as paradoxical vocal cord dysfunction or laryngeal dyskinesia, is characterized by abnormal closure of the vocal cords during inspiration (and sometimes at the very start of expiration). It can manifest in different ways depending on the patient's age. In the newborn, it is usually associated with stridor restricted to the inspiratory breath following crying, and the natural history is always one of rapid resolution. Occasionally, a more severe form presents with intense dyspnea and marked inspiratory stridor in a baby that usually has extensive gastroesophageal reflux which has not been treated adequately enough to improve the dyspnea or the associated vasovagal attacks. A tracheotomy may be necessary. It is rare for this disease to present between the ages of 2 and 8 years. Thereafter, it may present as a form of pseudo asthma resistant to bronchodilators and anti-inflammatory drugs. The dyspnea can be very severe and lead the family to seek hospital admission, at least during the initial episodes. There is a female preponderance. The key to making the diagnosis is the complete reversibility of the patient's symptoms when they are distracted. Exertion asthma can be mimicked by forms of ELD that occur only by effort (apart from the profile of the lung function tests). There may be significant gastroesophageal reflux. Medical intervention (hospitalization and tracheotomy) must be avoided, treatment being essentially behavioral. Finally, some cases of paradoxical adduction of the vocal cords have been described with the use of neuroleptics, brain stem compression, cortical lesions and, much more rarely, motoneuron disease. This diagnosis requires a high index of suspicion, particularly in patients with asthma whose presentation or clinical course with treatment is atypical.

Connexin 26 gene mutations in congenitally deaf children: pitfalls for genetic counseling

OBJECTIVE

To evaluate difficulties encountered in genetic counseling in deaf children carrying connexin 26 gene (CX26 or GJB2) mutations.

DESIGN

Prospective study.

SETTING

Outpatients, tertiary referral center.

PATIENTS

Ninety-six unrelated deaf children in whom CX26 mutations had been detected consecutively. Children were recruited to a center for genetic counseling for deaf children, and all had congenital deafness, sporadic or familial.

RESULTS

In 63 children, deafness was clearly a DFNB1 form with autosomal recessive inheritance: 47 of the 63 were homozygous for the most frequent mutation, the deletion of G at position 35 (35delG); 16 of 63 carried on both alleles of CX26 frameshift or stop mutations, or missense mutations affecting a critical region of the gene. In 33 of 96 children, genetic counseling was difficult: 21 of 33 had a single mutation detected, 11 of 33 had new missense mutations or mutations whose pathogenicity remains debated in the literature, and 1 of 33 had a genotype with both a recessive mutation (35delG) and a mutation acting as a dominant mutation.

CONCLUSIONS

Interpretation of results for the molecular diagnosis of mutations in the connexin 26 gene is difficult in almost one third of cases. Close collaboration between geneticists familiar with deafness and otolaryngologists is essential to provide a high standard of genetic advice.

Tracheal dyskinesia associated with midline abnormality: embryological hypotheses and therapeutic implications

Abnormalities of tracheal rigidity, which may lead to the collapse of the airway during expiration and consequent complications, characterize two groups of disorders: tracheomalacia (weakness of the anterior cartilaginous arc of the trachea) and tracheal dyskinesia (dysfunction of the posterior membranous trachea). Tracheal dyskinesia can either be isolated or associated with a more complex syndrome of malformations: esophageal atresia, tracheoesophageal fistula and laryngotracheal cleft. Although our knowledge of the embryological development of the tracheoesophageal axis remains limited, the existence of these associations suggests that tracheal dyskinesia is of congenital origin. The presentation of three clinical cases demonstrates that the coexistence of a midline malformation and of tracheal dyskinesia complicates the therapeutic management of the first malformation. In particular, the postoperative follow-up is often more difficult, and a long-term tracheostomy is often required (sometimes for several years). However, it must be pointed out that tracheal dyskinesia, even in the associated forms, has a good long-term prognosis, since spontaneous resolution as the child grows up is the rule.

Audiophonological results after cochlear implantation in 40 congenitally deaf patients: preliminary results

The aim of this study is to evaluate the prognostic factors of audiophonological results in cochlear implant in congenitally deaf patients. Between 1991 and 1996. 40 congenitally deaf children underwent cochlear implantation in our department, at an average age of 7 years (median: 5 years). The results of speech therapy were evaluated with a mean follow-up of 2 years and were classified according to four criteria: perception of sound, speech perception, speech production and the level of oral language. For each criterion, a score was established ranging from zero to four. These scores were weighted according to age such that the results before and after implantation only reflected the changes related to the implantation. The prognostic factors for good results were: a good level of oral communication before implantation, residual hearing, progressive deafness and implantation at a young age. On the other hand, poor prognostic factors were: the presence of behavioral disorders and poor communication skills prior to implantation. Overall, the major prognostic factor for a good outcome appeared to be the preoperative level of oral language, even if this was rudimentary.

Extensive lymphangioma presenting with upper airway obstruction

OBJECTIVE

To describe the results of an outcome survey of 18 cases of pediatric lymphangioma with dyspnea from encroachment on the tongue base, parapharyngeal space, and/or larynx.

DESIGN

Retrospective review of files from January 1983 to September 1998.

SETTING

Pediatric otolaryngology departments from 2 referral centers.

PATIENTS

Eighteen patients were treated. The average age at initial surgery was 22 weeks (median, 5 weeks). All presented with at least unilateral suprahyoid and infrahyoid cavernous (microcystic) lymphangioma. The tongue base was involved in 11 patients, the parapharyngeal space in 12, and the larynx in 8.

INTERVENTIONS

Neck dissection was performed initially in all patients. Tracheotomy was performed in 9 patients (50%). Macroglossia was treated by V glossoplasty. Parapharyngeal extensions were treated by cervicotomy or endoscopy, and larynx and tongue base extensions by carbon dioxide laser photocoagulation. Supraglottic laryngectomy was performed in 2 patients.

MAIN OUTCOME MEASURES

Residual disease, decannulation, duration of tracheotomy, and persistent respiratory symptoms.

RESULTS

The average follow-up was 4 years postoperatively. One postoperative death occurred. Sixteen (94%) of the remaining 17 patients had residual lymphangioma. Eight (89%) of the 9 patients with tracheotomy underwent decannulation (average duration, 22 months). Ten patients had persistent symptoms, and 6 were asymptomatic.

CONCLUSIONS

Involvement of the upper airway seems to be the determining prognostic factor in extensive lymphangioma. Patients with dyspnea by external compression of cervical lymphangioma on the airway responded well to surgery. Aggressive surgical treatment did not seem to significantly improve the prognosis in patients with intrinsic involvement of the upper airway. The natural evolution of untreated massive lymphangioma has not been documented. Less aggressive, symptomatic therapy may be an alternative to avoid mutilating surgery in patients with intrinsic involvement of the airway.

Characterization of inflammatory reaction in upper airways of cystic fibrosis patients

Inflammatory cell populations have not been yet precisely evaluated in cystic fibrosis (CF) airways. We intended to characterize morphological modifications, inflammatory cell infiltration and cell proliferation in nasal tissues obtained from 15 CF patients and from 6 non-CF patients with nasal polyposis. Morphological analysis showed an intense inflammatory infiltration in CF and non-CF tissues with only few modifications in the epithelium from CF tissues. Inflammatory cell populations characterized by specific immunolabeling were quantified, showing a predominance of macrophages and T- and B-lymphocytes and only moderate numbers of neutrophils in CF tissues; in non-CF polyps, lymphocytes and eosinophils were abundant. Proliferating cell percentages quantified after proliferating cell nuclear antigen immunolabeling were 5.3+/-4.1% (mean +/- SD) in CF polyps and 3.1+/-1.2% in non-CF polyps in epithelium but were very low in lamina propria. Intense inflammation in nasal tissues from CF patients is therefore dominated by macrophages and lymphocytes rather than by neutrophils. While morphology is preserved, proliferation is high in epithelium from CF polyps. These findings should be regarded in the future for a better understanding of inflammation in CF airway disease.

Head and neck infantile myofibromatosis--a report of three cases

Infantile myofibromatosis (IM) is a proliferative disorder characterized by the development of single or multiple nodular lesions arising from cutaneous, subcutaneous, muscular, bone or visceral structures. This proliferation may occur at any anatomical site, but in 30% of the cases it involves the head and neck. We report here three cases of head and neck IM occurring in young children and presenting as solitary lesions. The clinical heterogeneity and the misleading histopathological appearances can make the diagnosis difficult. The treatment is surgical but the low rate of recurrence and the possibility of spontaneous tumoral regression may lead to conservative surgery or therapeutic abstention.

Loss-of-function mutations in a human gene related to Chlamydomonas reinhardtii dynein IC78 result in primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) is a group of heterogeneous disorders of unknown origin, usually inherited as an autosomal recessive trait. Its phenotype is characterized by axonemal abnormalities of respiratory cilia and sperm tails leading to bronchiectasis and sinusitis, which are sometimes associated with situs inversus (Kartagener syndrome) and male sterility. The main ciliary defect in PCD is an absence of dynein arms. We have isolated the first gene involved in PCD, using a candidate-gene approach developed on the basis of documented abnormalities of immotile strains of Chlamydomonas reinhardtii, which carry axonemal ultrastructural defects reminiscent of PCD. Taking advantage of the evolutionary conservation of genes encoding axonemal proteins, we have isolated a human sequence (DNAI1) related to IC78, a C. reinhardtii gene encoding a dynein intermediate chain in which mutations are associated with the absence of outer dynein arms. DNAI1 is highly expressed in trachea and testis and is composed of 20 exons located at 9p13-p21. Two loss-of-function mutations of DNAI1 have been identified in a patient with PCD characterized by immotile respiratory cilia lacking outer dynein arms. In addition, we excluded linkage between this gene and similar PCD phenotypes in five other affected families, providing a clear demonstration of locus heterogeneity. These data reveal the critical role of DNAI1 in the development of human axonemal structures and open up new means for identification of additional genes involved in related developmental defects.

EPR spectroscopy: a powerful technique for the structural and functional investigation of metalloproteins

Numerous metal centers in proteins can be prepared in a redox state in which their ground state is paramagnetic. Complementary data provided by EPR, Mössbauer, electron nuclear double resonance, magnetic circular dichroism, and NMR spectroscopies have therefore played a major role in the elucidation of the structure and function of these centers. Among those techniques the most commonly used is certainly EPR spectroscopy. In this article various aspects of the current applications of EPR to the structural and functional study of metalloproteins are presented. They are illustrated by recent studies carried out in our laboratory in the field of metalloenzymes and electron transfer systems. The power of numerical simulation techniques is emphasized throughout this work.

Evolution of the bacteriologic features of persistent acute otitis media compared with acute otitis media: a 15-year study

OBJECTIVES

To define the epidemiologic features of persistent acute otitis media (PAOM) and modifications of these features during the past 15 years and to investigate for possible differences in bacterial resistance between acute otitis media (AOM) and PAOM.

DESIGN

Retrospective patient series.

SETTING

Academic tertiary care center.

PATIENTS AND METHODS

Persistent acute otitis media was defined as AOM lasting longer than 3 weeks despite 1 or several courses of antibiotic therapy, with the persistence of clinical and otoscopic signs of AOM. From 1982 to 1997, 475 children with PAOM were seen in our department. Every patient had 1 or several specimens of aspirations or swabs of spontaneous otorrhea (or both). Microbiologic characteristics of the isolated strains (including antibiotic susceptibility) were analyzed. Four successive series of specimens were analyzed-group 1: from October 1, 1982, to June 30, 1986 (136 patients); group 2: from January 1, 1987, to December 31, 1989 (165 patients); group 3: from January 1, 1992, to April 30, 1993 (73 patients); and group 4: from January 1, 1994, to January 31, 1997 (101 patients). During the same study periods, the bacteriologic results of patients with AOM in the same geographic region were recorded.

MAIN OUTCOME MEASURES

A longitudinal comparison between the groups of patients with PAOM and a cross-comparison within each group between patients with PAOM and those with AOM.

RESULTS

Obtaining repeated and multiple specimens from patients with PAOM led to a progressive decrease in the rate of sterile specimens, from 35.3% (group 1, 48 patients) to 14.9% (group 4, 15 patients) (P<.01). During this period, the prevalence of Streptococcus pneumoniae increased in patients with positive culture results, from 18.2% (group 1, 16 of 88 patients) to 44.2% (group 4, 38 of 86 patients) (P<.001). These strains rapidly and dramatically became resistant to penicillin (amoxicillin) (0% through 1989, 76.2% [16 of 21 patients] in 1993, and 97.4% [37 of 38 patients] in 1996) (P = .01). The overall prevalence of Haemophilus influenzae remained stable (between 31.4% [27 of 86 patients] and 45.4% [40 of 88 patients]), but the proportion of beta-lactamase-producing strains increased from 30.0% (group 1, 12 patients) to 55.6% (group 4, 15 patients) (P=.04). The prevalences of Pseudomonas aeruginosa and Staphylococcus aureus did not vary significantly (from 23.1% [group 2, 30 patients] to 10.7% [group 3, 6 patients] and from 10.2% [group 1, 9 patients] to 4.6% [group 4, 4 patients], respectively). Comparing data from patients with PAOM with those with AOM revealed that the increased resistance of H influenzae and, in particular, of S pneumoniae was more rapid and more marked in patients with PAOM than in those with AOM (highest rate of resistance in AOM: 36.0% [271 of 753 specimens] and 50.6% [398 of 787 specimens] for H influenzae and S pneumoniae, respectively; P<.001 for S pneumoniae).

CONCLUSIONS

The increase in bacterial resistance frequently encountered during otitis media is even more marked in patients with PAOM. The identification of the organism is essential when the otitis does not resolve, especially in patients with PAOM. Obtaining repeated specimens helps to decrease the rate of sterile cultures.

Surgical removal of subglottic hemangiomas in children

OBJECTIVE

To examine the indications and the results of surgical excision of severe subglottic hemangiomas.

DESIGN

Retrospective study and case series.

SETTING

Four academic tertiary care centers of pediatric otolaryngology.

PATIENTS

Twenty children were included from 1991 to 1997. All presented with severe subglottic hemangiomas resistant to classical treatments such as corticosteroids and/or CO2 laser.

INTERVENTION

Six children were operated on using laryngotracheal reconstruction and prolonged stenting by a reinforced Silastic roll and 14 children were operated on by a single-stage laryngotracheoplasty and postoperative intubation in a pediatric intensive care unit.

RESULTS

All patients were successfully decannulated or extubated and have been free from recurrent hemangiomas.

CONCLUSION

The surgery of severe subglottic hemangiomas is a reliable technique in selected patients and should be considered in corticoresistant or corticodependent, circular, or bilateral hemangiomas.

Congenital tracheoesophageal fistula without esophageal atresia

The authors report a series of eight cases of isolated tracheoesophageal fistula without esophageal atresia (or an H type fistula), treated in three pediatric ENT departments. This is a rare malformation whose diagnosis requires investigation for associated anomalies. The clinical signs are mainly respiratory but also digestive and the symptomatology can be severe. The diagnosis can be made with a barium swallow combined with cineradiography, but a tracheoesophageal endoscopy remains the investigation of choice. The treatment is surgical. In most cases, the fistula is accessible by a right or left cervicotomy, depending on the surgeon's practice, with a much lower postoperative morbidity as compared to a thoracotomy. The postoperative management was straightforward in most of our cases. We discuss the role of gastro-esophageal reflux with respect to postoperative morbidity as well as systematic treatment for reflux peri-operatively. The pros and cons of the various surgical approaches are also discussed.

The CHARGE association: the role of tracheotomy

OBJECTIVES

To evaluate the need for a tracheotomy and its timing during the evolution of an association of malformations, including coloboma, heart defects, choanal atresia, developmental and growth retardation, genitourinary malformation, and ear anomalies (CHARGE association).

DESIGN

Retrospective study from January 1988 through December 1997.

SETTING

Four academic tertiary care centers.

PATIENTS AND METHODS

Forty-five patients with CHARGE association having at least 3 cardinal malformations (growth retardation excluded) and review of the malformations and respiratory manifestations encountered. All the patients underwent endoscopic exploration on several occasions. We reviewed the nature and the timing of therapeutic interventions performed on the airway.

RESULTS

Two patients died (one patient of septicemia, the other of unknown causes). Abnormalities of blood gas levels and/or sleep were found in 30 patients (67%), were responsible for cardiorespiratory arrest in 9 (20%), and required admission to the intensive care unit in 21 (47%). Pharyngolaryngeal anomalies leading to dyspnea (discoordinate pharyngolaryngomalacia, glossoptosis, retrognathia, laryngeal paralysis, cleft, stenosis, and difficult intubation) were found in 26 patients (58%). Tracheobronchial anomalies (esophagotracheal fistula, esophageal atresia, and tracheomalacia) were present in 18 patients (40%). Resection of the aryepiglottic folds was attempted 3 times, but without success. Tracheotomy was necessary in 13 patients (29%) at a median age of 2.4 months (mean duration, 25 months). Among these infants, the posterior nasal choanae were patent in 10 patients at the time of tracheotomy. Gastroesophageal reflux was encountered in 36 patients (80%). Prolonged enteral feeding was necessary in 21 patients (47%), with gastrostomy in 16 (of whom 9 needed a tracheotomy). These feeding difficulties and airway problems were highly correlated.

CONCLUSIONS

We encountered multiple, complicated airway abnormalities. Resection of aryepiglottic folds was inadequate. Often, a tracheotomy could not be avoided in these patients, regardless of choanal patency. Tracheotomy needs to be performed early to avoid hypoxic events. In some selected patients, ventilation using bilevel positive airway pressure may be an alternative.

Nasal fossa malformations and paramedian facial cleft: new perspectives

Choanal atresia may be associated with other cranio-facial malformations, including various degrees of nasal fossa malformation, and may be a part of paramedian facial clefts (as described by Tessier et al. [1977]). We identified five such cases with combined clinical elements corresponding to Tessier's paramedian facial cleft, including eyelid coloboma, mild to severe choanal and nasal fossa anomalies, ethmoidal hypoplasia and anterior skull base malformation, sometimes with proboscis lateralis and half-nose hypoplasia. These observations incited us, first, to elaborate a conception which accounts for the likely embryological mechanisms involved; second, to propose a new classification based on anatomical and pathogenic embryological considerations; and last, to propose the use of transpalatal approach to restore choanal permeability, since endonasal laser therapy is particularly dangerous in such cases.

Myringoplasty in children: predictive factors of outcome

OBJECTIVES

To assess the results of myringoplasty in children and to determine which factors independently influence the postoperative results.

STUDY DESIGN

Retrospective study of the anatomic and functional results of 231 consecutive myringoplasties performed in 188 children between 1988 and 1992. Multivariate analysis of poor prognostic factors by cross-sectional comparison 1 year after surgery.

METHODS

Myringoplasties were performed via an endaural approach with a fascia temporalis underlay graft.

RESULTS

In 216 of 231 ears (93.5%) the tympanic membrane was closed. A good anatomic outcome was considered to have been achieved in 188 ears (81.6%), although in 18 ears (7.8%) seromucous otitis media occurred, in 8 ears (3.5%) a progressive retraction pocket was encountered, and in 2 ears significant lateralization was present. One hundred thirty-nine (67.5%) of the 206 ears tested in the postoperative period had a postoperative air-bone gap of 10 dB or less. On average, mean bone conduction remained unaltered. The age of the patient and the size and the location of the perforation did not affect the outcome. Three prognostic factors for an abnormal postoperative tympanic membrane were found, with 95% confidence intervals: inflammatory changes in the middle ear mucosa (P < .05), contralateral tympanic perforation (P < .05), and contralateral cholesteatoma (P < .01).

CONCLUSIONS

Myringoplasty with underlay grafting of the fascia temporalis in children gives good anatomic and functional results. Inflammatory changes within the middle ear mucosa, contralateral tympanic perforation, and contralateral cholesteatoma independently influence the risk of an abnormal postoperative tympanic membrane. The presence of one of these factors preoperatively should lead to the consideration of alternative, more durable graft material, such as autologous cartilage.

Pharyngo-laryngeal histoplasmosis: one case in an immunocompetent child

We report a very rare case of disseminated pharyngo-laryngeal histoplasmosis with systemic spread in a 10-year-old, immunocompetent child from Guyana. The main signs were a marked deterioration in his general condition, hepato-splenomegaly, multiple lymphadenopathy and ulcerated pharyngo-laryngeal lesions. The diagnosis was made from brushings of the ulcerative lesions, a lymph node biopsy and serological tests performed in the national reference center for histoplasmosis. The initial treatment was with amphotericin B, which was then replaced by oral itraconazole. We report here the main epidemiological, clinical and therapeutic characteristics.

Management of acute otitis media caused by resistant pneumococci in infants

OBJECTIVES

To assess the clinical outcome and risk of failure after oral vs. intravenous treatment in otitis media caused by penicillin-resistant pneumococci. To determine the possible correlations between pneumococcal minimal inhibitory concentration (MIC) to penicillin and clinical outcome.

DESIGN

Retrospective study of 156 cases collected between 1993 and 1995. Mean follow-up: 5 months. Setting. Two tertiary academic medical centers in Paris, France.

PATIENTS AND METHODS

Pneumococcus was isolated from 191 of 570 ear samples obtained from children with otitis media and shown to be penicillin-resistant in 156. Medical history, antibiotic therapy during the previous 3 months and day-care center attendance were reviewed. For the current episode microbiologic characteristics of the isolated strains, type of treatment, therapy efficacy and clinical outcome were analyzed. Patients were predominantly young (76.3% were <1 year old) and bacteriologic samples were taken mainly because of previous treatment failure.

RESULTS

Among 156 children with pneumococcal penicillin-resistant otitis media, 72.2% attended day-care centers, 71.8% had been previously treated with aminopenicillin and 52.5% with cephalosporins. Failure of previous empirical oral therapy was noted in 84% (one-third of these had been receiving amoxicillin-clavulanate). Patients treated intravenously had had a more protracted otitis but no greater number of previous episodes of acute otitis media than those receiving oral therapy. Acute mastoiditis occurred in 4 infants resulting in mastoidectomy. Oral treatment (mainly with high dose amoxicillin,120 to 150 mg/kg/day) and intravenous therapy (cephalosporin or glycopeptide) had been used in 59 and 41%, respectively. Mean duration of therapy was 10.7 days. Three failures (1.9%) and 10 recurrences (6.4%, average 28 days) occurred. No statistical difference was found between intravenous and oral therapy with respect to risk of recurrence. A high penicillin MIC value was correlated with previous antibiotic treatment but not with clinical outcome.

CONCLUSIONS

Oral therapy appears to be as effective as intravenous therapy for the treatment of penicillin-resistant pneumococcal otitis media. Intravenous treatment should not necessarily be dictated by the penicillin susceptibility value but should be considered in cases of failure to thrive, persistent otitis or other complications.