Neurodevelopmental outcome in children with congenital cytomegalovirus infection: A prospective multicenter cohort study

BACKGROUND

Congenital cytomegalovirus infection (cCMV) is the most common congenital infection worldwide and is a major cause of neurodevelopmental impairment in children. At this point there are insufficient data on neurodevelopmental outcome of children with cCMV, both symptomatic and asymptomatic.

AIM

This study aimed to describe the neurodevelopmental outcome in a large prospective cohort of children with cCMV.

METHODS

All children with cCMV, included in the Flemish cCMV register, were eligible for this study. Data on neurodevelopmental outcome was available in 753 children. Data on neuromotor, cognitive, behavioral, audiological and ophthalmological outcome were analyzed.

RESULTS

Neurodevelopmental outcome was normal in 530/753 (70,4 %) at any age of last follow-up. Mild, moderate and severe neurodevelopmental impairment was found in 128/753 (16,9 %), 56/753 (7,4 %) and 39/753 (5,2 %), respectively. Adverse outcome is found both in the symptomatic and asymptomatic children (53,5 % versus 17,8 %). Autism spectrum disorder (ASD) was diagnosed more often than in the general population in Flanders (2,5 % versus 0,7 %). Speech and language impairment was found in 2 %, even in absence of hearing loss.

CONCLUSION

Both symptomatic and asymptomatic cCMV children are at risk of sequelae, with higher risk in case of first trimester infection. During follow-up of this population, special attention should be given to the audiological follow-up, the presence of hypotonia at young age, the possible higher risk of ASD and the risk of speech and language impairment even in absence of hearing loss. Our results emphasize the need for multidisciplinary neurodevelopmental follow-up of all cCMV infected children.

Middle ear damages

Middle ear damages. The eardrum and middle ear are often exposed to blunt and penetrating trauma, blasts, thermal or caustic injuries. These injuries may result in tympanic membrane perforation, middle ear haemorrhage, dislocation and fracture of the ossicular chain, perilymphatic fistula and damage to the chorda tympani and/or facial nerve. In case of life-threatening injuries and/or mass casualty incidents, middle ear trauma obviously does not take highest priority. However, middle ear lesions should be suspected and recognized as early as possible. After meticulous history taking, physical examination consists of cranial nerve evaluation, thorough inspection of the outer ear, otoscopy and assessment of hearing and vestibular function. In the majority of cases, traumatic tympanic membrane perforations by penetrating and blunt injuries have a good prognosis with spontaneous resolution. Tympanic membrane perforations from blast trauma, thermal or caustic injuries are less likely to heal spontaneously. Perforations lasting six months after injury warrant surgery. A high resolution CT scan of the temporal bone is required in case of immediate complete facial nerve paralysis and when oval window pathology or perilymphatic fistula is suspected. Early surgical intervention is needed in case of early onset facial nerve paralysis, when there is suspicion of a perilymphatic fistula with persisting or increasing vestibular symptoms or neurosensory hearing loss and in case of vestibular dislocation of the stapes footplate. When ossicular chain damage is suspected, elective tympanoplasty is indicated. As any traumatic tympanic membrane perforation runs the risk of cholesteatoma formation, biannual follow-up during a minimum of two years is recommended.

Nasalance and nasality in children with cochlear implants and children with hearing aids

OBJECTIVES

In prelingually deaf children, many speech production aspects including resonance, are known to be problematic. This study aimed to investigate nasality and nasalance in two groups of prelingually hearing impaired children, namely deaf children with a cochlear implant (CI) and moderate-to-severely hearing impaired hearing aid (HA) users. The results of both groups are compared with the results of normal hearing children. Besides, the impact of the degree of hearing loss was determined.

METHODOLOGY

36 CI children (mean age: 9;0y), 25 HA children (mean age: 9;1y) and 26 NH children (mean age: 9;3y) were assessed using objective assessment techniques and perceptual evaluations in order to investigate the nasal resonance of the three groups. Ten HA children had thresholds above 70dB (range: 91dB-105dB) and fifteen below 70dB (range: 58dB-68dB). The Nasometer was used for registration of the nasalance values and nasality was perceptually evaluated by two experienced speech therapists using a nominal rating scale (consensus evaluation).

RESULTS

For nasal stimuli, both CI children and HA children showed lower nasalance values in comparison with NH children. The opposite was observed for the oral stimuli. In both hearing impaired groups, cul-de-sac-resonance was observed on a significantly larger scale than in the NH group, and the HA children were judged to be significantly more hypernasal in comparison with NH children.

CONCLUSIONS

Despite the fact that a substantial number of the CI and HA children demonstrate normal (nasal) resonance quality, this aspect of speech production is still at risk for hearing impaired children.

Olivocochlear efferent reflex strength in vestibular schwannoma patients

PROBLEM/OBJECTIVE

The olivocochlear reflex strength can be measured using contralateral acoustic stimulation (CAS) of transient evoked otoacoustic emissions (TEAOEs). The efferent suppression (ES) thus reflects the functional intactness of the efferent auditory system. In patients with unilateral vestibular schwannoma (VS), the results of ES are unclear.

METHODS

This cross-sectional study evaluated click and noise intensity conditions for measuring ES using CAS of TEOAEs in nine patients with unilateral VS and in gender-, age- and ear side-matched control subjects.

RESULTS

Two optimal click and noise intensity level combinations were identified. This pilot study compared the amount of ES between tumour and non-tumour ears versus control ears in patients with unilateral VS, but there were no statistically significant differences.

CONCLUSION

Future studies should include a larger population of unilateral VS patients with different grades of hearing loss.

Is cochlear implantation an effective treatment for Menière's disease?

OBJECTIVES

describe the results of a retrospective study of cochlear implantation (CI) in seven subjects with Menière's disease.

METHODOLOGY

The subjects received either the Nucleus CI24RE(CA)/CI512 or the Advanced Bionics HiRes90K CI systems which use the ACE, MP3000, or HiRes S Fidelity 120 coding strategies. The audiometric measures included monosyllabic word lists (NVA) in quiet at 65 dB SPL and sentences in noise (LIST) at +10 dB SNR. The quality of life after implantation was assessed by means of the Nijmegen Cochlear Implant Questionnaire (NCIQ).

RESULTS

After CI, the hearing of all subjects improved significantly (p < 0.001) as did their speech recognition (p = 0.018). Speech recognition in noise showed a mean improvement of 47%. The results were less clear for the treatment of vertigo associated with Menière's, as some patients continued to have vestibular attacks after implantation. On the NCIQ, subjects reported a mean quality of life after CI of 48.3%.

CONCLUSIONS

This study clearly demonstrates that cochlear implantation is an adequate treatment of speech perception for subjects with Menière's disease who go on to develop bilateral severe to profound sensorineural hearing loss.

New reference values must be established for the Alberta Infant Motor Scales for accurate identification of infants at risk for motor developmental delay in Flanders

BACKGROUND

The Alberta Infant Motor Scales (AIMS) is a reliable and valid assessment tool to evaluate the motor performance from birth to independent walking. This study aimed to determine whether the Canadian reference values on the AIMS from 1990-1992 are still useful tor Flemish infants, assessed in 2007-2010. Additionally, the association between motor performance and sleep and play positioning will be determined.

METHODS

A total of 270 Flemish infants between 0 and 18 months, recruited by formal day care services, were assessed with the AIMS by four trained physiotherapists. Information about sleep and play positioning was collected by mean of a questionnaire.

RESULTS

Flemish infants perform significantly lower on the AIMS compared with the reference values (P < 0.001). Especially, infants from the age groups of 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and of 15 months showed significantly lower scores. From the information collected by parental questionnaires, the lower motor scores seem to be related to the sleep position, the amount of play time in prone, in supine and in a sitting device. Infants who are exposed often to frequently to prone while awake showed a significant higher motor performance than infants who are exposed less to prone (<6 m: P = 0.002; >6 m: P = 0.013). Infants who are placed often to frequently in a sitting device in the first 6 months of life (P = 0.010) and in supine after 6 months (P = 0.001) performed significantly lower than those who are placed less in it.

CONCLUSION

Flemish infants recruited by formal day care services, show significantly lower motor scores than the Canadian norm population. New reference values should be established for the AIMS for accurate identification of infants at risk. Prevention of sudden infant death syndrome by promoting supine sleep position should go together with promotion of tummy time when awake and avoiding to spent too much time in sitting devices when awake.

Cochlear implantation in posttraumatic bilateral temporal bone fracture

Temporal bone (TB) fractures can cause loss of audiovestibular function. Four cases of profound hearing impairment following bilateral TB fracture are presented in this report. All patients received a cochlear implant. All 4 patients became regular users of their implants. None of the patients experienced facial nerve stimulation. Implant-aided audiometry demonstrated a hearing threshold of 28 dB HL. The performance in speech understanding was comparable to standard postlingual adult patients implanted. We believe that cochlear implantation in patients suffering from profound sensorineural hearing losses secondary to TB fractures can be an effective tool for rehabilitation.

Basic principles for paediatric care: what ENT professionals should know

Children undergoing medical or surgical treatment for ENT disorders should receive care from doctors familiar with the specificities of paediatric ENT pathology working in dedicated clinics where there are facilities for the activities that children usually indulge in and accommodation for parents. Many aspects of care for children with ENT problems involve a multidisciplinary team consisting of ENT surgeons working alongside a range of medical and paramedical professionals and nurses specifically trained in childcare, as well as in ENT nursing. Within this multidisciplinary approach, we will discuss some important aspects of the psychosocial approach and nursing, anaesthesia and pharmacotherapy that should be considered in order to raise the safety and quality of patient care in paediatric otorhinolaryngology.

Test-retest reliability of the assessment of postural stability in typically developing children and in hearing impaired children

The purpose of this study was to establish test-retest reliability of centre of pressure (COP) measurements obtained by an AccuGait portable forceplate (ACG), mean COG sway velocity measured by a Basic Balance Master (BBM) and clinical balance tests in children with and without balance difficulties. 49 typically developing children and 23 hearing impaired children, with a higher risk for stability problems, between 6 and 12 years of age participated. Each child performed the modified Clinical Test of Sensory Interaction on Balance (mCTSIB), Unilateral Stance (US) and Tandem Stance on ACG, mCTSIB and US on BBM and clinical balance tests: one-leg standing, balance beam walking and one-leg hopping. All subjects completed 2 test sessions on 2 different days in the same week assessed by the same examiner. Among COP measurements obtained by the ACG, mean sway velocity was the most reliable parameter with all ICCs higher than 0.72. The standard deviation (SD) of sway velocity, sway area, SD of anterior-posterior and SD of medio-lateral COP data showed moderate to excellent reliability with ICCs between 0.55 and 0.96 but some caution must be taken into account in some conditions. BBM is less reliable but clinical balance tests are as reliable as ACG. Hearing impaired children exhibited better relative reliability (ICC) and comparable absolute reliability (SEM) for most balance parameters compared to typically developing children. Reliable information regarding postural stability of typically developing children and hearing impaired children may be obtained utilizing COP measurements generated by an AccuGait system and clinical balance tests.

Tinnitus severity and the relation to depressive symptoms: A critical study

Introduction

Research indicates that subjective tinnitus severity varies among tinnitus patients. One of the variables held responsible for these differences is depression. However the relationship between depression and tinnitus severity was never investigated more in depth.

Objectives

If depression is responsible for differences in subjective tinnitus severity two conditions need to be fulfilled. First, there should be evidence for the presence of moderate to severe depressive symptomatology in a substantial group, and second, there should be evidence for a substantial relationship between depressive symptoms and tinnitus severity which can not be explained due to method and content overlap.

Aims

In this study we investigated whether tinnitus severity is a depression related problem.

Methods

136 consecutive help-seeking tinnitus patients were seen by a psychologist and an audiologist. All patients filled in the Beck Depression Inventory (BDI-II), the Tinnitus Handicap Inventory (THI), and underwent psychoacoustic measurement (pitch and loudness).

Results

Mean scores indicate the presence of no or minimal depressive symptoms. There was only a positive correlation (p < .01) between the BDI-II and the THI. No correlations were found between psychoacoustic measures and the self-report questionnaires. Linear regression analysis revealed that only the somatic depression subscale significantly predicted tinnitus severity.

Conclusions

Tinnitus does not seem to be a depression-like problem. There is no substantial group of tinnitus patients with moderate to severe depressive symptoms. The relation between depressive symptoms and tinnitus severity seems to be an artefact due to content overlap between de THI and the somatic subscale of the BDI-II.

A comparison of vowel productions in prelingually deaf children using cochlear implants, severe hearing-impaired children using conventional hearing aids and normal-hearing children

OBJECTIVE

The purpose of this study was to compare vowel productions by deaf cochlear implant (CI) children, hearing-impaired hearing aid (HA) children and normal-hearing (NH) children.

PATIENTS AND METHODS

73 children [mean age: 9;14 years (years;months)] participated: 40 deaf CI children, 34 moderately to profoundly hearing-impaired HA children and 42 NH children. For the 3 corner vowels [a], [i] and [u], F(1), F(2) and the intrasubject SD were measured using the Praat software. Spectral separation between these vowel formants and vowel space were calculated.

RESULTS

The significant effects in the CI group all pertain to a higher intrasubject variability in formant values, whereas the significant effects in the HA group all pertain to lower formant values. Both hearing-impaired subgroups showed a tendency toward greater intervowel distances and vowel space.

CONCLUSION

Several subtle deviations in the vowel production of deaf CI children and hearing-impaired HA children could be established, using a well-defined acoustic analysis. CI children as well as HA children in this study tended to overarticulate, which hypothetically can be explained by a lack of auditory feedback and an attempt to compensate it by proprioceptive feedback during articulatory maneuvers.

The prevalence of middle ear pathogens in the outer ear canal and the nasopharyngeal cavity of healthy young adults

Culturing middle ear fluid samples from children with chronic otitis media with effusion (OME) using standard techniques results in the isolation of bacterial species in approximately 30-50% of the cases. Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis, the classic middle ear pathogens of acute otitis media, are involved but, recently, several studies suggested Alloiococcus otitidis as an additional pathogen. In the present study, we used species-specific PCRs to establish the prevalence, in both the nasopharyngeal cavity and the outer ear, of H. influenzae, M. catarrhalis, S. pneumoniae and A. otitidis. The study group consisted of 70 healthy volunteers (aged 19-22 years). The results indicate a high prevalence (>80%) of A. otitidis in the outer ear in contrast to its absence in the nasopharynx. H. influenzae was found in both the outer ear and the nasopharynx (6% and 14%, respectively), whereas S. pneumoniae and M. catarrhalis were found only in the nasopharynx (9% and 34%, respectively).A. otitidis, described as a fastidious organism, were able to be cultured using an optimized culture protocol, with prolonged incubation, which allowed the isolation of A. otitidis in five of the nine PCR-positive samples out of the total of ten samples tested. Given the absence of the outer ear inhabitant A. otitidis from the nasopharynx, its role in the aetiology of OME remains ambiguous because middle ear infecting organisms are considered to invade the middle ear from the nasopharynx through the Eustachian tube.

Otitis media microbes: culture, PCR, and confocal laser scanning microscopy

OBJECTIVES

To assess the presence of middle ear pathogens in nasopharynx (NP), middle ear fluid (MEF), and middle ear mucosal swabs (MES) of 14 patients undergoing middle ear surgery.

METHODOLOGY

Bacteria were assessed by culture and species specific PCR. Biofilm was investigated by confocal laser scanning microscopy (CLSM) of middle ear biopsies (MEBs).

RESULTS

Bacteria were absent in CLSM of MEBs in three of the four closed and healthy middle ears. Bacteria occurred in the ear with a foreign body (middle ear prosthesis), which showed localized living and dead bacteria, indicating biofilm. Bacterial growth was present in ten patient ears, but biofilm occurred in only one patient. CLSM indicated biofilm in the middle ear of two patients for whom PCR detected Haemophilus influenzae in the MEF. The three classical pathogens could frequently be found in the nasopharynx, by culture and PCR, but not from the middle ear. Alloiococcus otitidis was detected in the MEF of all five patients with open inflamed ears, though virtually absent from the nasopharynx. Pseudomonas aeruginosa was present in seven. It was the only pathogen found on several occasions in all three locations in one patient.

CONCLUSIONS

This study confirms the association of H. influenzae with middle ear biofilm, and indicates a potential role of P. aeruginosa in middle ear inflammation and biofilm formation. Biofilm does not seem to cause inflammation. It is unclear whether the predominance of A. otitidis in chronically inflamed open middle ears indicates a pathogenic or contaminant role for this organism.

Contribution of the N-acetyltransferase 2 polymorphism NAT2*6A to age-related hearing impairment

BACKGROUND

Age-related hearing impairment (ARHI) is the most common sensory impairment in older people, affecting 50% of those aged 80 years. The proportion of older people is increasing in the general population, and as a consequence, the number of people affected with ARHI is growing. ARHI is a complex disorder, with both environmental and genetic factors contributing to the disease. The first studies to elucidate these genetic factors were recently performed, resulting in the identification of the first two susceptibility genes for ARHI, NAT2 and KCNQ4.

METHODS

In the present study, the association between ARHI and polymorphisms in genes that contribute to the defence against reactive oxygen species, including GSTT1, GSTM1 and NAT2, was tested. Samples originated from seven different countries and were combined into two test population samples, the general European population and the Finnish population. Two distinct phenotypes for ARHI were studied, Z(low) and Z(high), representing hearing in the low and high frequencies, respectively. Statistical analysis was performed for single polymorphisms (GSTM1, GSTT1, NAT2*5A, NAT2*6A, and NAT2*7A), haplotypes, and gene-environment and gene-gene interactions.

RESULTS

We found an association between ARHI and GSTT1 and GSTM1 in the Finnish population sample, and with NAT2*6A in the general European population sample. The latter finding replicates previously published data.

CONCLUSION

As replication is considered the ultimate proof of true associations in the study of complex disorders, this study provides further support for the involvement of NAT2*6A in ARHI.

Familial aggregation of tinnitus: a European multicentre study

INTRODUCTION AND AIM

Tinnitus is a common condition affecting approximately 20% of the older population. There is increasing evidence that changes in the central auditory system following cochlear malfunctioning are responsible for tinnitus. To date, few investigators have studied the influence of genetic factors on tinnitus. The present report investigates the presence of a familial effect in tinnitus subjects.

METHODS

In a European multicentre study, 198 families were recruited in seven European countries. Each family had at least 3 siblings. Subjects were screened for causes of hearing loss other than presbyacusis by clinical examination and a questionnaire. The presence of tinnitus was evaluated with the question "Nowadays, do you ever get noises in your head or ear (tinnitus) which usually last longer than five minutes". Familial aggregation was tested using three methods: a mixed model approach, calculating familial correlations, and estimating the risk of a subject having tinnitus if the disorder is present in another family member.

RESULTS

All methods demonstrated a significant familial effect for tinnitus. The effect persisted after correction for the effect of other risk factors such as hearing loss, gender and age. The size of the familial effect is smaller than that for age-related hearing impairment, with a familial correlation of 0.15.

CONCLUSION

The presence of a familial effect for tinnitus opens the door to specific studies that can determine whether this effect is due to a shared familial environment or the involvement of genetic factors. Subsequent association studies may result in the identification of the factors responsible. In addition, more emphasis should be placed on the effect of role models in the treatment of tinnitus.

Evaluation of the rotatory vestibular test: exploration of stimulus parameters

OBJECTIVES

The aim of this study was to construct a rotational test protocol after exploring the stimulus parameters of the rotatory vestibular test.

METHODOLOGY

Twenty-four normal subjects were submitted to three different rotational paradigms: the sinusoidal harmonic acceleration test (SHAT), the pseudorandom rotation test (PRRT), and the velocity step test (VST). We investigated the influence of frequency and velocity on gain, phase and asymmetry values for the SHAT and the PRRT. In the case of the VST, we examined the influence of velocity and deceleration on gain, slow component velocity at deceleration, time constant, nystagmus preponderance, and time constant asymmetry.

RESULTS

Frequency affected the SHAT response parameters, with significant phase differences between the frequencies 0.01, 0.02, 0.05, 0.1, and 0.2 Hz, while velocity, if kept below 150 degrees/s, had no influence on the results. In the case of the VST, responses were influenced by stimulus velocity and not by stimulus deceleration, with significantly higher gain values for the velocities 50 and 250 degrees/s.

CONCLUSIONS

A velocity of 50 degrees/s tested at the frequencies 0.01, 0.02, 0.05, 0.1, and 0.2 Hz was suggested for the SHAT and PRRT protocol, whereas a velocity of 100 degrees/s with a deceleration of 200 degrees/s2 was preferred for the VST. The relevance of this rotational protocol has yet to be established from patient data.

Clinical and molecular abnormalities in lipoid proteinosis

Lipoid proteinosis (hyalinosis cutis et mucosae) is a rare, autosomal recessive disease. The main clinicopathological features comprise skin and mucous membrane infiltration and scarring with deposition of hyaline material. In this report, we describe a 6-year-old boy in whom a diagnosis of lipoid proteinosis was first suspected when he presented with blisters and erosions at 4 years, a history of life-long dysphonia and a previous epileptic convulsion. The diagnosis was confirmed by histology and identification of a homozygous frameshift mutation, 501insC, in exon 6 of the gene encoding extracellular matrix protein 1, ECM1. Lipoid proteinosis may show protean clinical features and be difficult to diagnose on clinical grounds alone. This case report illustrates that lipoid proteinosis may show protean clinical features and yet remain undiagnosed for many years. Although the gold standard for definite diagnosis remains histology, molecular characterisation of the gene mutation will add to our understanding of genotype-phenotype correlation and perhaps to the development of a rationale for future therapeutics.

Management of otitis media with effusion in children

Otitis media with effusion in children: B-ENT Guidelines. OME is highly prevalent among young children, with peak prevalences at around two and five years of age. Although serious complications are rare, the burden of OM is large with impaired quality of life and high direct and indirect socio-economic costs. To date, medical treatment of OME is not recommended because of the limited scientific evidence that this treatment is effective in the long term. Surgical candidacy for OME depends largely on hearing status, associated symptoms, the child's developmental risk and the anticipated chance of spontaneous resolution of the effusion. Ultimately, the recommendation for surgery must be individualized.

CT and MRI of the semicircular canals in the normal and diseased temporal bone

Imaging of the semicircular canals specifically is part of the imaging process of the temporal bone in general. The semicircular canals are easily seen on CT images and 3DFT-CISS-weighted MR images, both performed with 1.0-mm-thick slices, or even thinner slices. In selected cases, the T1-weighted images give unique information on the semicircular canals. This article briefly reviews the variety of semicircular canal anomalies that are most frequently present and can be routinely seen on CT and MR examinations of the temporal bone. It also provides a list that can be used by the radiologist in clinical practice to decide which technique, CT or MR, should be used to detect specific anomalies at the level of the semicircular canals.

Hearing loss as a presenting symptom of cleidocranial dysplasia

OBJECTIVES

To report two cases of cleidocranial dysplasia in which hearing loss was the first presenting symptom.

STUDY DESIGN

Retrospective case review.

PATIENTS

Two cases of cleidocranial dysplasia, a rare autosomal dominant skeletal dysplasia affecting both membranous and enchondral bone formation.

SETTING

Tertiary referral center.

INTERVENTIONS

Clinical, audiometric, and imaging diagnostic procedures.

CONCLUSION

With this report, we want to illustrate the possibility of a rare genetic disorder as the underlying cause of hearing loss. We also want to emphasize the need for a multidisciplinary approach and evaluation of unexplained hearing loss to obtain a correct diagnosis, which is important for genetic counseling and management of the patient and his or her family.

Imaging studies in the diagnostic workup of neonatal nasal obstruction

Twelve neonates presenting with nasal obstruction after birth were evaluated by imaging studies for diagnostic reasons. Four groups were recognized: Group I: choanal atresia (n = 5) and choanal stenosis (n = 1); Group II: congenital nasal pyriform aperture stenosis (CNPAS) (n = 3) and holoprosencephaly (n = 1); Group III: nasolacrimal duct mucocele (n = 1); Group IV: nasal hypoplasia (n = 1). Associated anomalies were found in eight patients. Four patients with choanal atresia showed manifestations of the CHARGE (coloboma, congenital heart defect, atretic choanae, retarded physical and neuromotor development associated with central nervous system anomalies, genital hypoplasia, and ear anomaly and/or deafness) association. In the fifth patient with choanal atresia, the diagnosis of amnion disruption sequence was made. One patient with CNPAS had a solitary maxillary central incisor (SMCI), a mild form of holoprosencephaly. Besides proboscis and synophthalmos, SMCI was also present in the holoprosencephaly case. The patient with severe nasal hypoplasia had warfarin embryopathy. This review emphasizes the need for performing imaging studies in the diagnostic workup of neonates born with nasal obstruction.

Turnover of Haemophilus influenzae isolates in otitis-prone children

Arbitrarily primed PCR with primer ERIC2 and RAPD Ready-to-Go beads was applied to study the epidemiology of non-typable Haemophilus influenzae (NTHI) isolated from the nasopharynx of children with recurrent otitis media (otitis-prone children). Thirty-five otitis-prone children (OP-children) were included. Three pairs of siblings were identified in the study population. This study is part of a large prospective multicentric trial investigating the efficacy of a new conjugated pneumococcal vaccine in OP-children (OMAVAX trial). During a 2-year study period, NTHI strains were isolated from nasopharyngeal swabs and, when possible, middle ear aspirates were collected in OP-children between 1 and 6 years of age. In 20 out of the 35 children, 48 H. influenzae isolates were obtained simultaneously from different sites (left and/or right ear and/or nasopharynx) of the same child as well as from siblings or during initial and follow-up visits of the same child. Subsequent genotyping indicated substantial genetic diversity among the H. influenzae isolates studied, since for a total of 48 isolates in 20 OP-children, 29 different genotypes were observed. Simultaneous isolation for different sampling sites (ear or nasopharynx) as well as for siblings resulted mostly in identical fingerprints. Longitudinal follow-up of H. influenzae isolates in the nasopharynx almost always resulted in different genotypes. We can therefore conclude that both cross colonization (between sampling sites within the same patient and between siblings) and turnover of H. influenzae isolates are high in OP-children.

Congenital CMV-infection and hearing loss

CMV (cytomegalovirus) is one of the Herpesviridae, known for their potential for latency and reactivation. The sequelae of fetal infection are diverse: chronic stage of early fetal infection with brain anomalies, symptomatic late fetal infection with hepatitis and thrombocytopenia and asymptomatic infection. With any of these clinical phenotypes, permanent hearing loss is possible. CMV-infection is the only relevant viral cause of perinatal hearing loss because rubella, measles and mumps have become rare due to vaccination. Recent studies have suggested beneficial effects on outcome of i.v. ganciclovir treatment in symptomatic cases. We have recently taken the challenge of treating asymptomatic newborns on the basis of active sonographic brain lesions in order to prevent labyrinth destruction. We would also like to stress the importance of suspecting children with congenital hearing loss, or hearing loss that develops in the first year of life, of having an asymptomatic congenital CMV-infection. Follow up in the first years of life is necessary in these children because further progression of hearing loss is possible.

Turnover of Haemophilus influenzae isolates in otitis-prone children

INTRODUCTION

Previous studies have suggested a direct relationship between the nasopharyngeal carriage of potential middle ear pathogens and the development of middle ear disease. It has been shown that otitis-prone (OP) children tend to be colonized more often than non-OP children. To study the turnover of nontypeable Haemophilus influenzae (NTHI) in the nasopharynx of OP children, arbitrarily primed PCR was applied to NTHI strains isolated nasopharyngeal swabs collected prospectively during a 2-year study period from 35 OP children under 4 years of age at fixed intervals. METHODOLOGY/MATERIALS: In 20 patients, H. influenzae could be isolated from different sites (left and/or right ear and/or nasopharynx) or at different occasions during follow-up. Forty-eight H. influenzae isolates of different sites (left and/or right ear and/or nasopharynx) of the same patient as well as from siblings were typed using arbitrarily primed PCR with primer ERIC2 and RAPD Ready-to-Go beads (Pharmacia Biotech, Uppsala, Sweden).

RESULTS

Typing with arbitrarily primed PCR enabled to differentiate 29 genotypes among the 48 H. influenzae isolates. Sixteen of these fingerprints were observed only once. Thirteen of these fingerprints appeared on two or more occasions. In the three pairs of siblings the same strain was identified at one moment. Genetically identical NTHI strains from unrelated individuals were never identified. In 11 of 14 cases for which isolates were obtained simultaneously from different sites (throat and/or left ear and/or right ear) or from three pairs of siblings, identical fingerprints were observed. In nine cases whereby isolation was separated by a period of more than 4 weeks (maximum 28 weeks) the fingerprints of the isolates were different from the original isolate.

CONCLUSION

Typing with arbitrarily primed PCR indicated substantial genetic diversity among the H. influenzae isolates studied, since for a total of 48 isolates of 20 different patients, 29 different genotypes were observed. Since simultaneous isolation for different sampling sites (ear or nasopharynx) as well as for both of siblings, resulted mostly in identical fingerprints, and since sampling of the same site of the same patient, separated by an interval of more than 1 month, almost always resulted in different genotypes, one could conclude that both cross colonization (between sampling sites within the same patient and between siblings) and turnover are high. The relation between acquisition and development of disease needs further attention.

Communication problems in Turner syndrome: a sample survey

Turner syndrome is a condition first recognized in 1938 with an incidence estimated at 1/2500 female births. It is known to result from a missing X chromosome and has as its main features a short stature, ovarian dysgenesis, neck webbing, congenital peripheral lymphedema, coarctation of the aorta, cubitus valgus, dysplastic nails, and pigmented nevi. In addition, psychosocial difficulties including communication disorders may occur. While the physical characteristics of Turner syndrome have been well documented, information on the communication problems in Turner syndrome is scarce. This study reports the results of a sample survey in 128 girls with Turner syndrome ranging in age from 2.4 to 58.8 years. Results are presented on the occurrence and nature of speech and language problems (voice disorders, articulation problems, stuttering, and delayed language development), on the presence of learning disabilities, and on educational history.

Uncommon and unusual complications of otitis media with effusion

Some complications of otitis media with effusion (OME) are not obvious and not always associated with otitis media by physicians and patients; the authors propose to call them 'unusual complications', although they may be quite frequent. Complications such as dizziness, clumsiness and behavioural disorders are classified in this group. Other complications are rare and uncommon such as sensorineural hearing loss and cholesteatoma. Some of these sequelae are structural, others more functional. The impact of OME on complex functions such as language, learning or behaviour is still controversial but seems to have been underestimated until now. Not only withholding treatment in children with OME may cause complications but also the treatment of OME may lead to sequelae, although serious side effects caused by the treatment of OME are rare. In this literature review, the epidemiology, importance and diagnosis of the uncommon and unusual complications of OME will be discussed.

Otological manifestations of CHARGE association

The combined findings of abnormalities of the incus and stapes, absence of the oval window, absence of the stapedius muscle (with absent pyramidal eminence and tympanic sinus in most cases), and abnormalities of different parts of the inner ear (dysplastic cochlea, hypoplastic or dysplastic vestibule, and absent semicircular canals) are characteristic of the CHARGE association. Computed tomography and magnetic resonance imaging using 1-mm-thick contiguous slices proved useful in demonstrating the broad spectrum of temporal bone abnormalities in patients with the CHARGE association.

CT of the temporal bone in the CHARGE association

We reviewed the CT examinations of the temporal bone, performed with 1-mm-thick contiguous sections, of seven patients with the CHARGE association. We found abnormalities of the incus and stapes, with ossicular chain fixation, absence of the stapedius muscle and oval window, hypoplasia or dysplasia of the vestibule and absence of the semicircular canals in all ears. The pyramidal eminence and tympanic sinus were absent and there were anomalies of the cochlea in 13 of 14 ears. Absence of the semicircular canals is the most specific change in patients with the CHARGE association.

Secondary superficial siderosis of the central nervous system in a patient presenting with sensorineural hearing loss

We present a 50-year-old man who was investigated for sensorineural hearing loss. On MRI of the brain superficial siderosis of the central nervous system was seen, while MRI of the spine revealed an ependymoma of the cauda equina. This case illustrates the importance of performing T2-weighted imaging of the brain and posterior fossa when sensorineural hearing loss is present. Spine imaging is mandatory when superficial siderosis of the brain is diagnosed without identification of a bleeding source in the brain.

Value of rigid bronchoscopy and cytodiagnosis of bronchial washings in detecting bronchial carcinoma in the presence of a carcinoma of the upper aerodigestive tract

OBJECTIVE

To assess the usefulness of rigid bronchoscopy and bronchial washings in detecting primary lung carcinomas.

SETTING

Department of Otolaryngology, University Hospital of Ghent, Belgium.

DESIGN

Prospective analysis of patient investigations.

METHOD

The results of 127 rigid bronchoscopies with bronchial washings in patients with a new, untreated head and neck tumour and a normal chest radiograph were analyzed for their usefulness in detecting simultaneous primary lung carcinomas. All patients were followed for a minimum of 2 years or till death.

RESULTS

We found positive bronchial washings in 19 cases (21%). Unilateral positive bronchial washings were found in 8 patients (9%). In only one patient was a simultaneous primary lung tumour found. One patient was found to have a pulmonary metastasis. The remaining 6 patients with positive unilateral cytology (6/8) had normal chest roentgenograms and/or CT scans, and did not develop a lung tumour in the course of follow up. Of the 19 positive bronchial washings, 10 patients had a carcinoma of the larynx and two had a large hypopharyngeal carcinoma.

CONCLUSIONS

Contamination of bronchial washings with tumour cells from head and neck neoplasms limited seriously the usefulness of positive bronchial cytology. The sensitivity and specificity of the rigid bronchoscopy with bronchial washing is too low to justify its cost.

Diagnostic and therapeutic management of atypical mycobacterial infections in children

A series of 12 children (9 girls, 3 boys) with non-tuberculous mycobacterial lymphadenitis was reviewed to define the most frequent presenting features, helpful diagnostic measures and optimal management. The mean age at diagnosis was 42 months and cervical nodes in the submandibular region were most commonly affected. In most of the children the diagnosis was made on the basis of a positive intradermal skin test with specific antigens for atypical mycobacteria. The diagnosis was confirmed in all but one case by histopathologic examination. Total excision of the affected gland was recommended as the therapy of choice in the patients treated.