Effect of adenoid size on the post-adenoidectomy hypernasality in children with a normal palate

PURPOSE

Adenoidectomy, either alone or with tonsillectomy, is a common surgical procedure in the field of pediatric otorhinolaryngology. Resonance function may be altered postoperatively in the form of hypernasality, which is usually transient. This study aimed to investigate the effect of adenoid size on post-adenoidectomy hypernasality in children with a normal palate.

METHODS

Seventy-one children with different degrees of adenoid hypertrophy were included in this prospective observational study. Endoscopic assessment of the adenoid size and preoperative and postoperative evaluation of speech (at 1 and 3 months) with auditory perceptual assessment (APA) and nasometry were performed.

RESULTS

APA showed preoperative hyponasality in 59.1% of children and was found to be significantly related to the adenoid size, with more hyponasality in grades 3 and 4. One month postoperatively, hypernasality was detected in 26.7% of patients and was found to be related to the preoperative adenoid size with higher hypernasality in grades 3 and 4. Three months postoperatively, all patients had gained normal nasality except one (1.4%) who was subjected to a longer follow-up period. Nasometric assessment showed significant differences at the three visits (pre, 1, and 3 months postoperatively), with a negative correlation between the grade of adenoid size and nasalance scores preoperatively and a significant positive correlation between them at 1 month postoperatively. However, no significant correlation was detected at 3 months postoperatively.

CONCLUSION

Transient hypernasality may develop in some patients after adenoidectomy, especially in children with a larger preoperative adenoid size. However, transient hypernasality generally resolves spontaneously within 3 months.

Microstructure Study And Linear/Nonlinear Optical Properties of Bi-Embedded PVP/ PVA Films For Optoelectronic And Optical CUT-OFF Applications.. [DOI: 10.21203/rs.3.rs-1317913/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Hybrid polymer films of polyvinyl pyrrolidone (PVP)/ polyvinyl alcohol (PVA) embedded with gradient levels of Bi-powder were prepared using a conventional solution casting process. X-ray diffraction (XRD), Fourier transform infrared spectroscopic (FT-IR), and Scanning electron microscope (SEM) techniques have been used to examine the micro/molecular structural and morphological of the synthesized flexible films. The XRD peak intensity and FTIR spectra of the PVA gradually decline as Bi-metal is introduced. In addition, filler changes the microstructure surface of the pure film. The modification in the microstructure leads to an enhancement in the optical characteristic of the blend films. The indirect allowed transition energy was calculated via Tauc's and ASF models. The decrease in the hybrid film’s bandgap (\({E}_{gi}^{opt}\)) returns to the localized states in the forbidden region, as illustrated by the Urbach energy (Eu) values. The optical absorption parameters, including absorption coefficient (α) and edge (Ee), have also been evaluated. The relation between the transition energy and the refractive index (n) was studied. The rise of Bi-metal concentrations leads to an improvement in the nonlinear (χ(3)) susceptibility and (n2) refractive parameters. The optical limiting characteristics (OLC) revealed that the higher concentration dopant films reduce the light transmission intensity. The results suggest that hybrid films are promising materials in a wide range of applications, especially optical devices, and optoelectronics.

Acute Invasive Fungal Rhinosinusitis and Coronavirus Disease 2019

ABSTRACT

Acute invasive fungal rhinosinusitis (mucormycosis) is a rare, highly fatal disease. This opportunistic fungal infection causes angioinvasion and ischemic tissue necrosis. It mainly affects immunocompromised patients. Since the coronavirus disease 2019 (COVID-19) outbreak, many case reports have described the rhino-orbital-cerebral mucormycosis associated with COVID-19. However, the underlying predisposing factors are unknown. Several factors, other than diabetes, which is the most well-known contributing factor, may be involved in causing this severe fungal infection in COVID-19 patients. These factors may include steroid therapy, which is being used in severely dyspneic patients, the use of broad-spectrum antibiotics that may cause fungal flare-ups, and hospitalization with possible nosocomial infections. In addition, increased serum ferritin levels, possible endothelial damage, and pancreatic islets affection among COVID-19 patients may be implicated. Head and neck surgeons should be aware of the increasing prevalence of craniofacial mucormycosis among COVID-19 patients, as early diagnosis and prompt treatment are essential to improve the outcomes.

Adenoid hypertrophy is a common finding in children with antrochoanal polyp

Background

Many nasal pathological findings have been described with antrochoanal polyp (ACP). We aimed in this study to assess the prevalence of adenoid hypertrophy among children presented with ACP and to evaluate the efficacy of concomitant adenoidectomy on the outcome of endoscopic removal of the lesion.

Results

Forty-three children with ACP were included in this study. Preoperative nasal endoscopy and computed tomography were performed for all patients. Endoscopic sinus surgery (ESS) with widening the maxillary ostium was used for removal of ACP in all patients. Associated nasal pathology was recorded and managed accordingly. The patients were followed up for at least 3 years postoperatively. Coexistent nasal pathology with ACP was detected in 39 patients (90.7%); adenoid hypertrophy was found to be the commonest concomitant lesion (83.7%). Adenoidectomy was performed during ESS for those who had adenoid hypertrophy. Postoperatively, no patients developed adenoid regrowth; however, recurrence of ACP was detected in five patients (11.6%).

Conclusion

Adenoid hypertrophy is a common pathological finding in children presented with ACP. Endoscopic removal of ACP with concomitant adenoidectomy is an effective procedure and has a favorable outcome.

A guide to do randomized controlled trials in the field of otolaryngology

Background

Randomized controlled trials (RCTs) are prospective comparative studies in which study groups are allocated randomly to intervention or serve as controls. RCT is the mainstay to achieve evidence in the literature in clinical research. A RCT is the main research design to study the effect of an intervention and the only way to confirm the value of a new treatment.

Main body

RCT also gives the way to generate meta-analyses and systematic reviews giving a stronger evidence for clinical practice. Evidence-based medicine (EBM) is crucial for safe, effective, and standardized patient care. Although there is an agreement on the importance of performing RCT, it can be challenging to do it efficiently including different aspects like study design, funding, randomization, blinding, follow-up, data analysis, statistics, generalization of results, and reporting of quality of the studies.

Conclusion

In this article, we gave a comprehensive review for RCT in otolaryngology discussing their importance, advantages, and drawbacks, types, steps, challenges, reporting their quality and their prevalence in the literature.

Nasopharyngeal Polyp in a Patient With Submucous Cleft Palate

Encountering a nasopharyngeal polyp in a patient with submucous cleft palate (SMCP) is a difficult problem, as the lesion could support the weak palate. Removal of this lesion may unmask the SMCP with consequent worsening of speech nasality. Nasal septal polyp protruding to the nasopharynx in a patient with SMCP has not been reported before in the literature. This report describes a septal polyp arising from the posterior border of the nasal septum and protruding in the nasopharynx in a 16-year-old girl with submucous cleft palate. The polyp appeared to support the weak palate, and they acted as a ball and socket during speech articulation. Removal of this polyp may result in velopharyngeal insufficiency. Trans-nasal endoscopic removal of the polyp with obturation of the velopharyngeal port with a superiorly-based pharyngeal flap was performed in the same sitting. Pre- and postoperative speech evaluation using auditory perceptual assessment and nasometry revealed no worsening of nasality, also the patient reported improvement of her nasal breathing. We concluded that, the presence of a nasopharyngeal polyp in a patient with SMCP may compensate the speech problem. Removal of the polyp and treatment of SMCP by a pharyngeal flap in one-sitting is an effective procedure without adverse effect on patient’s speech.

The benefits of endoscopic look after curettage adenoidectomy

Background

Conventional curettage adenoidectomy (CCA) has a risk of incomplete removal of all adenoid tissue, and digital nasopharyngeal palpation is not enough to assess adenoid removal. The aim of this study was to evaluate the benefits of trans-oral endoscopic look of the nasopharynx (ELN) after CCA.

Results

This prospective study included 1900 children with adenoid hypertrophy. CCA was used for treatment, followed by ELN. Bleeding points and/or adenoid tissue remnants were recorded and managed. One year postoperatively, nasal endoscopy was performed to detect adenoid regrowth. ELN showed bleeding points in 17 patients (0.9%) and residual adenoid tissue remnants in 855 patients (45%). Intraoperatively, the lesions were cauterized and ablated under visualization. However, adenoid regrowths were detected in 263 (42%) out of 627 children (33%) who were subjected to endoscopic examination after 1 year of adenoid removal.

Conclusions

Trans-oral endoscopic look of the nasopharynx after CCA is a beneficial method in detection of adenoid remnants and bleeding points. Also, it could decrease symptomatic adenoid regrowth postoperatively.

Pediatric COVID-19 and the Factors That May Mitigate Its Clinical Course

The clinical manifestations of novel coronavirus disease 2019 (COVID-19) vary from mild flu-like symptoms to severe fatal pneumonia. However, children with COVID-19 may be asymptomatic or may have mild clinical symptoms. The aim of this study was to investigate clinical features of pediatric COVID-19 and to search for the factors that may mitigate the disease course. We reviewed the literature to realize the clinical features, laboratory, and radiographic data that may be diagnostic for COVID-19 among children. Also, we studied the factors that may affect the clinical course of the disease. Fever, dry cough, and fatigue are the main symptoms of pediatric COVID-19, sometimes flu-like symptoms and/or gastrointestinal symptoms may be present. Although some infected children may be asymptomatic, a recent unusual hyperinflammatory reaction with overlapping features of Kawasaki's disease and toxic shock syndrome in pediatric COVID-19 has been occasionally reported. Severe acute respiratory syndrome-coronvirus-2 (SARS-CoV-2) nucleic acid testing is the corner-stone method for the diagnosis of COVID-19. Lymphocyte count and other inflammatory markers are not essentially diagnostic; however, chest computed tomography is highly specific. Factors that may mitigate the severity of pediatric COVID-19 are home confinement with limited children activity, trained immunity caused by compulsory vaccination, the response of the angiotensin-converting enzyme 2 receptors in children is not the same as in adults, and that children are less likely to have comorbidities. As infected children may be asymptomatic or may have only mild respiratory and/or gastrointestinal symptoms that might be missed, all children for families who have a member diagnosed with COVID-19 should be investigated.

Pharyngeal flap for a poorly repaired cleft palate with posterior palatal defect

OBJECTIVE

Posterior palatal defect after cleft palate (CP) repair is not a rare problem, it may cause velopharyngeal insufficiency (VPI). The aim of this study was to assess the effectiveness of a superiorly-based pharyngeal flap (PF) with modification of its end to accommodate the defect in treatment of post-palatoplasty VPI.

METHODS

Thirteen children with VPI due to posterior palatal defect after CP repair were included in this study. PF was used in treatment of all patients, the lower end of the flap was fashioned in a V-shape to accustom the shape of the defect with peeling of its overlying mucosa to enhance wound healing. The PF was inserted deeply into a tunnel created within the defect between the oral and nasal layers of the palate. Pre- and postoperative evaluation using auditory perceptual assessment (APA), nasometric assessment and velopharyngoscopy were performed.

RESULTS

Significant improvement of APA and nasalance score for both oral and nasal sentences was achieved. Also, velopharyngoscopy showed complete velopharyngeal closure in all patients postoperatively.

CONCLUSION

A modified PF is an effective treatment for VPI caused by posterior palatal defect that may be encountered after CP repair.

Concomitant adenotonsillectomy and cleft palate repair in one sitting

PURPOSE

When adenotonsillar hypertrophy (ATH) is encountered in children during cleft palate (CP) repair, the decision for adenotonsillectomy is challenging. The aim of this study was to evaluate the effectiveness of adenotonsillectomy done during CP repair for children with ATH on speech and breathing.

METHODS

Nine children with CP and ATH underwent adenotonsillectomy prior to palatoplasty in same sitting. The age of patients ranged between 1.5 and 3.5 years with a mean age of 2.3 years at the time of operation. Auditory perceptual assessment (APA), nasometric assessment, and velopharyngeal function evaluation were performed when the children reached the age of 4 years.

RESULTS

No children developed obstructive breathing episodes postoperatively as witnessed by parents. APA showed normal nasality in six patients and mild hypernasality in three patients. Nasalance scores for both nasal and oral sentences were found to be comparable with that of normal children of the same age. Velopharyngeal closure was seen competent in four patients, borderline competent in three patients, and borderline incompetent in two patients.

CONCLUSION

Performing adenotonsillectomy during CP repair does not deleteriously affect the speech and it prevents the occurrence of postoperative obstructive breathing episodes that may be caused by the hypertrophied tonsils and/or adenoid.

Pediatric COVID-19 and the Factors That May Mitigate Its Clinical Course

The clinical manifestations of novel coronavirus disease 2019 (COVID-19) vary from mild flu-like symptoms to severe fatal pneumonia. However, children with COVID-19 may be asymptomatic or may have mild clinical symptoms. The aim of this study was to investigate clinical features of pediatric COVID-19 and to search for the factors that may mitigate the disease course. We reviewed the literature to realize the clinical features, laboratory, and radiographic data that may be diagnostic for COVID-19 among children. Also, we studied the factors that may affect the clinical course of the disease. Fever, dry cough, and fatigue are the main symptoms of pediatric COVID-19, sometimes flu-like symptoms and/or gastrointestinal symptoms may be present. Although some infected children may be asymptomatic, a recent unusual hyperinflammatory reaction with overlapping features of Kawasaki's disease and toxic shock syndrome in pediatric COVID-19 has been occasionally reported. Severe acute respiratory syndrome-coronvirus-2 (SARS-CoV-2) nucleic acid testing is the corner-stone method for the diagnosis of COVID-19. Lymphocyte count and other inflammatory markers are not essentially diagnostic; however, chest computed tomography is highly specific. Factors that may mitigate the severity of pediatric COVID-19 are home confinement with limited children activity, trained immunity caused by compulsory vaccination, the response of the angiotensin-converting enzyme 2 receptors in children is not the same as in adults, and that children are less likely to have comorbidities. As infected children may be asymptomatic or may have only mild respiratory and/or gastrointestinal symptoms that might be missed, all children for families who have a member diagnosed with COVID-19 should be investigated.

Treatment of post-adenotonsillectomy velopharyngeal stenosis with bivalved uvular flaps

OBJECTIVE

Velopharyngeal stenosis (VS) is a rare devastating complication of adenotonsillectomy that causes obstructive sleep apnea (OSA). Its treatment is challenging and has a high recurrence rate. The aim of this study was to assess the efficacy of a bivalved uvular flap technique with topical application of mitomycin C for treatment of this problem.

STUDY DESIGN

Case series.

METHODS

Fourteen children with VS after adenotonsillectomy were treated with a bivalved uvular flap technique with application of mitomycin C after release of the adhesions and removal of scar tissue. Preoperative and postoperative evaluation of patients were performed. Flexible nasopharyngoscopy was used to assess the patency of the velopharynx, and apnea/hypopnea (A/H) index and minimum O₂ saturation were measured before and after surgery.

RESULTS

Adequate patent airway was obtained in all patients as seen by oropharyngeal examination and flexible nasopharyngoscopy. Additionally, significant improvement in A/H index and minimum O₂ saturation were achieved postoperatively.

CONCLUSION

The bivalved uvular flap technique with topical application of mitomycin C after removal of scar tissue is an effective treatment for VS that may follow adenotonsillectomy in children.

Adenoid hypertrophy causing obstructive sleep apnea in children after pharyngeal flap surgery

PURPOSE

Pharyngeal flap surgery used for treatment of velopharyngeal insufficiency (VPI) may be followed by obstructive sleep apnea (OSA) especially if the patient has developed adenoid hypertrophy. However, adenoidectomy may adversely affect speech in these patients. The aim of this study was to assess the effectiveness of transnasal endoscopic power-assisted adenoidectomy in relieving OSA in patients with adenoid hypertrophy who underwent pharyngeal flap surgery, and the impact of the procedure on their speech.

METHODS

Transnasal endoscopic power-assisted adenoidectomy for nine children presenting with adenoid hypertrophy was performed. The patients had previously undergone pharyngeal flap surgery for treatment of VPI. Flexible nasopharyngoscopy was used in the diagnosis of adenoid hypertrophy. Pre- and postoperative polysomnography with measurement of apnea-hypopnea index (AHI) was done. Additionally, auditory perceptual assessment of speech (APA) and nasalance scores was measured pre- and postoperatively.

RESULTS

All patients were shown to have OSA by polysomnography, and a larger adenoid size was significantly associated with a higher AHI. We achieved a significant improvement in AHI after adenoidectomy. However, six patients still demonstrated OSA, albeit with a reduced severity. Speech was not adversely affected postoperatively as the APA and nasalance scores showed non-significant changes.

CONCLUSION

Adenoid hypertrophy may be encountered in children who undergo pharyngeal flap surgery, which may cause OSA. Transnasal endoscopic power-assisted adenoidectomy is a safe and effective method for treatment of OSA in those patients without prejudicing the pharyngeal flap, and it has no adverse effect on speech.

Closure of fistula of the hard palate with two layers of mucoperiosteum

OBJECTIVE

Oronasal fistula represents a functional problem, as it may result in nasal regurgitation of food and fluids and it also leads to hypernasal speech. Many methods have been proposed for its closure with a high recurrence rate. The aim of this study was to assess the efficacy of closure of hard palate fistula by two layers of mucoperiosteal flaps.

METHODS

Eighteen patients with fistula of the hard palate were included. The fistula was repaired by two layers of mucoperiosteal flaps; the first layer was created from the mucoperiosteum surrounding the fistula as bilateral hinge flaps and the second layer was formed of a rotational flap based on the greater palatine artery. Pre- and postoperative clinical assessment was performed.

RESULTS

The etiology of fistulas was previous cleft palate repair in 13 patients, previous nasal septal surgery in 3 patients, and untreated sharp accidental trauma to the palate in 2 patients. All patients presented with nasal regurgitation and hypernasal speech. Complete closure of all fistulas was achieved at first attempt, with no recurrence through the follow up period.

CONCLUSIONS

Closure of oronasal fistula by two layers of mucoperiosteal flaps is an effective method and it has neither complications nor recurrence.

The effect of adenotonsillectomy on obstructive sleep apnea in children with Down syndrome. Acta Otolaryngol 2017;137:981-985. [PMID: 28399695 DOI: 10.1080/00016489.2017.1312016]

OBJECTIVE

Children with Down syndrome (DS) are liable to develop obstructive sleep apnea (OSA) due to many anatomical airway abnormalities. The tonsils and adenoid occupy part of the airway space, and their removal may be helpful in relieving airway obstruction. The aim of this study was to assess the effectiveness of adenotonsillectomy in the treatment of OSA in those children.

METHODS

Fifty DS children with difficult breathing were recruited, and they were subjected to polysomnographic examination (PSG). Patients with apnea-hypopnea index (AHI) > 1 were considered to have OSA. Adenotonsillectomy was performed for patients who had OSA and adenotonsillar hypertrophy, and after 3 months PSG was done for them with recording of the same preoperative parameters.

RESULTS

Forty-three children demonstrated OSA on PSG, and they were included in the study. The preoperative mean AHI was 9.18 (± 6.17) that improved postoperatively to 2.72 (± 3.80) with its normalization in 72% of patients. Also, significant improvement of arousal index, minimum oxygen saturation, desaturation index, and peak end-tidal CO₂ was achieved postoperatively.

CONCLUSION

Adenotonsillectomy is an effective method for the treatment of OSA in children with DS. However, the condition may persist in some children who usually have airway narrowing at multiple levels.

Swallowing disorders among patients with diffuse idiopathic skeletal hyperostosis

CONCLUSION

Diffuse idiopathic skeletal hyperostosis (DISH) is a cause of swallowing disorders in elderly, and otolaryngologists should be aware of the disease on dealing with old patients complaining of dysphagia. The condition may be treated conservatively in most patients; however, surgical reduction of cervical osteophytes may be needed in severe cases.

OBJECTIVE

Large cervical osteophytes may cause dysphagia; they compress the pharynx leading to mechanical impairment of swallowing. DISH is characterized by ossification of the anterior longitudinal spinal ligament with formation of osteophytes. The aim was to investigate swallowing disorders among patients with DISH.

METHOD

The study included 139 patients with DISH. Their swallowing was evaluated using the eating assessment tool (EAT-10), and patients with swallowing disorders were subjected to fiber-optic endoscopic evaluation of swallowing (FEES), they received conservative treatment for 6 months. Patients were assessed again after treatment using the same measures that were employed before treatment.

RESULTS

Twenty-three patients (16.5%) demonstrated swallowing disorder, and FEES showed residues of food in the pharynx after swallow in all of them. Significant overall improvement after conservative treatment was achieved, with two patients resuming their normal regular diet. However, one patient demonstrated no improvement, and he needed surgical reduction of his large cervical osteophytes.

Trans-oral endoscopic partial adenoidectomy does not worsen the speech after cleft palate repair

Introduction

Adenoid hypertrophy may play a role in velopharyngeal closure especially in patients with palatal abnormality; adenoidectomy may lead to velopharyngeal insufficiency and hyper nasal speech. Patients with cleft palate even after repair should not undergo adenoidectomy unless absolutely needed, and in such situations, conservative or partial adenoidectomy is performed to avoid the occurrence of velopharyngeal insufficiency. Trans-oral endoscopic adenoidectomy enables the surgeon to inspect the velopharyngeal valve during the procedure.

Objective

The aim of this study was to assess the effect of transoral endoscopic partial adenoidectomy on the speech of children with repaired cleft palate.

Methods

Twenty children with repaired cleft palate underwent transoral endoscopic partial adenoidectomy to relieve their airway obstruction. The procedure was completely visualized with the use of a 70° 4 mm nasal endoscope; the upper part of the adenoid was removed using adenoid curette and St. Claire Thompson forceps, while the lower part was retained to maintain the velopharyngeal competence. Preoperative and postoperative evaluation of speech was performed, subjectively by auditory perceptual assessment, and objectively by nasometric assessment.

Results

Speech was not adversely affected after surgery. The difference between preoperative and postoperative auditory perceptual assessment and nasalance scores for nasal and oral sentences was insignificant (p = 0.231, 0.442, 0.118 respectively).

Conclusions

Transoral endoscopic partial adenoidectomy is a safe method; it does not worsen the speech of repaired cleft palate patients. It enables the surgeon to strictly inspect the velopharyngeal valve during the procedure with better determination of the adenoidal part that may contribute in velopharyngeal closure.

Mucocele of the hard palate in children

OBJECTIVE

Mucus retention cyst of the hard palate may result from obstruction of the ducts of the minor salivary glands, and it was defined as a mucocele. Although, the disease is not common in the hard palate, it was previously reported by many authors in the soft palate. The aim of our study was to present pediatric patients who were diagnosed to have mucocele of the hard palate, and to evaluate the outcome of the surgical excision of this lesion.

METHODS

This is a case series study included 8 pediatric patients who presented with cystic lesions on the hard palate which were removed surgically, and were diagnosed as mucoceles. Preoperative data, surgical procedures, and postoperative outcome were presented. Follow up of patients was performed for at least one year.

RESULTS

The swelling was detected as a single isolated lesion, on the side of the hard palate, covered with healthy mucosa, not tender, oval or round in shape, and measuring 0.4 to 1.7cm in its greatest dimension. Computed tomography showed a well defined cavity which was not invading the bone, and not disrupting the muscles of the palate. Histopathological examination confirmed that the lesion was a cavity that is lined with an epithelial layer with pseudoepitheliomatous hyperplasia. No patients developed intraoperative or postoperative complications, and no recurrence was detected in any patient.

CONCLUSIONS

Oral mucoceles can develop on the hard palate of the children, the lesions are mucus retention cysts. Complete surgical removal of the lesions with their cystic wall is a good treatment options, it carries no risk of recurrence.

The association of Varicella zoster virus reactivation with Bell's palsy in children

OBJECTIVES

Bell's palsy is considered the most common cause of facial nerve paralysis in children. Although different theories have been postulated for its diagnosis, reactivation of the Varicella zoster virus (VZV) has been implicated as one of the causes of Bell's palsy. The aim of the study was to evaluate the association of Varicella-zoster virus infection with Bell's palsy and its outcome in children.

METHODS

A total of 30 children with Bell's palsy were recruited and were assayed for evidence of VZV infection. The severity of facial nerve dysfunction and the recovery rate were evaluated according to House-Brackmann Facial Nerve Grading Scale (HB FGS). Paired whole blood samples from all patients were obtained at their initial visit and 3 weeks later, and serum samples were analyzed for VZV IgG and IgM antibodies using ELISA.

RESULTS

A significantly higher percentage of Bell's palsy patients were seropositive for VZV IgM antibodies than controls (36.6% of patients vs 10% of controls) while for VZV IgG antibodies the difference was statistically nonsignificant. HB FGS in Bell's palsy patients with serologic evidence of VZV recent infection or reactivation showed a statistiacally significant less cure rate than other patients.

CONCLUSIONS

VZV reactivation may be an important cause of acute peripheral facial paralysis in children. The appropriate diagnosis of VZV reactivation should be done to improve the outcome and the cure rate by the early use of antiviral treatment.

Trans-oral endoscopic cerclage pharyngoplasty for treatment of velopharyngeal insufficiency

OBJECTIVES

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair, it leads to speech distortion with consequent affection of speech intelligibility. Many techniques have been used in the treatment of VPI with varying results and complications. The aim of this study was to evaluate the efficacy of trans-oral endoscopic cerclage pharyngoplasty in the treatment of VPI.

METHODS

Eighteen patients with hypernasality after palatoplasty were subjected to trans-oral endoscopic cerclage pharyngoplasty. Pre and postoperative evaluation of velopharyngeal function were performed by using auditory perceptual assessment, nasometric assessment, and flexible nasopharyngoscopy.

RESULTS

Significant postoperative improvement of speech parameters measured with auditory perceptual assessment were achieved, and the overall postoperative nasalance score was improved significantly for nasal and oral sentences. Also, flexible nasopharyngoscopy showed significant improvement of velopharyngeal closure. No marked postoperative complications were reported apart from throat pain and dysphagia that disappeared with time.

CONCLUSIONS

Trans-oral endoscopic cerclage pharyngoplasty is an effective method for the treatment of VPI.

Recurrent acute otitis media in infants: analysis of risk factors

OBJECTIVE

Recurrence acute otitis media (RAOM) may cause a considerable morbidity and a great parental concern. The aim of this study was to analyze the risk factors that are likely to be responsible for RAOM in infants, and their impact on treatment failure.

METHODS

A retrospective study on 340 infants with RAOM was conducted. Data were collected from hospital charts. A 10 days course of amoxicillin/clavulanate was used for treatment of recurrence, while surgical management in the form of adenoidectomy and/or myringotomy was reserved for patients with persistent disease. We analyzed various risk factors that may affect the prognosis of RAOM, including: age, prematurity, upper respiratory tract infections (URTI), duration of breastfeeding, use of pacifiers, parental smoking, seasonality, the presence of siblings (family size), gender, adenoid hypertrophy, allergy, and craniofacial abnormalities.

RESULTS

Use of pacifiers, short duration of breastfeeding, older infantile age, winter season, URTI and presence of adenoid hypertrophy were identified as risk factors for RAOM. Treatment failure may be due to adenoid hypertrophy, short duration of breastfeeding and it is more common in older age infants. We did not find a significant association between RAOM and gender, prematurity, exposure to passive smoking, the presence of siblings, allergy, craniofacial abnormalities.

CONCLUSIONS

Factors that may cause recurrence of the disease in infant population are use of pacifiers, short duration of breastfeeding, older infantile age, winter season, upper respiratory tract infections and adenoid hypertrophy. Also, treatment failure may be caused by adenoid hypertrophy and short duration of breastfeeding. Good understanding of these factors may help to decrease the recurrence rate and to improve the treatment of the disease.

Speech outcome after early repair of cleft soft palate using Furlow technique

OBJECTIVE

The earlier closure of palatal cleft is the better the speech outcome and the less compensatory articulation errors, however dissection on the hard palate may interfere with facial growth. In Furlow palatoplasty, dissection on the hard palate is not needed and surgery is usually limited to the soft palate, so the technique has no deleterious effect on the facial growth. The aim of this study was to assess the efficacy of Furlow palatoplasty technique on the speech of young infants with cleft soft palate.

METHODS

Twenty-one infants with cleft soft palate were included in this study, their ages ranged from 3 to 6 months. Their clefts were repaired using Furlow technique. The patients were followed up for at least 4 years; at the end of the follow up period they were subjected to flexible nasopharyngoscopy to assess the velopharyngeal closure and speech analysis using auditory perceptual assessment.

RESULTS

Eighteen cases (85.7%) showed complete velopharyngeal closure, 1 case (4.8%) showed borderline competence, and 2 cases (9.5%) showed borderline incompetence. Normal resonance has been attained in 18 patients (85.7%), and mild hypernasality in 3 patients (14.3%), no patients demonstrated nasal emission of air. Speech therapy was beneficial for cases with residual hypernasality; no cases needed secondary corrective surgery.

CONCLUSION

Furlow palatoplasty at a younger age has favorable speech outcome with no detectable morbidity.

The effectiveness of tonsillectomy and partial adenoidectomy on obstructive sleep apnea in cleft palate patients

OBJECTIVES/HYPOTHESIS

The most common cause of pediatric obstructive sleep apnea (OSA) is adenotonsillar hypertrophy (ATH). In cleft palate patients, however, the obstructive effects of ATH are more severe due to narrow airways. The aim of this study was to assess the effectiveness of tonsillectomy and/or partial adenoidectomy on OSA in cleft palate patients.

STUDY DESIGN

Case series.

METHODS

Tonsillectomy and/or partial adenoidectomy was performed in 17 repaired cleft palate patients with tonsillar and/or adenoid hypertrophy and OSA. Apnea/hypopnea (A/H) index and minimum O(2) saturation were measured before and after surgery. In addition, because these patients are vulnerable to speech impairment after pharyngeal surgery, auditory perceptual assessment (APA) and nasometric assessment of speech were performed.

RESULTS

The mean preoperative A/H index was 17.6 ± 3.9, and the mean preoperative minimum O(2) saturation was 88.7 ± 1.5%. Both parameters improved postoperatively, to 1.9 ± 2.3 and 93.7 ± 1.5% respectively, and the changes were significant (P < 0.001). In 12 cases (70.6%), A/H indexes were normalized following surgery. Associated comorbidities such as retrognathia and narrow pharyngeal airways may underlie incomplete recovery in some cases. There were no significant postoperative changes in APA and nasalance scores.

CONCLUSIONS

In most cases, tonsillectomy and/or partial adenoidectomy is an effective method for treatment of OSA in repaired cleft palate patients presenting with tonsillar and/or adenoid hypertrophy. However, some cases may need further procedures to relieve airway obstruction due to associated comorbidities.

Repair of submucous cleft palate with Furlow palatoplasty

OBJECTIVE

Submucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI.

METHODS

This prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy.

RESULTS

Significant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory.

CONCLUSIONS

Furlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity.

Congenital cholesteatoma of the infratemporal fossa with congenital aural atresia and mastoiditis: a case report

BACKGROUND

Congenital cholesteatoma may be expected in abnormally developed ear, it may cause bony erosion of the middle ear cleft and extend to the infratemporal fossa. We present the first case of congenital cholesteatoma of the infratemporal fossa in a patient with congenital aural atresia that has been complicated with acute mastoiditis.

CASE PRESENTATION

A sixteen year old Egyptian male patient presented with congenital cholesteatoma of the infratemporal fossa with congenital aural atresia complicated with acute mastoiditis. Two weeks earlier, the patient suffered pain necessitating hospital admission, magnetic resonance imaging revealed a soft tissue mass in the right infratemporal fossa. On presentation to our institute, Computerized tomography was done as a routine, it proved the diagnosis of mastoiditis, pure tone audiometry showed an air-bone gap of 60 dB. Cortical mastoidectomy was done for treatment of mastoiditis, removal of congenital cholesteatoma was carried out with reconstruction of external auditory canal. Follow-up of the patient for 2 years and 3 months showed a patent, infection free external auditory canal with an air-bone gap has been reduced to 35db. One year after the operation; MRI was done and it showed no residual or recurrent cholesteatoma.

CONCLUSIONS

Congenital cholesteatoma of the infratemporal fossa in cases of congenital aural atresia can be managed safely even if it was associated with mastoiditis. It is an original case report of interest to the speciality of otolaryngology.

The effect of steroid injection of the tongue base on reducing postoperative airway obstruction in cleft palate repair

Upper airway obstruction (UAO) is a well known complication of cleft palate repair. The aim of this study was to evaluate the efficacy of local tongue base steroid injection in preventing or reducing the lingual oedema that can cause UAO following palatoplasty. Thirty children with unilateral complete cleft palate were included. They were randomly divided into two equal groups. Children in group I received intravenous dexamethasone whilst children in group II received both intravenous dexamethasone and local betamethasone injected at the tongue base. Both groups underwent the same technique of palatoplasty, postoperative breathing was assessed and UAO was rated as mild, moderate or severe. Postoperative UAO developed in six cases (40%) in group I and in two cases (13%) in group II. In group I, it was mild in three cases, moderate in one case, and severe in two cases. In group II, it was mild in one case and moderate in another case. Despite the differences in the number and severity of the condition in both groups, comparison was statistically insignificant. Local steroid injection of the tongue base during cleft palate surgery reduced the incidence and severity of post-palatoplasty UAO.

Hypertrophied tonsils impair velopharyngeal function after palatoplasty

OBJECTIVES/HYPOTHESIS

When tonsillar hypertrophy obstructing the airway is encountered in a child with a repaired cleft palate and velopharyngeal insufficiency, the surgeon may opt for tonsillectomy to relieve the airway obstruction, with possible effects on velopharyngeal closure. The aim of this study was to assess the impact of hypertrophied tonsils on velopharyngeal function in children with repaired cleft palate and to measure the effect of tonsillectomy on velopharyngeal closure and speech resonance.

STUDY DESIGN

Case series.

METHODS

Twelve children with repaired cleft palate and tonsillar hypertrophy underwent tonsillectomy to relieve airway obstruction. Preoperative and postoperative evaluation of velopharyngeal function was performed. Auditory perceptual assessment of speech and nasalance scores were measured, and velopharyngeal closure was evaluated by flexible nasopharyngoscopy.

RESULTS

Preoperative impairment of velopharyngeal function was detected. However, significant postoperative improvement of speech parameters (hypernasality, nasal emission of air, and weak pressure consonants measured with auditory perceptual assessment) was achieved, and the overall postoperative nasalance score was improved significantly for nasal and oral sentences. Reduction of velopharyngeal gap size was detected after removal of hypertrophied tonsils. Although the improvement of velopharyngeal closure was not significant, three cases demonstrated complete postoperative closure with no gap.

CONCLUSIONS

Hypertrophied tonsils may impair velopharyngeal function in children with repaired cleft palate, and tonsillectomy is beneficial for such patients as it can improve the velopharyngeal closure and speech resonance. Secondary corrective surgery may be avoided in some cases after tonsillectomy.

Furlow technique for treatment of soft palate fistula

OBJECTIVE

Fistula of the palate is a common complication of palatoplasty, it leads to nasal regurgitation of fluids and hypernasality of speech. Its treatment is technically difficult due to paucity and fibrosis of palatal tissues. The aim of this study was to evaluate the efficacy of closure of soft palate fistula by using Furlow double opposing Z-palatoplasty.

METHODS

Nineteen patients were subjected for repair of their soft palate fistulas using Furlow Z-plasty. Pre and postoperative speech analysis using auditory perceptual assessment, measurement of nasalance score using nasometric assessment, and measurement of velar movement using flexible nasopharyngoscopy were done.

RESULTS

All cases showed complete closure of their fistulas at first attempt, with no operative or postoperative complications. Recurrence was not recorded in any case after a follow up period of at least 12 months. Significant improvement of speech quality and nasalance score was achieved. Flexible nasopharyngoscopy showed postoperative increase in velar movement which was not significant relative to the preoperative records.

CONCLUSIONS

Treatment of soft palate fistula by using Furlow technique is an effective method as a primary treatment with a high success rate and a good functional outcome.

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management

OBJECTIVE

Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management.

METHODS

Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year.

RESULTS

Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Down's syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms.

CONCLUSIONS

Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.

Endoscopic nasopharyngeal exploration at the end of conventional curettage adenoidectomy

Adenoid hypertrophy (AH) is a common cause of airway obstruction in children and its recurrence after conventional curettage adenoidectomy is not rare. The purpose of this study is to assess the efficacy of endoscopic nasopharyngeal exploration at the end of curettage adenoidectomy on decreasing the incidence of adenoid re-hypertrophy. Three hundred and fifty children diagnosed as having AH, underwent conventional curettage adenoidectomy by a single surgeon. The cases were randomly divided into two equal groups A and B, group B were further subjected to nasopharyngeal exploration by the nasal endoscope after removal of their adenoids with cauterization of any visible residuals, while group A were not subjected to this endoscopic maneuver. Follow-up was carried out for at least 2 years; flexible nasopharyngoscopy was used for detection of recurrent AH. Cases that were not subjected to endoscopic nasopharyngeal exploration (group A) showed a high recurrence rate (6.6%), while explored cases (group B) showed a low incidence of recurrence (1.18%). Most recurrence of group A (6%) was detected within the first year of the follow-up period which may indicate re-growth of residual adenoidal tissues that were missed during conventional curettage adenoidectomy. Endoscopic nasopharyngeal exploration at the end of conventional curettage adenoidectomy is a useful method in decreasing the incidence of recurrent AH.

Laryngeal involvement in juvenile idiopathic arthritis patients

Juvenile idiopathic arthritis (JIA) is an autoimmune diseases characterized by chronic arthritis and systemic manifestations. Autoimmune diseases can affect the upper airways including the larynx. The aim of this study was to investigate laryngeal involvement in JIA patients and its possible association with JIA disease parameters. Fifty consecutive JIA patients were screened for laryngeal abnormalities using flexible fiberoptic laryngoscope and laryngeal computerized tomography. Laryngeal abnormalities were detected in nine (18%) of our cases, with cricoarytenoiditis in six cases (12%) and a rheumatoid nodule in the pyriform fossa in only one case (2%). Diffuse congestion and edema of the posterior part of the larynx with normal vocal cord mobility was detected in two cases (4%). In our study, laryngeal abnormalities were significantly higher in patients with polyarticular seropositive disease subtype and also were significantly higher in patients with longer disease duration, higher disease activity scores, and those with erosive disease. JIA may affect the larynx. Laryngeal involvement in JIA patients is more in polyarticular seropositive cases. JIA patients have to be subjected to thorough otolaryngologic examination for early diagnosis and prompt management.

Epstein-Barr virus infection as a cause of cervical lymphadenopathy in children

OBJECTIVE

Cervical lymphadenopathy is a common pediatric problem; reactive hyperplasia, specific infective agents, and malignancy are mainly the differential diagnosis. The aim of our study was to detect the prevalence of Epstein-Barr virus infection among children who complained of cervical lymphadenopathy and also to evaluate the clinical manifestations of the disease in pediatric patients.

METHODS

One hundred and sixty children presented with cervical lymphadenopathy were subjected to Epstein-Barr Virus (EBV) serology testing. Cases that showed positivity to heterophile antibody test, and/or EBV-specific antibodies; IgM against viral capsid antigen (VCA-IgM) and IgG against viral capsid antigen (VCA-IgG) were evaluated clinically for manifestations of the disease.

RESULTS

Twenty-four cases (15%) showed positivity to EBV serology, all of them had posterior cervical lymph nodes enlargement, 70.8% had fever, 66.6% had tonsillo-pharyngitis, 58.3% had splenomegaly, 25% had hepatomegaly, 41.6% had generalized lymphadenopathy, while skin rash was detected in 12.5%, and both palatal petechiae and palpebral edema were detected in 8.3%.

CONCLUSIONS

EBV infection is not a rare cause of cervical lymphadenopathy in children. Posterior cervical lymphadenopathy in pediatric age group may represent a password for suspicion of EBV infection, while other clinical manifestations of the disease may include hepato-splenomegaly, skin rash, palpebral edema and palatal petechiae.

Thyroid hormone patterns in elderly patients undergoing elective coronary procedures

BACKGROUND AND OBJECTIVES

Thyroid dysfunction is common in the elderly. We sought to explore thyroid hormone patterns in a series of elderly patients undergoing elective coronary procedures and their relation to the extent of coronary artery disease.

MATERIALS AND METHODS

We enrolled 81 consecutive elderly patients admitted to undergo elective diagnostic or interventional coronary procedures. Samples were collected for assay of free thyroxin, free tri-iodothyronine, thyroid stimulating hormone, anti-thyroglobulin and anti-thyroid peroxidase antibodies. According to the number of coronary arteries affected by significant stenosis (> or = 70% luminal obstruction), we classified patients into a group with insignificant coronary disease, another with single vessel disease, and a third group with multi-vessel disease.

RESULTS

Forty one (50.6%) patients were euthyroid, two patients (2.5%) had subclinical hypothyroidism, and 12 (14.8%) had clinical hypothyroidism. Yet, neither subclinical nor clinical hypothyroidism was statistically different among the 3 groups, (p > 0.05 for both). Additionally, 3 patients (3.7%) had subclinical, and 2 (2.5%) had clinical hyperthyroidism. Finally, 21 patients (25.9%) had sick euthyroid syndrome. Again, all were statistically similar between the study groups, (p > 0.5 for all). Similarly, both anti-thyroglobulin antibodies and anti-thyroid peroxidase antibodies were statistically similar among the 3 groups (p > 0.05 for both).

CONCLUSION

Thyroid hormone disturbances are quite frequent in elderly patients undergoing elective coronary procedures, chiefly in the form of a hypothyroid state. These data do not support that thyroid hormone patterns relate to the extent of coronary artery disease in the elderly.

V-Y two-layer repair for oronasal fistula of hard palate

OBJECTIVE

Oronasal fistula represents a functional problem after cleft palate repair; its closure is technically difficult with a high recurrence rate after primary treatment. The aim of this study was to evaluate the efficacy of closure of oronasal fistula using 2 layers of oral mucoperiosteum in a V-Y manner.

METHODS

Fourteen patients were subjected for repair of their oronasal fistulas using 2 layers; the first is the oral mucoperiosteum that is elevated and inverted to close the nasal side as a hinge flap, and the second is also the oral mucoperiosteum that is elevated and sutured in a V-Y manner to close the oral side.

RESULTS

In all cases, the fistula was completely closed at first attempt, no cases developed operative or postoperative complications. Recurrence with not recorded in any case after a follow-up period of at least 12 months.

CONCLUSION

Closure of oronasal fistula of the hard palate that may develop after cleft palate repair using a two-layer closure in V-Y manner is an easy and ideal method with a high success rate.

Nasal encephalocele: endoscopic excision with anesthetic consideration

OBJECTIVE

Nasal encephalocele may presents as a nasal mass, its treatment is surgical and it should be done early in life. When removal is indicated, there are multiple surgical approaches; including lateral rhinotomy, a transnasal approach and a coronal flap approach. However, the treatment of a basal intranasal encephalocele using transnasal endoscopic approach could obviates the possible morbidity associated with other approaches. The aim of this study was to evaluate the efficacy of endoscopic removal of intranasal encephalocele, also to document the role of anesthetist in the operative and postoperative periods.

METHODS

Nine cases with nasal encephalocele were included in this study; CT and/or MRI were used in their examination. The lesions were removed via transnasal endoscopic approach. Preoperative evaluation, intervention and postoperative follow-up were presented with discussion of anesthesia used for those children.

RESULTS

The lesions of all patients were removed successfully with no recurrence through the follow-up period of at least 21 months. No cases showed morbidity or mortality intra- or post-operatively.

CONCLUSIONS

Endoscopic excision of intranasal encephalocele is an effective method with high success rate. Anesthetist plays an important role in the operative and postoperative period, even during the endoscopic follow up; sedation of the children is usually needed.

Acute mastoiditis: A one year study in the pediatric hospital of Cairo university

Background

Acute mastoiditis is a serious complication of acute otitis media especially in the pediatric age group. This study reports the authors' experience in the treatment of children admitted with acute mastoiditis to the Pediatric Hospital of Cairo University throughout the year 2007, also we aimed to evaluate our current management of this serious disease.

Methods

Nineteen children were included in this study, 11 females and 8 males, their ages ranged from 9 months to 11 years. All children were treated with intravenous antibiotic on initial admission, myringotomy was considered for cases that did not respond to medical treatment for 48 hours, while cortical mastoidectomy (with myringotomy) was reserved for cases that presented initially with subperiosteal abscess with or without post-auricular fistula, cases with intracranial complications and for cases that showed no response to myringotomy (after 48 hours). Follow up of the patients was carried out for at least 1 year.

Results

Medical management alone was enough in 5 cases (26%); all of them had erythematous tender mastoid on first presentation. Seven cases (37%) needed myringotomy; 2 of them showed no response and they needed cortical mastoidectomy and the other 5 cases responded well except for 1 case that developed post-auricular subperiosteal abscess 2 months later necessitating cortical mastoidectomy with no evidence of recurrence till the end of the follow-up period. Seven cases (37%) presented with subperiosteal abscess and they needed cortical mastoidectomy with myringotomy; they showed no recurrence till the end of the study.

Conclusion

Conservative management is an effective method in the treatment of non-complicated acute mastoiditis, but myringotomy should be considered if there is no response within 48 hours. Cortical mastoidectomy should be used in conjunction with the medical management in the treatment of complicated cases.

The use of buccal flap in the closure of posterior post-palatoplasty fistula

OBJECTIVE

Palatal fistulation is a common complication after cleft palate repair, it could occur at any site along the line of cleft closure. Many techniques have been proposed for its repair. However, the incidence of recurrence after initial fistula closure is high. The aim of this study is to evaluate the efficacy of closure of posterior palatal fistula using buccal myomucosal flap.

METHOD

Fifteen cases with posterior palatal fistulas - after cleft palate repair - were included in this study. Their fistulas were closed in two-layers; an oral mucoperiosteum hinge flap to reconstruct the nasal side and a buccal myomucosal flap from the inner surface of the cheek to reconstruct the oral side. Follow-up was carried out for 1 year.

RESULTS

The fistulas were completely closed in all cases (100%) with no failure or recurrence. This was a single-stage operation in all cases, with no need for further procedure to divide the pedicle of the flap.

CONCLUSIONS

Closure of posterior palatal fistula using buccal myomucosal flap in addition to mucoperiosteal flap is a useful method with high success rate and no morbidity.

Congenital aural atresia: transmastoid approach; an old technique with good results

OBJECTIVE

Congenital aural atresia prevents sound conduction to the inner ear, so the child may suffer learning problems. Transmastoid approach is a safe method to create functional pathway by which sound can reach the cochlear fluids but it leaves mastoid cavity which may be problematic. The purpose of this study is to assess the feasibility of improving hearing in those patients on the expense of mastoid cavity.

METHODS

Forty children with congenital aural atresia were included in this study. All had functioning cochlea on evoked response audiometry and normal cochlear morphology with pneumatized mastoid on CT scan. Transmastoid approach was used for reconstruction of the external auditory canal with covering of the newly created canal using split thickness skin graft. Reconstruction of the tympanic membrane was carried out by temporalis fascia graft. Follow-up of the patients for 3 years was carried out.

RESULTS

Surgical success is considered on restoration of hearing and maintenance of a patent, infection-free ear canal. This study showed a successful hearing result in 85% of patients at 3 months postoperatively, this result diminished to 65% after 3 years. The incidence of canal restenosis was 17.5%; the narrowing was in the outer cartilaginous part. No cases developed facial nerve paralysis or sensorineural hearing loss postoperatively.

CONCLUSIONS

Congenital aural atresia is one of the most difficult and challenging surgeries for the otologic surgeon. However, in the hands of experienced otologists, repair of this deformity can be performed safely and with predictable results using transmastoid approach.

Palatopharyngeal sling: a new technique in treatment of velopharyngeal insufficiency

OBJECTIVE

(a) Pharyngeal flap and sphincter pharyngoplasty are the procedures most frequently chosen by craniofacial surgeons for surgical management of velopharyngeal insufficiency. Both operations may be complicated by obstructive breathing and even sleep apnea. (b) The purpose of this study is to evaluate the efficacy of a palatopharyngeal sling in the treatment of velopharyngeal insufficiency in cases with weak palatal mobility and its effect on breathing.

METHODS

Seventeen cases of post-palatoplasty velopharyngeal insufficiency were subjected to treatment by palatopharyngeal sling. This sling, created by elevation of bilateral myomucosal flaps formed of palatopharyngeus and superior constrictor muscles, passed through palatal split, sutured together and to a raw area on the oral surface of the soft palate. Pre- and post-operative evaluation was carried out by perceptual speech analysis and flexible nasopharyngoscopy. Polysomnography was used to assess the effect of the operation on breathing.

RESULTS

Complete closure was achieved in 13 cases (76.5%) while 4 cases showed incomplete closure (2 of them showed improvement when compared with the pre-operative video). The overall improvement of speech and velopharyngeal closure was 88.2%. Polysomnography showed no obstructive breathing.

CONCLUSIONS

Palatopharyngeal sling is a useful technique for correction of velopharyngeal insufficiency in cases with little palatal motion and it carries no risk of obstructive sleep apnea.

Treatment of submucous cleft palate by pharyngeal flap as a primary procedure

OBJECTIVE

(a) Palatal repair is the standard surgical method for correction of velopharyngeal incompetence due to submucous cleft, but some patients may need further narrowing of velopharynx by pharyngeal flap. (b) The purpose of this study is to evaluate the efficacy of a pharyngeal flap as a single surgical procedure in the treatment of symptomatic cases.

METHODS

Nine cases of symptomatic submucous cleft palate were subjected to treatment by pharyngeal flap only as a primary and single procedure after failure of speech therapy. Preoperative flexible nasopharyngoscopy was carried out for all children to determine the width of the velopharyngeal gap; the results were recorded on videotape and reviewed in the operating theatre for determination of the width of the pharyngeal flap. Postoperative follow-up by flexible nasopharyngoscopy and parent's questionnaire were used to assess the success rate.

RESULTS

Follow-up flexible nasopharyngoscopy showed complete closure of the lateral ports in eight cases (89%) while one case (11%) showed incompetence. Hypernasality was improved in all cases witnessed by parent's questionnaire and this improvement was satisfactory in seven cases (78%) but not satisfactory in two cases (22%). One of the last two cases reached to satisfactory level after speech therapy, while the other case showed no further improvement.

CONCLUSIONS

Speech therapy alone cannot correct hypernasality in presence of anatomical defect. Pharyngeal flap is a useful procedure monitored by flexible nasopharyngoscopy. When pharyngeal flap is used, the need for adjunctive procedure is absent.

Superior laryngeal nerve preservation in peri-apical surgery by mobilization of the viscerovertebral angle

Iatrogenic lesions of the superior laryngeal nerve (SLN) are much more common than is generally recognized. Since injury to this nerve may cause transient or even persistent changes either in quality of voice or in deglutition, an attempt should be made to localize and identify the nerve during surgery. This study included 74 patients who underwent surgical dissection near the thyroid apex in the neck. Effective prevention of SLN injury during surgery was achieved by anatomical localization of the nerve in the viscerovertebral angle and its functional identification with the nerve stimulator. Post-operative analysis consisted of subjective interview, rigid laryngoscopy, acoustic analysis, laryngeal videostroboscopy and cricothyroid electromyography. Four patients complained of post-operative voice changes; two were diagnosed as SLN injury (2.4 per cent), one as reflux laryngitis and the fourth as intubation granuloma. Surgical access to the SLN in the periapical area may be achieved through mobilization of the viscerovertebral angle. The use of a nerve stimulator during difficult situations should keep SLN injury at a minimum.