Surgical emergencies in pediatric otolaryngology

To obtain baseline data on the most common surgical emergencies in pediatric otolaryngology in Saudi Arabia. This report is a retrospective study of all children presenting to the pediatric otolaryngology emergency service at King Abdulaziz University Hospital in Riyadh, Kingdom of Saudi Arabia. Between January 2001 to January 2006 data were carefully collected and then analyzed for patients requiring emergent surgical intervention by the pediatric otolaryngology service. A total of 15,850 children presented to our pediatric otolaryngology emergency service. Surgical intervention was indicated in 183 children [1.2%].The larynx/head and neck was the most common site involved. Foreign body related emergencies were the most common presentation requiring surgical interventions [42%]. The aero-digestive tract was the most common site for foreign body retrieval [54%].Pediatric patients have always constituted a significant portion of the general otolaryngology service. Most pediatric otolaryngology emergencies are relatively benign. Aero-digestive tract foreign bodies are the most common indication for surgical intervention in pediatric otolaryngology

Percutaneous screw fixation of unicondylar tibial plateau fractures

Tibial plateau fractures are common injuries which often produce major disability. Open reduction and internal fixation of these fractures has a significant complication rate and numerous recent reports have a tendency to avoid open plating in favour of a variety of limited surgical approaches and percutaneous techniques usually in association with external fixation. The technique of closed manipulation, indirect reduction and percutaneous screw fixation was attempted in 29 displaced tibial plateau fractures [Schatzker types I - IV] in 29 patients. Closed, indirect reduction was successful in only 25 fractures [86.2%]; and the remaining four cases were excluded from the study. Patients' age ranged from 19 - 62 years [average 41 y.]. Of the 25 fractures, 4 [16%] were open; type I or II Gustilo Anderson classification. Additional mini incision to raise a depressed articular fragment and to apply a bone graft was needed in 12 fractures [48%]. Post operative cast or brace was applied for 3-5 weeks. Full weight bearing was started 8-12 weeks postoperatively. Anatomical reduction was achieved in 20 fractures [80%], and the remaining 5 [20%] were showing grade I residual step or gap formation. Bone healing was achieved in all cases [100%]; and occurred in 8-12 weeks [average 9.4 w.]. Patients were followed for 24-37 months with an average of 30 months. According to the HSS knee score; there were 9 excellent [36%], 13 good [52%], and 3 fair [12%] final end results. According to the Iowa Knee Score there were 14 excellent [56%], 9 good [36%], and 2 fair [8%] final end results. Of these 25 patients, 76% [19 patients] were satisfied; and 24% [6 patients] were not satisfied by the final end result. There were no cases of loss of reduction, wound infection, or cases with poor final clinical outcome. Indirect technique of reduction combined with percutaneous screw fixation could effectively reduce most displaced unicondylar tibial plateau fractures [Schatzker types I - IV] and is associated with good final outcome, with few reported complications

Tibial pilon fracture, results of limited internal fixation

Intra-articular fractures of the tibial plafond [pilon fractures] are a combination of an ankle and distal tibial metaphyseal fracture; usually with intra-articular comminution. They are considered among the most challenging of orthopaedic problems. The optimum treatment of these fractures remains controversial. Eighteen patients [19 - 54 y.] with 18 tibial pilon fractures were operated upon. There were 4 fractures [22.2%] type II; and 7 fractures [38.9%] type III Ruedi and Allgower classification. Another four fractures [22.2%] were type IV and the remaining three fractures [16.7%] were type V; Ovadia and Beals added other types. Eleven fractures [61.1%] were open type I, II or IIIA Gustilo and Anderson classification. Treatment was: limited open reduction with small direct incisions over the main fractures fragments and with the least needed dissection and with minimal internal fixation of both the tibia and the fibula. Only two patients [11.1%], who had an intact fibula, had fixation of their tibiae only. Only inter fragmentary screws [ +/- K. wires] were used for fixation. Bone-grafting of structurally deficient metaphyseal areas was done in seven [38.9%] cases. Post-operative below knee bracing was used for 4 - 6 weeks. Early mobilization and early weight bearing were always aimed. Bone healing was achieved in all cases [in 6 - 18 weeks; average 10.3 w]. At a minimum of two years of follow-up postoperatively, [range: 24 to 33 months with an average of 28 m.], the range of motion was excellent in 6 patients [33.3%], good in nine [50%], fair in two [11.1%], and poor in one [5.6%]. The final clinical score was: excellent in 7 patients [38.9%], good in another 7 patients [38.9%], fair in 3 patients [16.6%] and poor in one patient [5.6%]. Limited open reduction with minimal internal fixation is a satisfactory method for treatment of pilon fractures. It is associated with good final outcome, significant reduction in bone healing time, delayed union incidence and reoperation rate; with few reported complications

One stage intervention for infected, non-united, short tibia

Post-traumatic tibial non-union in association with infection is a real surgical problem. When tibial shortening occurs and soft tissue [especially skin] complications are added to this problem due to multiple surgical procedures to solve the first problem, this is one of the heaviest complications in bone-joint surgery. Twenty five tibial non-united fractures; [8-65y],complicated with infection shortening [4-9 cm.] and skin or other soft tissue complications; following repeated surgeries [2-5 previous operations] were subjected to debridement of the soft tissues at the non-union site with excision of bone ends till healthy bone [adding more shortening]. Mono-planer external fixators were applied to all cases; compression was applied to fracture site, and distraction-callotasis principle was performed at a proximal [or distal] corticotomy. Bone healing was achieved in 24 cases [96%] in 12 - 28 weeks [mean of 18.2 weeks]. Infection was eradicated in 22 cases [88%]; all were united. The mean length gained was 7.7 cm [6 to 12.5 cm]. Satisfactory results were obtained in 22 patients [88%] and unsatisfactory results in 3 patients [12%].No major complications were encountered; There have been no refractures or loss of length, after a follow-up of 2.3 years [range 2 - 4 y] mono-planer devices when applied properly and combined with proper debridement can give a high success rate in achieving bone healing, eradication of infection and correction of shortening in tibial non-union associated with infection and shortening

Holmium: YAG laser intracoproeal lithotripsy in the treatment of middle and upper urinary tract calculi: preliminary report

To evaluate the efficacy of Holmium:YAG laser lithotripsy in treatment of upper urethral and renal calculi, 20 patients with a mean age of 47 years with upper urinary tract calculi [3 renal and 17 ureteric] were treated by Holmium:YAG laser lithotripsy via 7F flexible ureteroscope. The size of stones ranged from 7 to 20 mm [means is 10 + 2 mm]. All patients were followed for three months after treatment. Seventeen [85%] out of 20 patients were stone free at three months follow up. All stones were accessible using 7F flexible ureteroscope. All stones were fragmented regardless of its composition, size or location. No complications were encountered in relation to the procedure or laser fiber

T lymphocyte subpopulation and function in children with shigellosis

This study was carried on sixty-two children aged from 12 to 60 months, attending TABARAK pediatric hospital with acute dysentery [visible blood in the stool and the presence or absence of fever]. Of the 62 children enrolled in this study, 43 had shigella dysentery 1 [S, dysentery] infection and 19 children matched for age and without any infection as control group, [NI; n= 19]. Children with S. dysentery were divided into 3 groups: those who had HUS or leukomoid reactions [complicated shigellosis, CS; n=25], those who developed complications following enrollment [subsequently complicated shigeliosis, SCS; n=6], and those who had no complication [uncomplicated shigellosis, US; n=12]. T lymphocyte subpopulation and function was evaluated for these children

RESULTS showed that children with SCS differed from other groups in as follows: [i] the number of CD3 and CD4 was lower compared to NI children [P<0.05]. [ii] CD4/CD8 ratio was lower compared to US children [PO.05] and NI children [PO.05]. [iii] The level of DTH response was lower than this in children with US [PO.05]. Three to five days after enrollment, the number of CD4 cells increased in children with SCS, The results showed that T lymphocyte phenotypes and function were altered prior to development ofcomplication in children with shigellosis, and once complications develop, the pattern of alteration changes. Whether these alterations have a role in predicting complications or whether they reflect events underlying the development of complications remains to be elucidated

Cigarette smoking and spermatozoa II. effect of ascorbic acid supplementation on spermatozoa of cigarette smokers [histochemical study]

The thirty heavy smoking men investigated in the first portion of our work were randomly divided into two subgroups [each contained 15 men]. Each participant from the first subgroup of smokers took one 1000-mg tablet of ascorbic acid [AA] daily for 4 weeks. For the same period, the members of the second subgroup took placebo tablets, serving as negative controls. Also, another fifteen of the non-smokers participated as a separate group and each took one 1000-mg tablet of AA daily for 4 weeks, serving as positive controls. The histochemical differences between sperms of cigarette smokers and non-smokers in the first portion of this work were surveyed. Serum and seminal plasma ascorbic acid levels were measured. Statistically significant increases in the histochemical reactions and ascorbic acid levels in the treated subgroup were observed weekly. After the 4 weeks of supplementation, no significant difference was detected between the treated subgroup and non-smokers. However, no significant changes were observed in the non-smokers or the placebo subgroup indicating that increased ascorbic acid bioavailability was associated with the pronounced improvement in sperm activity. These useful effects of AA supplementation may be due to its reductive properties nullifying the possible iniurious effects of the reactive oxidants of nicotine or nicotine melabolites

Growth hormone improves immune function in GH-deficient young adolescents

To delineate the role of growth hormone [GH] in the development and function of the immune system, sixteen GH-deficient young adolescents were studied for evaluation of the immune status before and after treatment with recombinant human growth hormone [rhGH]. Ten apparently healthy young adolescents age and sex-matched with the study group were included in the study as control group. Blood samples were obtained for immune studies before treatment and at 2, 6 and 9 months after. Immune studies included; enumeration of total T and B lymphocyte number, CD3+, CD4+, CD8+ and CD4+/ D8+ ratio, serum immunoglobulin concentrations [IgG, IgM], assessment of Iympho-proliferative response to phytohemagglutinin and testing for intracellular killing by Nitro blue tetrazolium test [NBT]. Results showed significant impairment in mitogen stimulation and phagocytic function in GH-deficient young adolescents when compared to control group [73.18 +/- 5.2 versus 146.2 +/- 7.6, P < 0.0001 and 50.13 +/- 5.8 versus 82.2 +/- 4.49, P < 0.0001 respectively]. This impairment improved significantly after treatment with rhGH [p < 0.0001]. However, there were no significant differences in the total B-Iymphocytes numbers, CD3+, CD4+, CD8+, CD4+ / CD8+ ratio, and serum immunoglobulin levels between GH-deficient group and control group, as well as between values obtained before and after rhGH treatment. These results indicate that growth hormone administration has profound immune-enhancing effects in GH-deficient young adolescents and may be of therapeutic effect in states of compromised immune function

Increased carotid intimal medial thickness in type 2 diabetes: relation to D-dimers

We investigated common carotid artery intimal - medial thickness [CCA-IMT] as an evidence of generalized atherosclerosis and D-dimers plasma concentrations as a measure of fibrinolytic activity, in 30 type 2 diabetic subjects [with no clinical coronary artery disease [CAD] cerebrovascular or peripheral vascular disease] and 15 healthy control subjects. Also the interrelation between CCA-IMT and D-dimers plasma concentrations and their relations with lipid status and blood sugar levels were evaluated. Diabetic subjects had significantly higher CCA-IMT and D-dimers plasma concentrations than control subjects. In diabetic subjects CCA-IMT and D-dimers plasma concentrations were significantly directly correlated with each other [P<0.01] and with FBS. 2 hPPBS, HbA[Ic], duration of diabetes, plasma fibrinogen, serum cholesterol, LDL-C and age of diabetic subjects. Diabetic subjects with better blood sugar control [FBS<140mg/dl] had significantly lower D-dimers plasma concentrations and non significantly less CCA-IMT than those with poor blood sugar control [FBS>140mg/dl]. suggesting that control of hyperglycaemia reduce haemostatic activation significantly. It is concluded that type 2 diabetic subjects without clinical CAD.cerebrovascular or peripheral vascular diseases, have a higher degree of atherosclerosis than normal control. Also this atherosclerosis is associated with enhanced Fibrin deposition and degradation as evidenced by increased D-dimers plasma concentrations. The control of hyperglycaemia and dyslipidemia that accompanies diabetes, possibly reduce or even prevent the progression of intimal medial thickening and will reduce significantly the activation of haemostasis leading to reduction of CAD and stroke risk

Effect of ascorbic acid supplementation on sperm acrosin activity in cigarette smokers

Thirty heavy smoking men randomly divided into one of two subgroups [each contained 15 men]. Each participant from the first subgroup of smokers took 1000-mg AA tablets daily for 4 weeks. For the same period, the second subgroup took placebo tablets, serving as a negative control Another fifteen of the non-smokers participated also as a separate group and took 1000-mg tablets of AA/day, serving as a positive control. Semen analyses of all were normal. Acrosin activity of sperms by gelatin substrate film technique was surveyed. Serum and seminal plasma ascorbic acid levels were measured and expressed as mg/dL. Statistically significant increases in the acrosin activity and ascorbic acid levels in the treated subgroup were observed weekly. After the 4 weeks of supplementation, no significant difference was detected between the treated subgroup and nonsmokers. However, no significant weekly changes were observed in the nonsmokers or the placebo subgroup. The increases in AA levels and acrosin activity in the treated smokers indicate that increased ascorbic acid bioavailability was associated with the pronounced improvement in sperm acrosin activity. This useful effect of AA supplementation on acrosin activity may be due to its reductive properties nullifying the possible injurious effects of the reactive oxidants of nicotine or nicotine metabolites

Prognostic significance of some immunological parameters in wheezy baby syndrome

This study was carried on 40 infants [with age range from 6 - 20 months] suffering from wheezy chest [group 1] to evaluate some risky factors as predictive parameters for developing future asthma in these infants and to assess the value of two different lines of treatment. Twenty apparently normal infants were included in the study as control group [group 2]. Results showed that serum IgE was significantly high in group 1 before treatment [p < 0.05], IgG and complement fraction [C1q] showed no significant difference from the control [P > 0.05]. Absolute Eosinophilic Count [ABE] and Migration Inhibition Factor [MIF] were significantly high in group 1 [P < 0.05]. Treatment with Sodium Chromoglycate improved the condition better than treatment with Dexamthasone, however total IgE, ABE count and MIF were still higher in patients than normal even after one year follow up. These results suggest that risky factors are useful parameters for assessing wheezy infants and have a predictive value for developing future asthma. Unresponsiveness to treatment could be attributed to genetic factors or other positive family history

Thromboxane biosynthesis and platelet function in type II diabetes mellitus

It has been suggested that platelet hyper-reactivity in patients with diabetes mellitus [D.M.] is associated with increased platelet production of thromboxane. We therefore compared the excretion of thromboxane metabolite and platelet function in 30 patients with diabetes mellitus who had normal renal function and 18 healthy controls. The mean [ +/- SD] excretion rate of urinary 11-dehydro-thromboxane B2 was siginifcantly higher than in the controls [p<0.00/]. Aspirin in low doses [50 mg per day for 7 daye] reduced urinary excretion of the metabolite by approximately 80% in four patients. We concluded that in type l/ diabetes that [i], increased 11-dehydtro-thromboxane B2 excretion reflects enhanced biosynthesis of thromboxane A2 by platelets rather than a shift in its metabolic disposition [ii]. This is likely to reflect in Vivo platelet activation. [iii]. Improved metabolic control as well as low doses aspirin therapy may correct these abnormality in platelet function to a variable extent

Assessment of some treatment of head and neck hemangiomas

Forty three cases of head and neck haemangiomas were treated at otorhinolaryngology and General Surgery Departments in Mansoura University Hospital during the period of 1988 to 1991. They were 23 cases of cutaneous haemangiomas, 14 cases lip haemangiomas and 6 cases oropharyngeal haemangiomas. The adopted modalities of treatment were discussed including surgery, injection sclero therapy using ethanolamine, and intra-lesional steroid injection. Ethanolamine and intra-lesional steroid injection are capable of producing a satisfactory therapeutic effect and should be tried as the first line of treatment in head and neck haemangiomas

Underlay allograft myringoplasty

Temporalis fascia, taken from other patients during tympanoplasties, was used as allograft for closure of dry central small and medium sized [7 x 7 mm or less] tympanic membrane perforations via a transcanal underlay technique. Fifty-eight myringoplasties were done under local anesthesia except for three received general anesthesia. Assessment of outcome was judged by two criteria; graft take and hearing gain. Forty-six were successful with total graft take, while twelve failed with a partial take in 15.52% and total no take in 5.17%. No significant influence of sex, age, duration of perforation and discharge free period was found. There was inverse linear relationship between perforation size and success rate. Posterior and central perforations showed better success rates than anterior perforations. Improvement air conduction thresholds was achieved in 69.57% of successful myringoplasties with closure of air-bone gap within 10 dB in 52%. Postoperative bone conduction thresholds were slightly altered

Bacterial isolates and efficacy of antibiotics in acute otitis media in children

This research was done for study of bacterial isolates and efficacy of the antibiotics, amoxicillin, calvulanate amoxicillin and cefaclor, in AOM in children. 148 children with AOM were randomly assigned to receive a 10 day course of either treatment regimen. Aspiration of middle ear fluid for culture was done initially and repeated during treatment if fluid persisted. Bacterial isolates in initial aspirates were S. pneumonia [42%], H. influenzae[34%], S. pyogenes [9%], B. catarrhalis[6%], Staph. Aureus [5%] and nonpathogens [7%]. Isolated main strains were susceptible to the study antibiotics except 24% of isolates of H. influenzae, 67% of B. catarrhalis and 71% of Staph. Aureus were resistant to amoxicillin. Clinical responses were assessed at 3 and 10 days and 4 weeks later. On day 10 patients were either cured or unresolved with either drainage or persistent effusion. The cure rates were 71% for amoxicillin, 88% for clavulanate amoxicillin and 81% for cefaclor. However, the differences are not statistically significant. Recurrences during 4 weeks after treatment occurred in 15 children, 7 in amoxicillin, 3 antibiotics. While, in those with H. influenzae, cure rates were 60% for amoxicillin and 76% for cefaclor. Favorable clinical results were obtained with clavulanate amoxicillin and cefaclor as compared with amoxicillin, mainly in cases with H, Influenzae, B. catarrhalis and Staph. Aureus. This relates to amoxicillin resistant strains. Therefore, it would be prudent to consider them in the event of treatment failure and persistent effusion after amoxyclillin treatment or as initial therapy

Antibiotic concentrations in middle ear effusions

Concentrations of amoxicillin, clavulanate amoxicillin and cefaclor, were determined in middle ear fluid in 106 children with otitis media with effusion after the administration of single oral dose. One to four hours after administration, tympanocentesis was done and middle ear fluid and venous blood specimens were obtained. Concentrations of antibiotic in both specimens were determined with microbiological assays by disk diffusion method. The peak concentrations of amoxicillin and clavulanate amoxicillin in middle ear fluid were detected three hours after administration and one hour after their peak in serum, while that of cefaclor was detected after one hour and simultaneously with its peak in serum. Both clavulanate amoxicillin and cefaclor penetrated readily into middle ear fluid in concentrations greater than minimal inhibitory concentration for S. pneumonia, amoxicillin sensitive and resistant H. influenzae and S. pyogenes. Amoxycillin penetrated in concentrations greater than MICS for these pathogens except for resistant H. influenzae. So clavulanate amoxicillin or cefaclor can be considered either as reasonazble choice to amoxicillin for treatment of acute otitis media or as alternative antibiotics for treatment failure with amoxicillin due to resistant strains of H. influenzae