Pediatric sinusitis:symptom profiles with associated atopic conditions.

INTRODUCTION: Sinusitis is a very common disease in childhood. Clinical manifestations in childhood sinusitis are different than in adult. Information in childhood sinusitis in Thailand is limited. We performed a prospective descriptive study to determine clinical characteristics of childhood sinusitis in Thailand MATERIAL AND METHOD: One hundred pediatric patients with clinical diagnosis of sinusitis attending pediatric allergy clinic, pediatric outpatient clinic, and pediatric ENT clinic were recruited. Clinical diagnosis was defined by presence of symptoms indicating upper respiratory infections with exudates at middle meatus by anterior rhinoscopy. Thorough history taking and physical examinations were conducted with findings recording into sinusitis questionnaire. Sinus radiographs were taken in 77 patients and were read blindly a single radiologist who was unaware of clinical conditions of patients. Allergy skin prick tests were performed with a panel of common aeroallergens in Thailand. RESULTS: Age range of the 100 patients were between 1.7 to 12.4 years with a mean (+/- SD) of 6 +/- 2.72 years. History of atopic disease among patients and their families was positive in 49% and 47% respectively. Four most common clinical manifestations were rhinorrhea (95%), nocturnal and productive cough (91%), nasal congestion (74%) and posterior nasal dripping (66%). The three most common signs were obstruction of middle meatus (100%), swelling of turbinates (92%) and granular pharynx (48%). All paranasal sinuses X-rays were abnormal with maxillary sinus being the most commonly involved sinus (99%) followed by ethmoid sinus (91%). The majority of patients had involvement of more than one sinus. Skin prick tests were positive in 53.6%. The two most common sensitizing allergens were dust mites (57.7) and cockroaches (18.6%). CONCLUSION: The presence of symptoms of rhinorrhea, cough, nasal congestion and posterior nasal drip should alert physicians for diagnosis of sinusitis in pediatric patients. Maxillary and ethmoid sinus were the most common sinuses involved. Atopic predisposition is present in up to 53.6% in this population.

Slide tracheoplasty with pericardial patch augmentation for reconstruction of severe congenital tracheal stenosis involving carina : A case report.

Objective: Slide tracheoplasty seems to be the most efficient surgical procedure for correcting long-segment funnel-shaped congenital tracheal stenosis. However, in cases of extremely long-segment or those involve carina, slide tracheoplasty when operated alone has certain degree of limitations which often need additional operative procedure. The authors report a technique of slide tracheoplasty in combination with pericardial patch augmentation in a child with congenital tracheal stenosis involving the carina. Methods: A 3-month-old girl, previously diagnosed with Tetralogy of Fallot and congenital tracheal stenosis, presented with severe cyanosis and serious major airway obstruction after a few days of upper respiratory tract infection (URI). Because of the failure to maintain her ventilation with a high positive pressure ventilator, an emergency slide tracheoplasty with a modified right Blalock’s Taussig shunt was performed under a cardiopulmonary bypass. The intraoperative finding revealed a complete tracheal ring stenosis involving the lower half of the trachea and carina. It was transected at the middle and a vertical incision was made at the posterior wall of the upper trachea and anterior wall of the lower and extended into orifices of the main bronchus. The upper and lower tracheal flaps were slid together and sutured with interrupted Proline 5-0. Consequently, she still had significant obstruction of the main bronchi postoperatively and needed a re-operation two days later. Under cardiopulmonary bypass support, the lower anastomotic sutures were removed and an additional bronchial incision was made into the main bronchus. The anterior upper tracheal flap was separated into two, and each equal flap was pulled down and sutured to the main bronchus. Then an autologous pericardial patch was used to cover all the airway defects. Intraoperative fiberoptic bronchoscopy demonstrated adequate tracheo-bronchial lumen. Results: The child had postoperative hyperactive airway reaction and needed prolonged ventilator support and tracheostomy for tracheal toileting. Repeated postoperative bronchoscopy found moderated granulation tissue which was easily removed by catheter suction. Unfortunately, the patient expired six months after the surgery due to uncontrolled sepsis. However, a bronchoscopic finding before the patient’s death revealed adequate major airway patency. Conclusion: Combined slide tracheoplasty with pericardial patch augmentation made reconstruction of the complex congenital tracheal stenosis involving carina or tracheal bronchus possible and minimized the result of unflavoric excessive granulation tissue forming caused by pericardial tracheoplasty alone.

Development of a health-related quality of life questionnaire for Thai patients with rhinoconjunctivitis.

The objective of this study was to develop a disease-specific questionnaire for patients with rhinoconjunctivitis. All patients were recruited at the Out-Patient Clinic at Siriraj Hospital. Related topics were gathered from several sources, and a list of 63 items was produced. In phase I, the first version of the questionnaire was completed by 363 patients. Forty-eight items were identified by clinical impact analysis during the item removal process, two more questions were then added, giving a total of 50. Two hundred and forty-three patients completed the second version questionnaire in phase II. The average time taken to complete the questionnaire was 6.38 minutes. The item removal process in phase II was achieved by a multi-step process. There were 36 items in the third version questionnaire which consisted of six dimensions and two independent items as follows: symptoms (17 items), physical functioning (3 items), role limitations (3 items), sleep (3 items), social functioning (3 items), emotions (5 items), general health (1 item), and absenteeism (1 item). The scores of each item ranged from 1 to 5; a lower score indicating a better quality of life. Data from the selected 36 items was extracted to test the validity and reliability of the final version. The floor and ceiling effects of the scores for each dimension were low. Multitrait multi-item analysis was conducted to examine construct validity. The scaling success of convergent and divergent validity was 100% and 94%, respectively. Internal consistency determined by Cronbach's alpha coefficient, was satisfactory (0.79-0.87). The study indicates that the questionnaire is suitable for use in clinical settings. While the test results are encouraging, further work needs to be done on the test-retest reliability and on responsiveness.

Otitis media in cleft palate children: A prospective survey.

Children with cleft palate and craniofacial anomalies are more prone to otitis media due to the anatomical defect of the cranial base and the eustachian tube. This prospective study was conducted in the cleft palate patients of the Craniomaxillofacial Clinic from January 2001 to April 2002. Pneumatic otoscopic examination was done monthly in every patient since they registered in the clinic for cleft palate correction. Thirty-eight children were included. Mean age was 21.4 + 33.7 months and 89.5% of the children were under 24 months old. Mean time for follow up was 150 + 132 days (mean + S.D.). Twenty-six patients (68.4%) had ear diseases at least once during the study period. Otitis media with effusion (OME) was the most common ear disease found in this series. Twenty-one percent of the patients had at least one episode of OME by the age of one and 47.5% of the patients had at least one episode of OME by the age of two. The incidence of OME was 3.85 per person per year. Acute otitis media and atelectatic ear drum were found with the incidence of 0.51 and 0.30 per person per year respectively. Tympanogram type B was found in 47.4% and type C was found in 10.5%. Periodical ear examination in cleft palate children is recommended for early detection of otitis media in order to prevent irreversible middle ear damage or hearing loss in the future.

Pediatric obstructive sleep apnea.

Obstructive sleep apnea in children is most commonly caused by adenotonsillar hypertrophy. Chronic longstanding hypoxia at night can lead to cardiovascular complications such as pulmonary hypertension and cor pulmonale. We reported a case of a four-year-old boy who had suffered from adenotonsillar hypertrophy and obstructive sleep disturbance for 3 years, resulting in right ventricular hypertrophy. Adenotonsillectomy was performed. Pre-operative awareness of potential omplications, good co-operation between pediatric cardiologist and pediatric anesthesiologist with post-operative monitoring in intensive care unit were essential for the success of surgical treatment.

Primary ciliary dyskinesia: A case presentation and A current review.

We present a 14 year-old girl with a history of chronic rhinorrhoea and nasal obstruction. Physical findings showed huge nasal polyp with broadening of the nasal bridge, perforation of the left ear drum and a right middle ear effusion. Despite a strict program of nasal saline toilet, broad-spectrum antibiotics covering beta-lactamase producing organisms, and meticulous technique of endoscopic sinus surgery, the patient's symptoms and nasal polyp reappeared very quickly. A set of investigations had been done in order to confirm and rule out suspected diseases. The electron microscopic study of the patient's nasal mucosa revealed partial absence of inner dynein arms and extra singlet at the center in some axoneme compatible with Primary ciliary dyskinesia.

Broncho-alveolar lavage: An aid to diagnosis in immuncompromised children with pulmonary lesion.

Conventional broncho-alveolar lavage with flexible bronchoscope has proven to be an effective method for the diagnosis of pulmonary lesions, especially in immunocompromised patients. The disadvantage of flexible endoscopy is that it can not be performed safely in pediatric patients with compromised airway due to the lack of ventilating channel. We designed an alternative method for broncho-alveolar lavage by target bronchus and secure the airway at the same time. We performed brocho-alveolar lavage via that method in 15 immunocompromised paediatric patients with signs and symptoms of pneumonia from December 1995 to September 1997. The group comprised eight males and seven females with a mean age of 30.35+24.60 months. Most of the patients had positive HIV titre (86.67 percent). Causative agents were identified in 11 of 15 patients (77.33 percent) Pneumocystis carinii was found in four cases (26.7 percent) followed by fungus (four cases, 26.7 percent), Mycobacterium tuber culosis (one cases, 6.7 percent) and Respiratory syncytial virus (one cases, 6.7 percent). No complications were reported. Compared to the literature control which gave an average yield of 45-84 percent, this technique of brocho-alveolar lavage was proven to be an effective, safe diagnostic method which gave satisfactory results.

Upper aerodigestive tract endoscopy during the first year of life: A current review.

A five-year retrospective review of 52 infants who underwent 67 endoscopic procedures of the upper aerodigestive tract was performed. The ages of the patients ranged from one day to one year with a mean of 157 days. The most common indication of endoscopy was stridor/respiratory distress (46.3 per cent) and persistent wheezing (16.4 per cent). Congenital anomalies were the causes of airway problems in more than half of the patients and laryngomalacia was the most common diagnosis (34.6 per cent), followed by congenital subglottic stenosis (7.6 per cent). There were 19.2 per cent of cases who had more than one airway lesion. Diagnosis was obtained from endoscopy in90.4 per cent of cases. There were two cases of gastroesophageal reflux (GER) diagnosed by nuclear scintigraphy. Therapeutic procedures during and after endoscopy were also reviewed. Only minor complications were found in three cases (4.5 per cent) (one bronchospasm, two subglottic oedema ). Endoscopy was found to be a safe, accurate diagnostic method which also offered useful therapeutic interventions.

Myiasis of the maxillary sinus caused by cochliomyia macellaria larvae and review of literature.

A case of myiasis of the maxillary sinus caused by Cochliomyia macellaria was reported in a seventy-four-year old Thai woman. She had a history of enucleation of her left eye because of endophthalmitis due to chronic maxillary sinusitis. She presented with painful facial swelling and purulent nasal discharge and was admitted. The patient was treated successfully with parenteral antibiotics to control associated bacterial infection, and Caldwell-Luc operation with removal of the maggots and antrostomy. Chronic sinusitis was considered to be a contributing factor to the myiasis of the paranasal sinus in the patient. Previously reported cases in Thailand are reviewed.

Deep neck infection from cervical osteomyelitis in an intravenous drug abuser: A case report.

Prevertebral space abscess in the cervical region is a rare deep neck infection. Tuberculosis of the spine used to be the most frequent cause. We report a case of a 33-years-old male with Staphylococcal cervical osteomyelitis as a cause of prevertebral abscess. The patient was an IV drug abuser with positive HIV. The skin was the most likely source of infection in this patient. Diagnosis was made by lateral neck x-rays which showed collapse of an intervertebral disk between C4 and C5 with destructive lesions of the body of the spines, along with an abnormal widening of the prevertebral soft tissue. Management of the prevertebral abscess was discussed and the literature was literature was reviewed. Appropriate management should include establishment of the airway, stabilization of the spine, antibiotics and incision and drainage by external approach.