Conscious sedation for the management of peritonsillar abscess in pediatric patients: A prospective case series and literature review.

OBJECTIVE: Peritonsillar abscess (PTA) is a common pediatric infection requiring drainage. Conscious Sedation (CS) can facilitate drainage in uncooperative children. However, it carries risks, especially if the airway is compromised. Moreover, evidence on its safety and efficacy is limited. This study examined the safety, pain reduction, and anxiety management of hospitalized pediatric patients treated for PTA under CS. MATERIALS AND METHODS: We performed a prospective observational case series of 118 children aged 2-15 years with 155 PTA episodes, managed from 2016 to 2023. Conscious sedation was used in 42 episodes. Outcomes were compared among CS and non-CS (local anesthesia only). Complications assessed safety. Efficacy was evaluated by the amount of pus, hospitalization parameters, pain scores, and recurrence. RESULTS: No significant differences were found regarding the demographic and presentation parameters except for younger age among the CS group (9 vs 11 years p = 0.001). One minor oxygen desaturation (2 %) event occurred with CS. Abscess drainage amount was greater with CS than non-CS, 4.9±4 mL vs. 3.2±2 mL, respectively (p = 0.03). Hospitalization stays were similar among groups. Maximum pain scores were lower with CS than non-CS, 1.4 ± 2 vs 4.2 ± 3 (p < 0.001); similarly, IV pain medication was used less frequently, 0.9 ± 1 vs. 1.6 ± 3 (p = 0.045), and the need for re-aspiration was less common 14 % vs. 28 % (p = 0.04), with CS than non-CS, respectively. The three-month recurrence rate was numerically lower with CS (5 % vs. 14 % non-CS). CONCLUSIONS: Conscious sedation facilitates PTA drainage with excellent safety and improved efficacy compared to local anesthesia in children. Pain scores are reduced both during drainage and hospitalization. Our prospective data add to the limited evidence supporting CS as a viable option for abscess drainage in uncooperative pediatric patients. Further study is warranted to confirm potential long-term reductions in recurrence.

Pediatric Epistaxis-Effectiveness of Conservative Management.

OBJECTIVES: Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management. METHODS: This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018. RESULTS: Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population. CONCLUSIONS: Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

Assessing the Accuracy of Systolic Aortic Pressure Estimation From a Brachial Cuff Alone: A Comparison With Radial Tonometry.

BACKGROUND: A novel method for estimating central systolic aortic pressure (cSAP) has emerged, relying solely on the peripheral mean (MBP) and diastolic (DBP) blood pressures. We aimed to assess the accuracy of this Direct Central Blood Pressure estimation using cuff alone (DCBPcuff = MBP2/DBP) in comparison to the use of a generalized transfer function to derive cSAP from radial tonometry (cSAPtono). METHODS: This retrospective analysis involved the International Database of Central Arterial Properties for Risk Stratification (IDCARS) data (Aparicio et al., Am J Hypertens 2022). The dataset encompassed 10,930 subjects from 13 longitudinal cohort studies worldwide (54.8% women; median age 46.0 years; office hypertension: 40.1%; treated: 61.0%), documenting cSAPtono via SphygmoCor calibrated against brachial systolic BP (SBP) and DBP. Our analysis focused on aggregate group data from 12/13 studies (89% patients) where a full BP dataset was available. A 35% form factor was used to estimate MBP = (DBP + (0.35 × (SBP-DBP)), from which DCBPcuff was derived. The predefined acceptable error for cSAPtono estimation was set at ≤ 5 mm Hg. RESULTS: The cSAPtono values ranged from 103.8-127.0 mm Hg (n = 12). The error between DCBPcuff and cSAPtono was 0.2 ±â€…1.4 mm Hg, with no influence of the mean. Errors ranged from -1.8 to 2.9 mm Hg across studies. No significant difference in errors was observed between BP measurements obtained via oscillometry (n = 9) vs. auscultation (n = 3) (P = 0.50). CONCLUSIONS: Using published aggregate group data and a 35% form factor, DCBPcuff demonstrated remarkable accuracy in estimating cSAPtono, regardless of the BP measurement technique. However, given that individual BP values were unavailable, further documentation is required to establish DCBPcuff's precision.

The management of acute supraglottitis patients at the intensive care unit.

INTRODUCTION: Acute supraglottitis is a potentially life-threatening condition that often necessitates intensive care unit (ICU) admission for airway monitoring. The objective of this study was to identify clinical criteria that predict a benign course for patients with acute supraglottitis. METHODS: A prospective observational study was performed. Adult patients hospitalized in the ICU between 2007 and 2019 diagnosed with acute supraglottitis were included. All patients were treated with antibiotics and corticosteroids. Fiber optic laryngoscopy (FOL) was performed every 12 h, with each exam defined as "improving", "no change" or "deteriorating" based on the presence of airway edema. Need for airway intervention was correlated to changes in the FOL exam. RESULTS: Of 146 patients included, 14 (10%) required intubation, ten on admission, and four during the first 6 h of ICU admission. FOL follow-up was performed on 528 occasions-427 (81%) exams showed improvement, 16 (3%) deterioration, and 85 (16%) with no change. On no occasions was improvement in FOL followed by deterioration. The median ICU length of stay was 3 (IQR 2-3.5) vs. 1 (IQR 1.0-1.25) day for patients who did or did not require intubation (p < 0.001), respectively. CONCLUSION: Improvement in FOL exam accurately predicted the absence of need for intubation and might represent a criterion for early ICU discharge.

The isobaric pulmonary arterial compliance in pulmonary hypertension.

Pulmonary hypertension is associated with stiffening of pulmonary arteries which increases right ventricular pulsatile loading. High pulmonary artery wedge pressure (PAWP) in postcapillary pulmonary hypertension (Pc-PH) further decreases pulmonary arterial compliance (PAC) at a given pulmonary vascular resistance (PVR) compared with precapillary pulmonary hypertension, thus responsible for a higher total arterial load. In all other vascular beds, arterial compliance is considered as mainly determined by the distending pressure, due to non-linear stress-strain behaviour of arteries. We tested the applicability, advantages and drawbacks of two comparison methods of PAC depending on the level of mean pulmonary arterial pressure (mPAP; isobaric PAC) or PVR. Right heart catheterisation data including PAC (stroke volume/pulse pressure) were obtained in 112 Pc-PH (of whom 61 had combined postcapillary and precapillary pulmonary hypertension) and 719 idiopathic pulmonary arterial hypertension (iPAH). PAC could be compared over the same mPAP range (25-66 mmHg) in 792 (95.3%) out of 831 patients and over the same PVR range (3-10.7 WU) in only 520 (62.6%) out of 831 patients. The main assumption underlying comparisons at a given PVR was not verified as the PVR×PAC product (RC-time) was not constant but on the contrary more variable than mPAP. In the 788/831 (94.8%) patients studied over the same PAC range (0.62-6.5 mL·mmHg-1), PVR and thus total arterial load tended to be higher in iPAH. Our study favours comparing PAC at fixed mPAP level (isobaric PAC) rather than at fixed PVR. A reappraisal of the effects of PAWP on the pulsatile and total arterial load put on the right heart is needed, and this point deserves further studies.

Supraglottoplasty for severe laryngomalacia. Can we predict success?

OBJECTIVES: Laryngomalacia is the dynamic collapse of supraglottic structures during inspiration, leading to a variable degree of airway obstruction. Clinical symptoms appear in the first months of life and are usually mild and resolve by the age of 12-18 months. In severe cases, surgical intervention may be considered. The goal of the study was to review the clinical outcome of pediatric patients who underwent supraglottoplasty for laryngomalacia. MATERIAL AND METHODS: Clinical and demographic data were retrieved from medical records of children diagnosed with laryngomalacia by laryngo-bronchoscopy between 2013 and 2019. Indications, outcome and long-term follow-up were collected from children undergoing surgery. RESULTS: During the study period, 115 children were diagnosed with laryngomalacia. The median age at diagnosis was 3 months. Synchronous airway lesions were diagnosed in 20% of patients. Ten (8.7%) children underwent surgical treatment because of significant respiratory symptoms and/or failure to thrive. Three of them had comorbidities. All otherwise healthy children had significant respiratory and nutritional improvement after surgery while those with comorbidities had less successful outcomes. CONCLUSION: We conclude that in severe cases of laryngomalacia, supraglottoplasty has an important role to play in management. In children with comorbidities, the surgical results may be less successful. Therefore, we recommend that the decision to operate should be individualized, ensuring full disclosure to the family regarding the probable benefit along with the limitations of surgery.

Nasal blowing induces subcutaneous emphysema post penetrating mastoid tip trauma.

We describe the case of a child with an isolated penetrating trauma to the mastoid tip. Nasal blowing consequently induced air bubbles coming through the mastoid cutaneous fistula and causing extensive subcutaneous neck emphysema. A computed tomography (CT) demonstrated a right mastoid tip bone fracture with extensive cervical subcutaneous emphysema. The patient was treated conservatively with antibiotics and did not require operative intervention. His subsequent course was uncomplicated. This case emphasizes the importance of taking seriously even what seems to be a minor skin laceration.

Golden Ratio and the Proportionality Between Pulmonary Pressure Components in Pulmonary Arterial Hypertension.

BACKGROUND: The golden ratio (phi, Φ = 1.618) is a proportion that has been found in many phenomena in nature, including the cardiovascular field. We tested the hypothesis that the systolic over mean pulmonary artery pressure ratio (sPAP/mPAP) and the mean over diastolic pressure ratio (mPAP/dPAP) may match Φ in patients with pulmonary arterial hypertension (PAH) and in control patients. METHODS: In the first, theoretical part of the study, we discuss why our hypothesis is consistent with three known hemodynamic features of the pulmonary circulation: (1) the 0.61 slope of the mPAP vs sPAP relationship, (2) pulmonary artery pulse pressure and mPAP have an almost 1:1 ratio, and (3) the proportional relationship among sPAP, mPAP, and dPAP. In the second part of the study, fluid-filled pressures were analyzed in 981 incident, untreated PAH and high-fidelity pressures were also analyzed in 44 historical control patients (mPAP range, 9-113 mm Hg). RESULTS: In PAH (non-normal distribution), median values of sPAP/mPAP and mPAP/dPAP were 1.591 (98%Φ) and 1.559 (96%Φ), respectively. In control patients (normal distribution), mean sPAP/mPAP and mPAP/dPAP were 1.572 (97%Φ) and 1.470 (91%Φ), respectively. In both PAH and control patients, this was consistent with the Φ hypothesis, assuming < 1 mm Hg error in estimation of sPAP, mPAP, and dPAP on average. CONCLUSIONS: In PAH and in control patients, the fluctuations in sPAP and dPAP around mPAP exhibited a constant scaling factor matched to Φ. This remarkable property allows linkage of various empirical observations on pulmonary hemodynamics that were hitherto apparently unrelated. These findings warrant further confirmation in other types of pulmonary hypertension and warrant explanation.

Clinical and Hemodynamic Correlates of Pulmonary Arterial Stiffness in Incident, Untreated Patients With Idiopathic Pulmonary Arterial Hypertension.

BACKGROUND: The role of decreased pulmonary arterial (PA) compliance (C), equivalent to increased PA stiffness (1/C), as a critical determinant of right ventricular dysfunction and prognosis has been emphasized in pulmonary arterial hypertension (PAH). METHODS: This study retrospectively reviewed all incident patients diagnosed with idiopathic PAH according to right heart catheterization who were enrolled in the French Pulmonary Arterial Hypertension Network registry between 2006 and 2016 and who had complete baseline data allowing calculation of stiffness (PA pulse pressure/stroke volume index). RESULTS: In the 719 patients included (median age: 66 years; 53.7% female), PA stiffness was 1.49 mm Hg × m2/mL (interquartile ratio: 1.08-2.04 mm Hg × m2/mL). Stiffness was related to mean pulmonary artery pressure (mPAP) (r2 = 0.33) and heart rate (r2 = 0.15) but not to age or sex. Higher PA stiffness and higher pulmonary vascular resistance (PVR) were documented in high-risk vs low-risk patients, as defined according to the European Society of Cardiology/European Respiratory Society guidelines. The dispersion of the PVR × C product was as variable as patient age and mPAP, and C could not be estimated on the basis of PVR alone (95% limits of agreement of the bias: -50% to 54%). Although transplant-free survival differed across PA stiffness quartiles (P = .04), stiffness was not an independent predictor of long-term outcome (median follow-up duration: 2.43 years). CONCLUSIONS: In incident idiopathic PAH, PA stiffness was related to mPAP and heart rate, and this finding outperformed the potential influences of age and sex. Baseline PA stiffness did not independently predict outcome. The great dispersion of the PVR × C product implied that PVR and PA stiffness were differently affected by the disease process.

Influence of critical closing pressure on systemic vascular resistance and total arterial compliance: A clinical invasive study.

BACKGROUND: Systemic vascular resistance (SVR) and total arterial compliance (TAC) modulate systemic arterial load, and their product is the time constant (Tau) of the Windkessel. Previous studies have assumed that aortic pressure decays towards a pressure asymptote (P∞) close to 0mmHg, as right atrial pressure is considered the outflow pressure. Using these assumptions, aortic Tau values of ∼1.5seconds have been documented. However, a zero P∞ may not be physiological because of the high critical closing pressure previously documented in vivo. AIMS: To calculate precisely the Tau and P∞ of the Windkessel, and to determine the implications for the indices of systemic arterial load. METHODS: Aortic pressure decay was analysed using high-fidelity recordings in 16 subjects. Tau was calculated assuming P∞=0mmHg, and by two methods that make no assumptions regarding P∞ (the derivative and best-fit methods). RESULTS: Assuming P∞=0mmHg, we documented a Tau value of 1372±308ms, with only 29% of Windkessel function manifested by end-diastole. In contrast, Tau values of 306±109 and 353±106ms were found from the derivative and best-fit methods, with P∞ values of 75±12 and 71±12mmHg, and with ∼80% completion of Windkessel function. The "effective" resistance and compliance were ∼70% and ∼40% less than SVR and TAC (area method), respectively. CONCLUSION: We did not challenge the Windkessel model, but rather the estimation technique of model variables (Tau, SVR, TAC) that assumes P∞=0. The study favoured a shorter Tau of the Windkessel and a higher P∞ compared with previous studies. This calls for a reappraisal of the quantification of systemic arterial load.

Starplasty tracheostomy: case series and literature review.

OBJECTIVES: The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center. METHODS: A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012. RESULTS: Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred. CONCLUSIONS: In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

Bipolar tonsillotomy: A novel and effective tonsillotomy technique.

OBJECTIVE: To present, for the first time, tonsil size reduction using reusable bipolar forceps electrocautery (RBFE), as a treatment for pediatric OSAS and to assess the safety and efficacy of the procedure. METHODS: A prospective interventional design study was performed. Thirty children aged 2-15 years with OSAS (AHI>5) diagnosed by means of polysomnography were included. All children were treated with adenoidectomy and RBFE tonsillotomy without dissection. Re-polysomnography was performed after 1 year. The size of the tonsils was blindly assessed by two ENT specialists and the parents were asked to fill out 'Pediatric Sleep Questionnaires' (PSQ), before surgery, and one month and one year after surgery. RESULTS: There were no complications during or after surgery. There were no events involving postoperative bleeding or dehydration. The surgery mean time, including adenoidectomy, was 20.6min. The AHI was 10.9 before surgery and decreased to 1.8 after surgery (p<0.001), minimum saturation (SaO2 min) increased from 86.1% to 93.2% (p<0.001). The size of the tonsils decreased from a mean of +3.3 before surgery to +1.3 and +1.4 one month and one year after surgery, respectively. The mean of the PSQ scores went down from 23.6 to 5.5 and to 6.2 one month and one year after surgery, respectively. CONCLUSION: We demonstrated that simple cauterization of the tonsils using a RBFE device with an adenoidectomy is a safe and effective treatment to decrease tonsil size in OSAS. In addition, the method is inexpensive, rapid and does not cause bleeding, which may be particularly interesting in the presence of coagulation problems.

Pulmonary vascular resistance and compliance relationship in pulmonary hypertension.

Right ventricular adaptation to the increased pulmonary arterial load is a key determinant of outcomes in pulmonary hypertension (PH). Pulmonary vascular resistance (PVR) and total arterial compliance (C) quantify resistive and elastic properties of pulmonary arteries that modulate the steady and pulsatile components of pulmonary arterial load, respectively. PVR is commonly calculated as transpulmonary pressure gradient over pulmonary flow and total arterial compliance as stroke volume over pulmonary arterial pulse pressure (SV/PApp). Assuming that there is an inverse, hyperbolic relationship between PVR and C, recent studies have popularised the concept that their product (RC-time of the pulmonary circulation, in seconds) is "constant" in health and diseases. However, emerging evidence suggests that this concept should be challenged, with shortened RC-times documented in post-capillary PH and normotensive subjects. Furthermore, reported RC-times in the literature have consistently demonstrated significant scatter around the mean. In precapillary PH, the true PVR can be overestimated if one uses the standard PVR equation because the zero-flow pressure may be significantly higher than pulmonary arterial wedge pressure. Furthermore, SV/PApp may also overestimate true C. Further studies are needed to clarify some of the inconsistencies of pulmonary RC-time, as this has major implications for our understanding of the arterial load in diseases of the pulmonary circulation.

Impact of successful treatment of acromegaly on overnight heart rate variability and sleep apnea.

BACKGROUND: Successful treatment of acromegaly improves disease-related cardiovascular mortality and morbidity, but its effects on autonomic modulation of the heart rate are unknown. OBJECTIVES: We documented treatment-induced changes in time-domain heart rate variability, taking into account the confounding effects of obstructive sleep apnea. PATIENTS AND METHODS: Sixteen consecutive patients (12 males, aged 43 ± 12 y) with newly diagnosed acromegaly underwent overnight (12:00-7:00 am) cardiac Holter recordings coupled with polysomnography. Data were obtained before and 10 ± 6 months after successful treatment of acromegaly. RESULTS: IGF-1 levels fell from 807 ± 333 to 207 ± 69 µg/L and normalized in all patients. Seven patients (44%) had obstructive sleep apnea (apnea-hypopnea index 33 ± 21/h) at baseline. Treatment had no significant effect on polysomnographic indices. After treatment, increases were noted in the normal-to-normal heart period (NN), SD-NN, the percentage of NN differing from the previous NN by greater than 50 msec, and the root mean square of successive differences in NN (each P < .05). These heart rate variability results were not influenced by the type of treatment, and there was no relationship between changes in NN and changes in the apnea-hypopnea index (P = .58). CONCLUSION: Early after successful treatment of acromegaly, we observed increased parasympathetic modulation/decreased sympathetic modulation of the nighttime heart rate, an effect that seems unrelated to changes in sleep apnea status. Treatments aimed at normalizing IGF-1 may improve cardiovascular homeostasis through improved cardiac autonomic nervous system modulation.

Endocrine aspects of obstructive sleep apnea.

CONTEXT: Some endocrine and metabolic disorders are associated with a high frequency of obstructive sleep apnea (OSA), and treatment of the underlying endocrine disorder can improve and occasionally cure OSA. On the other hand, epidemiological and interventional studies suggest that OSA increases the cardiovascular risk, and a link between OSA and glucose metabolism has been suggested, via reduced sleep duration and/or quality. EVIDENCE ACQUISITION: We reviewed the medical literature for key articles through June 2009. EVIDENCE SYNTHESIS: Some endocrine and metabolic conditions (obesity, acromegaly, hypothyroidism, polycystic ovary disease, etc.) can be associated with OSA. The pathophysiological mechanisms of OSA in these cases are reviewed. In rare instances, OSA may be improved or even cured by treatment of underlying endocrine disorders: this is the case of hypothyroidism and acromegaly, situations in which OSA is mainly related to upper airways narrowing due to reversible thickening of the pharyngeal walls. However, when irreversible skeletal defects and/or obesity are present, OSA may persist despite treatment of endocrine disorders and may thus require complementary therapy. This is also frequently the case in patients with obesity, even after substantial weight reduction. CONCLUSIONS: Given the potential neurocognitive consequences and increased cardiovascular risk associated with OSA, specific therapy such as continuous positive airway pressure is recommended if OSA persists despite effective treatment of its potential endocrine and metabolic causes. "Apropos of sleep, that sinister adventure of all our nights, we might say that men go to bed daily with an audacity that would be incomprehensible if we did not know that it is the result of ignorance of the danger." Charles Baudelaire, in "Fusées, IX"

A phenotypic and functional characterization of NK cells in adenoids.

Adenoids are part of the MALT. In the present study, we analyzed cell surface markers and cytolytic activity of adenoidal NK (A-NK) cells and compared them with NK cells derived from blood of the same donors (B-NK). NK cells comprised 0.67% (0.4-1.2%) of the total lymphoid population isolated from adenoids. The majority (median=92%) of the A-NK cells was CD56(bright)CD16(-). A-NK cells were characterized by the increased expression of activation-induced receptors. NKp44 was detected on >60%, CD25 on >40%, and HLA-DR on >50% of freshly isolated A-NK cells. Functional assays indicated that the cytotoxic machinery of A-NK is intact, and sensitive target cells are killed via natural cytotoxicity receptors, such as NKG2D. Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1; CD66) expression was up-regulated in 23% (median) of the A-NK cells by IL-2 activation but unchanged in B-NK cells. CEACAM1 inhibited the A-NK killing of target cells. CXCR4 was expressed on more than 40% A-NK cells prior to activation. Its ligand, CXCL12, was found in endothelial cells of the capillaries within the adenoid and in cells of the epithelial lining. In addition, A-NK cells migrated in vitro toward a gradient of CXCL12 in a dose-responsive manner, suggesting a role for this chemokine in A-NK cell recruitment and trafficking. We conclude that the A-NK cells are unique in that they display an activated-like phenotype and are different from their CD16(-) B-NK cell counterparts. This phenotype presumably reflects the chronic interaction of A-NK cells with antigens penetrating the body through the nasal route.

Redefining parapharyngeal space infections.

OBJECTIVES: Our intent was to review the clinical signs, computed tomography (CT) scans, treatment, and outcome of parapharyngeal space infections (PPIs), and to define 2 types of infections of the parapharyngeal space (PPS) according to the location of the infectious process. METHODS: We performed a retrospective analysis of patients hospitalized in a tertiary university hospital with a diagnosis of PPI, abscess, or deep neck abscess between 1988 and 2004. Files and CT scans were reviewed after classification into 2 groups: 1) infection located in the posterior part of the PPS (PostPPI); and 2) infection located in the anterior part of the PPS (AntPPI). RESULTS: Twenty-two patients had a PostPPI; their ages ranged from 10 months to 24 years. Five patients underwent surgical drainage, and 17 others were treated solely with intravenous antibiotic therapy. No pus was found during surgery in 2 patients. The average time of hospitalization was 10 days. Only 1 complication (aspiration pneumonia) was observed. Seven patients had an AntPPI; their ages ranged from 1.5 years to 65 years. All patients underwent surgical drainage, and pus was detected in all cases. The average time of hospitalization was 35 days. Complications (septic shock, respiratory arrest, mediastinitis, pleural empyema, pericarditis) were observed in 4 patients. CONCLUSIONS: The term "parapharyngeal abscess" was assigned long before the CT scan era, and was based on physical examination and plain film radiology. In essence, the entity PPS "abscess" or "infection" is composed of 2 different disorders. Infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and with no extension into other cervical spaces except the adjacent retropharyngeal space may be termed posterior parapharyngeal infection or parapharyngeal lymphadenitis. This is a relatively benign condition, and nonsurgical treatment should be considered. Infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. Urgent surgical drainage is therefore mandatory.

Schwannoma of the external auditory canal.

Schwannomas are uncommon tumors of the external auditory canal. In the English literature, very few cases of schwannomas originating in the external auditory canal were reported. In this report, we described a 44-year-old patient who presented with external auditory canal mass which was managed by local excision. The clinical and histologic features, the differential diagnosis, and the treatment of external auditory canal schwannoma is discussed.