Frequency of fimbriation of nontypable Haemophilus influenzae and its ability to adhere to chinchilla and human respiratory epithelium.

To date, we have examined nearly 60 clinical isolates of nontypable Haemophilus influenzae (26 nasopharyngeal, 33 from middle ear effusions) and have found that 100% were fimbriated. The percentage of cells bearing fimbriae within each isolate varied from less than 10 to 100%, with fimbriae being either peritrichous or bipolar in distribution. Fimbriae were approximately 2.4 to 3.6 nm in width; however, there was a high degree of variability in both length and number of fimbriae per individual bacterial cell among these isolates. All isolates tested adhered to both human oropharyngeal cells and chinchilla tracheal epithelium regardless of the degree to which the particular isolate was fimbriate. The level or degree of fimbriation did not correlate with either site of isolation, biotype, strength of hemagglutination reaction, or type of effusion present in the ear. These appendages appear to be quite different from those described for type b H. influenzae in which the ability to adhere and strength of ability to hemagglutinate correlated strongly with degree of fimbriation.

The movable stent in choanal atresia.

The purpose of this paper is to report our experience in the surgical management of choanal atresia. All of the patients in our series have been treated by endonasal puncture and application of a movable stent. Seventeen patients were operated on using this technique between July 1978 and January 1984. Eleven of the 17 were bilateral atresias and the remaining 6 were unilateral. All 17 cases were successfully treated using this technique. Based on our experience, we believe the key to successful repair of choanal atresia lies not in the method of opening the atretic plate, but in providing a stent that is movable and will thus reduce the occurrence of restenosis. At the same time, we propose a simple method of diagnosis.

Biotypes of serologically nontypable Haemophilus influenzae isolated from the middle ears and nasopharynges of patients with otitis media with effusion.

A biotype analysis was performed on serologically nontypable Haemophilus influenzae isolates from the middle ear effusions and nasopharynges of 33 children with chronic otitis media with effusion (serous otitis media). Over 50% of the H. influenzae isolates from the middle ears belonged to biotype II. The incidence of beta-lactamase production was 17%. The results of this study indicate that future clinical or experimental investigations of chronic otitis media with effusion induced by serologically nontypable H. influenzae should focus on this clinically important biotype.

Endotoxin in middle-ear effusions from patients with chronic otitis media with effusion.

Endotoxin concentrations were determined in middle-ear effusions (MEEs) from 89 children with chronic otitis media by using the Limulu's amoebocyte lysate assay. Mean concentrations of endotoxin in Haemophilus influenzae-positive and Streptococcus pneumoniae-positive MEEs were 157 and 21.8 ng/ml, respectively, and were significantly different (P less than 0.01). Endotoxin was also found in Gram stain-positive, culture-negative and Gram stain-negative, culture-negative MEEs, but the levels were not significantly different (P greater than 0.05). However, the endotoxin concentrations in both groups of culture-negative MEEs significantly lower than those found in MEEs that grew either H. influenzae or S. pneumoniae (P less than 0.05). These results show that endotoxin is present in a high percentage of human MEEs, including those that are culture negative, and may contribute to the pathogenesis of otitis media with effusion.

Esophageal burns secondary to disc battery ingestion.

Accidental ingestion and impaction of disc batteries in the esophagus has been a constant predictor of severe morbidity presumably due to leakage of highly caustic potassium or sodium hydroxide contained in these electric cells. Fewer than ten reports of esophageal burns from disc battery ingestion have appeared in the medical literature; an additional case involving ingestion of a mercury disc battery was recently encountered at the James Whitcomb Riley Hospital for Children, Indiana University School of Medicine. Two children died as a direct result of the impaction and resultant esophageal burn; six children experienced perforation of the esophagus, with four children developing tracheoesophageal fistulae. We report the ingestion of a 1.35-V mercury camera disc battery by a 10-month-old girl in whom a severe burn of the anterior midesophagus was noted 18 to 22 hours after impaction. The child subsequently developed a tracheoesophageal fistula and esophageal stricture at the site of the burn and required tracheotomy, closure of the fistula, partial esophagectomy and gastrostomy for eventual successful management. Stimulated by this experience, we have conducted an in vivo study of the time course and severity of esophageal burns resulting from alkaline and mercury battery ingestion in 15 cats. Mucosal damage can be seen as early as one hour after ingestion, rapidly progressing to involvement of all muscular layers by four hours. Removal of this foreign body should be assigned highest priority to prevent rapid development of these burns and the long-term sequelae mentioned above.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric caustic ingestion.

Accidental caustic ingestion in the pediatric age group continues to be a controversial and difficult problem. This retrospective study gives clinical support to treating this problem with early esophagoscopy, steroids, antibiotics and dilatation. Four hundred two patients were evaluated for possible caustic burn of the esophagus. Of the 70 patients who had esophageal burns demonstrated at esophagoscopy and who were treated with steroids, antibiotics and dilatation, none developed strictures. The two patients not treated in this fashion developed strictures.

Assessment of intubation in croup and epiglottitis.

Nasotracheal intubation for the management of airway obstruction in acute epiglottitis has become a well-received practice. However, the same technique has not received widespread support in laryngotracheobronchitis. The purpose of this study was to update the series of nasotracheal intubations in croup and epiglottitis from Columbus Children's Hospital with the specific intent to evaluate its effectiveness. All patients were evaluated for any immediate and delayed complications. Delayed complications were evaluated using parent interviews and measuring expiratory flow rates. This study of 45 children intubated for epiglottitis and 83 intubations for croup reconfirms the earlier report from this institution about its safety in both conditions. However, it has identified a subset of the croup patients who are definitely at risk to develop complications of the technique. In those children under 1 year of age, a disturbingly high incidence of subglottic stenosis was identified and this appeared to be related to the patient's age, tube size, serial intubations (dilatations), and duration of intubation. Suggested guidelines for airway management in the light of the new information are presented.

Operative treatment and postoperative management of saccular cyst and laryngocele.

We describe two infants with respiratory difficulty. The respiratory difficulty in one infant was secondary to a lateral saccular cyst, and the other infant had a laryngocele. Surgical treatment was marsupialization of the lesion. Postoperatively, a polyethylene endotracheal tube was left in place for three days to serve as a postoperative airway and also as a stent. With this procedure, we were able to avoid tracheostomy and recurrence of disease.

Antibiotic-resistant bacteria in otitis media with effusion.

Eighty-two bacterial isolates recovered from the middle ear effusions (192) of children with otitis media with effusion (OME) were tested for antibiotic sensitivity. Nearly 50% of all bacteria isolated were found to be resistant to penicillin, and in particular, 61% of the Haemophilus isolates were penicillin-resistant; 48% of the Haemophilus isolates were ampicillin-resistant. In addition, we we compared the bacterial recovery rate from effusions of patients who were receiving antibiotics with those who were not. Among patients who were receiving antibiotics, 33% of the effusions were culture positive, while 82% of the effusions were culture positive in the patients who were not given antibiotics. These results are discussed with respect to the possible role of bacteria in the pathogenesis of OME.

Serous otitis media and type 1 tympanoplasties in children. A retrospective study.

The prevalence of serous otitis media has caused a philosophical difference as to when a tympanoplasty should be performed in children. This retrospective study of 74 children (aged 3-17) who underwent 80 operations was undertaken to investigate this problem. The overall success rate for type 1 tympanoplasty was 66%. Age was not a reliable factor in predicting successful results. A history of recurrent serous otitis media was not an important indicator. Adenoidectomy did not influence the surgical outcome. The status of the nonoperated ear was probably a significant factor. Type 1 tympanoplasty has a reasonably good chance of success in children regardless of age and/or previous middle ear ventilation problems. However, a good clinical test of eustachian tube function is still needed to improve further the predictability of timpanoplasty in children.

Otitis media with effusion. Cytological and microbiological correlates.

A quantitative cytologic study of 83 middle ear effusions from children with otitis media with effusion (OME) was made with the use of cytocentrifuge-prepared smears and was correlated with bacteriological findings. The identification of the types of cell present in an effusion was confirmed by electron microscopic findings. The most common cell types were neutrophilic leukocytes, lymphocytes, and macrophages, but a few eosinophils were found in only one case. The cytologic profile of an effusion correlated well with the bacterial culture results. Neutrophil counts were significantly higher in effusions that contained pathogenic bacteria (P less than .01) than in culture-negative effusions. Lymphocytes were the dominant cell type in culture-negative effusions. The results support the idea that bacteria are involved in the pathogenesis of many cases of OME.

Antibody activity in otitis media with effusion.

Bacteria were isolated from a high percentage of the effusions from patients with otitis media with effusion (OME, serous otitis media). In an attempt to determine if the isolated bacteria were involved in the disease process, we analyzed the serum and effusion of 25 OME patients for the presence of antibacterial antibodies by the indirect immunofluorescence antibody method. Specific antibody activity was detected in 20 of 25 effusions (80%) and 19 of 22 sera (86%). IgG antibodies were the most frequently found class of antibodies in both sera and effusions, but IgA antibodies were detected more frequently in the effusions than in the sera. Hemophilus influenzae, Streptococcus pneumoniae, and diphtheroids were the most frequently isolated organisms, and antibody activity to all bacterial species isolated was detected. The results support the concept that the isolated bacteria are not contaminants but are actively involved in the disease process.

Immunoglobulin E in chronic middle ear effusions: conmparison of RIST, PRIST, and RIA techniques.

To investigate the possible role of allergy in otitis media with effusion (OME), the immunoglobulin E (IgE) content of 138 middle ear effusions (MEE) and paired serum samples from patients with chronic otitis media with effusion was determined. The initial 62 paired specimens were assayed for IgE by the radioimmunosorbent test (RIST), while the later 76 paired specimens were assayed for IgE by the paper radioimmunosorbent test (PRIST). When the results obtained by these two techniques were compared, it was noted that the PRIST procedure gave significantly lower IgE values for effusions than the RIST method. When the effusion-to-serum ratios (E/S ratios) were computed from the PRIST data, the E/S ratio was less than one, while RIST data gave an E/S ratio greater than one. The results obtained with the PRIST procedure were confirmed by double antibody radioimmunoassay for IgE. Thus, the PRIST procedure appears to measure the IgE content of MEE more accurately, and the results obtained by this procedure fail to support the concept of allergy as a major causative factor in OME.

Laryngeal problems following infant esophageal surgery.

This paper focuses on vocal cord paralysis in children after operation for tracheoesophageal fistula and/or esophageal atresia. We reviewed the charts of 65 children who were operated upon for congenital esophageal atresia and/or tracheoesophageal fistula during a period from 1964 to 1974. Ten of these children manifested laryngeal symptoms. Five had laryngeal paralysis. Two were untreated. One was treated with cordectomy and stent. Two were treated successfully with the Thornell arytenoidectomy, one of these being done without a tracheotomy in place. Mention is made of a third case of bilateral vocal cord paralysis due to hydrocephalus treated successfully by the Thornell procedure. Follow-up laryngoscopy was done on 21 children without laryngeal symptoms whiich revealed two previously unsuspected vocal cord paralyses and one vocal cord paresis which cleared.

Microorganisms in chronic otitis media with effusion.

A total of 175 effusions obtained from 172 patients suffering from chronic otitis media with effusions was examined for bacterial smear and culture. Eighty percent showed positive bacterial smear, but only 49% yielded positive bacterial culture. The mucoid effusions had positive cultures in only 37%, whereas the bacterial culture rate was higher in serous (59%) and leukocytic (64%) types. The isolation of common pathogens accounted for about 50% of the isolates, and nonpathogens accounted for the remaining 50%. The high incidence of microorganisms in the middle ear effusions in the present series raises the possibility of bacterial contribution in many cases of OME.

Antimicrobial factors and bacterial correlation in chronic otitis media with effusion.

Analyses of effusions and sera from patients with otitis media with effusion demonstrated local production in the middle ear of lysozyme, IgA and IgG. The effusion IgM was markedly elevated in some patients, also indicating local production. Complement C3 with rare exception was significantly lower in effusions than sera, suggesting utilization of complement in the middle ear, perhaps in conjunction with antibodies. The presence of high levels of lysozyme and immunoglobulins in effusions correlates with the low isolation rate of microorganisms in culture and may influence survival of organisms in the middle ear.

Immunoglobulin E in chronic middle ear effusions.

A total of 61 middle ear effusions and matched sera obtained from patients suffering from chronic otitis media with effusions (OME) was examined for IgE and other immunoglobulins to see if a reaginic antibody is involved in OME. The IgE levels were determined by the Phadebas IgE radioimmunoassay test. Excluding one patient who had extremely high IgE as a result of parasitosis, there were only three cases which showed marginally increased serum IgE levels. Elevated IgE levels in sera and/or in effusions were unrelated to a history of allergy. The mucoid effusions had significantly higher effusion levels than the levels in corresponding sera (p less than .0005). Fourteen percent of the cases examined showed effusion IgE levels five times or more higher than serum levels. Biopsy specimens of these patients showed numerous degranulating mast cells. Only two specimens showed eosinophilic infiltration. It is suggested that the IgE is produced locally by the mucosa in mucoid-type effusions and may have been involved in mast cell degranulation. However, this study cannot confirm the allergic nature of the OME.

Myringostomy for middle ear effusions. Results of a two-year study.

From 1972 to 1974, 736 children had tympanostomy tubes inserted for chronic serous otitis media resistant to medical therapy. The total number of ears involved was 2,237. The cleft palate patients constituted 8.8% of the total and had 15.4% of all procedures. Patients with allergy comprised 19% of the total population and had a higher incidence of otitis media following tube insertion. Adenoidectomy was performed in 44% of all patients and 35% of these required further tube insertions, suggesting that adenoidectomy in combination with tube insertion is not necessarily the primary treatment of choice. Children under six made up 78.5% of the total. The most common complication, a draining ear with an incidence of 15.1% was treated successfully with aqueous Merthiolate irrigations. There were 14 tympanic membrane perforations.

Chronic middle ear effusions. Immunochemical and bacteriological investigations.

Middle ear effusions from 100 patients (ages 6 months to 10 years) with serous otitis media were examined. The IgA, IgG, and lysozyme were demonstrated at a higher level in the effusions than the corresponding sera, indicating local production. The mucoid type contained higher level of immunoglobulins and lysozyme compared to serous type effusions. Bacteria were found in 77 percent of the effusions by means of a smear, and 52 percent yielded positive bacterial culture. The incidence of positive culture in effusions of the patients less than 6 years of age was 60 percent, while the group older than 6 years old was 32%, and the group over 8 was only 22 percent. Bacterial recovery rate was inversely related to the dramatic increase with age of IgA and IgG and lysozyme levels in effusions.