Middle ear pressure variation: effect of nitrous oxide.

Previous studies examining middle ear pressure changes due to inhalant anesthesia, including nitrous oxide, have cited equivocal results. An investigation was performed to closely monitor changes in middle ear pressure during middle ear surgery. Baseline tympanometry was performed before anesthesia, and middle ear pressure was then documented in 1-min time intervals. A total of 97 subjects were studied; 51 received nitrous oxide and halothane, and 46 received halothane alone. Results indicate that nitrous oxide causes significantly greater pressure fluctuations than halothane alone. There were no effects for time of surgery, type of fluid, or baseline. Pressure fluctuation was attributed to eustachian tube function. Case studies are presented to demonstrate subject variability, and suggestions for validation study procedures are presented.

Congenital syringocystadenoma papilliferum of the ear and neck treated with the CO2 laser.

Syringocystadenoma papilliferum (SCAP) is a rare benign skin tumor which clinically resembles papilloma. It is characterized by extensive papillary epithelial elements growing into the dermis. SCAP often presents at birth and most commonly in the head and neck. We present a case of a newborn with SCAP of the right ear and neck, treated with CO2 laser excision because the lesion was poorly amenable to excision and closure or grafting. Two CO2 laser procedures have produced a good result and reasonable cosmesis. CO2 laser excision of SCAP of the head and neck is a clinical treatment option in anatomic areas unfavorable to excision and grafting.

Membranous posterior glottic stenosis successfully treated by extended cricoid split procedure: a case report.

Posterior glottic stenosis resulting in limitation of vocal cord abduction is a difficult clinical problem. Usually secondary to intubation, mature posterior glottic stenosis is a difficult clinical problem better prevented than treated. We present a case of a patient with early, membranous posterior glottic stenosis successfully treated with a cricoid split procedure, lysis of the stenosis and planned postoperative intubation. This treatment allowed healing of the interarytenoid area and resulted in good vocal cord abduction. A literature review and rationale for the procedure are presented.

Bilateral ear canal stenosis from retained Goode T-tubes.

A 14-year old white male presented with a 2-year history of bilateral otorrhea. Purulent otorrhea with very stenotic external auditory canals (EAC) were found, and the patient was treated with topical otic solutions. Bilateral conductive hearing loss was found on audiometric studies. Biopsies were taken after the patient failed medical treatment. The results were consistent with granulation tissue and chronic inflammation. A CT scan revealed complete bilateral EAC stenosis. At surgery the patient was found to have bilateral retained Goode T-tubes, which were placed at 2 years of age. After removal of the tubes, the patient made a good recovery with improved hearing. This case illustrates a severe complication of retained tympanostomy tubes. Patients with these tubes require close long-term follow-up with careful management of problems such as granulation tissue or otorrhea to prevent this type of complication.

Microbial flora of the subglottis in intubated pediatric patients.

Infection of the intubated subglottis is felt to be one of the many factors involved in the pathogenesis of acquired cicatricial subglottic stenosis. The precise role of infection is unclear and the microbial flora has not been established. An analysis of subglottic culture material, from 22 intubated pediatric patients undergoing tracheotomy, has been performed to establish the nature of the subglottic microbial flora. Fifty-nine isolates were found, including 19 types of organisms. The number of isolates per patient ranged from one to eight, with an average of 2.7 isolates per patient. The most common isolates in the 22 patients were alpha-hemolytic Streptococcus viridans (17 isolates-77%), Neisseria sp. (6 isolates-27%), Pseudomonas sp. (5 isolates-22%), and coagulase negative Staphylococcus sp. (5 isolates-22%). This data indicates that colonization of the subglottis in intubated pediatric patients is polymicrobial in nature. alpha-Hemolytic Streptococcus viridans and Neisseria sp. were most common, with a shift in cultured flora towards Pseudomonas sp. in patients intubated for more than 10 days. In view of this, antimicrobial therapy may be of benefit in preventing acquired cicatricial subglottic stenosis.

Choanal atresia: a new anatomic classification and clinical management applications.

The anatomic classification of choanal atresia is commonly quoted as 90% bony and 10% membranous. This incidence is from a review by Fraser in 1910 of 115 cases, "many of which were insufficiently described." We have reviewed 47 computed tomography scans of choanal atresia from the literature and 16 from our clinical experience, and classified the anatomy as bony, mixed bony-membranous, or pure membranous. Our results reveal a combined incidence of 18 (29%) pure bony, 45 (71%) mixed bony-membranous, and no pure membranous atresia. We propose a new classification of choanal atresia to include bony, mixed, and membranous to accurately reflect the anatomic abnormalities. Our series of 11 patients undergoing transnasal microsurgical repair, a critical review of the literature, and the implications of the anatomic classification on the choice of surgical procedure are presented.

Incidence of sensorineural hearing loss in patients evaluated for tympanostomy tubes.

There are currently no standard guidelines for assessing hearing in pediatric patients who are evaluated for tympanostomy tubes. We describe the results of audiologic testing on 600 consecutive pediatric patients evaluated for tube placement. Six patients (1%) were found to have previously undiagnosed unilateral or bilateral moderate or severe neurosensory loss. Patients undergoing evaluation for tympanostomy tube placement have a low but significant likelihood of neurosensory hearing loss and should have age-appropriate hearing assessment as part of their overall evaluation.

Effects of inhalant anesthesia on the middle ear as measured by tympanometry.

This investigation examined the effects of inhalant anesthesia, nitrous oxide and halothane, on middle ear pressure. Moreover, the effect of inhalant anesthesia on the validation procedure for tympanometry was examined. Tympanometry was used to measure middle ear pressure variations. Subjects were examined with tympanometry prior to and after the administration of inhalant anesthesia. Group 1 (N = 86) received halothane and nitrous oxide. Group 2 (N = 52) received halothane only. Group 1 data were gathered in a previous investigation. The investigation was continued with subjects in group 2. Results indicated that middle ear status prior to anesthesia was not significantly different from middle ear status under anesthesia. In addition, middle ear pressure changes due to nitrous oxide were not significantly different from middle ear pressure changes due to halothane alone. Moreover, there was no effect on the tympanometry validation procedure. These findings are consistent with previous studies that indicate nonsignificant changes in middle ear pressure associated with the use of nitrous oxide and halothane.

Congenital abnormalities of the submandibular duct.

Five newborns presented with cystic lesions of the floor of mouth. Four of these patients proved to have congenitally imperforate submandibular salivary gland ducts and the other newborn proved to have a duplication anomaly of the submandibular gland duct and gland. The patients with imperforate Wharton's ducts underwent marsupialization with or without ductoplasty and have been without evidence of recurrence for up to three years. The duplication anomaly of the submandibular gland duct responded to simple excision. The diagnosis of congenital anomalies of the submandibular gland and duct can be made on physical examination. Magnetic resonance imaging can be helpful in differentiating congenital imperforate submandibular duct and duplication anomalies of the ductal system. Treatment of the former consists of duct marsupialization in the floor of mouth with or without ductoplasty. Treatment of the duplicated ductal system may best be treated with excision. A failure in diagnosis and treatment may result in ranula formation or sialoadenitis requiring more extensive therapy.

Measles: an epidemic of upper airway obstruction.

Between October 1989 and August 1990, Dallas County experienced an 11-month epidemic of measles. Of 995 cases of pediatric measles diagnosed in the outpatient department of Children's Medical Center, 108 patients were admitted and 34 of these demonstrated significant upper airway obstruction at the time of admission. Airway problems ranged from mild inspiratory stridor with nasal flaring to frank obstruction and arrest in the emergency room, requiring intubation. Eight of the 34 airway patients were eventually diagnosed with bacterial tracheitis on the basis of endoscopic findings and culture results. The remaining patients had pictures more consistent with viral laryngotracheitis, but all patients were treated with broad-spectrum antibiotics to prevent possible progression to bacterial tracheitis. A total of nine patients overall required intubation for airway obstruction and all were successfully extubated. Large outbreaks of measles are becoming common again in populations of urban poor--largely unvaccinated children. The disease in these populations tends to occur at a younger age and may be more aggressive with more associated complications. Physicians must keep in mind the possibility of upper airway obstruction in a significant proportion of these patients. Early diagnosis on the basis of clinical signs and symptoms, endoscopy, and radiographs is the key to timely appropriate management.

Rhabdomyoma of the cricopharyngeus in an infant.

Rhabdomyoma is a rare benign tumor characterized histologically by striated skeletal muscle. Rhabdomyomas can be classified into adult and fetal variants. The majority of adult variants arise in the head and neck region and are derived from the skeletal muscles of the pharyngeal (branchial) arches. The majority of cases of fetal variant rhabdomyomas have been described in the postauricular region of young children and the vulvovaginal region in middle-aged women. We present a case of a 15-month-old infant with a circumferential rhabdomyoma of the cricopharyngeus muscle requiring excision of the esophageal inlet and reconstruction with a free microvascular jejunal interposition graft. This case represents the youngest reported case of adult variant rhabdomyoma. The clinical, radiographic, and histologic findings of this unusual case and a review of reported cases of rhabdomyoma in the pediatric population will be presented.

The ototoxicity of ceftazidime in the chinchilla middle ear.

Ceftazidime (Tazicef) is a broad-spectrum cephalosporin antibiotic that may be useful as a topical agent in the treatment of otorrhea. To test the potential ototoxicity of the drug, 0.5 mL of a 10% solution of ceftazidime was introduced into the bullae of 22 chinchillas. The organ of Corti was normal in 20 temporal bones examined at 1 week after administration of the ceftazidime solution. Only 2 of 24 temporal bones examined after 4 weeks showed minor outer hair cell loss of the basal turn of the organ of Corti. Focal hemorrhage and occasional serous effusions were found in the middle ears of all animals after 1 week; these findings had mostly cleared after 4 weeks. Our results indicate that ceftazidime causes reversible middle ear inflammation, and may have some minor ototoxic potential under these experimental conditions.

Allergic aspergillosis: a newly recognized form of sinusitis in the pediatric population.

In 1983, Katzenstein, et al. first described a form of noninvasive sinusitis in adults, which was histologically identical to allergic bronchopulmonary aspergillosis, with mucin-containing eosinophils, Charcot-Leyden crystals, and fungal elements resembling Aspergillus species. The authors have treated six pediatric patients ages 8 to 16 who had findings typical of allergic Aspergillus sinusitis. All patients presented with nasal polyposis and progressive facial deformity. All patients had computed tomography findings of diffuse expansile sinus disease and four patients had evidence of bony erosion, raising the suspicion of malignancy. At surgery, all were found to have multiple sinuses densely packed with greenish-black inspissated mucin. Therapy consisted of wide surgical drainage with careful follow-up and nasal steroids.

Congenital nasal pyriform aperture stenosis.

Congenital nasal pyriform aperture stenosis is an unusual and previously undescribed cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed due to bony overgrowth of the nasal process of the maxilla. This anomaly may produce signs and symptoms of nasal airway obstruction in newborns and infants similar to those seen in bilateral posterior choanal atresia. Computed tomography confirms the diagnosis and delineates the anomaly. A series of six patients with nasal pyriform aperture stenosis is presented. Four patients were treated with surgical enlargement of the nasal pyriform aperture via a sublabial approach. One patient was repaired via a transnasal approach, and one patient did not undergo surgical intervention. Follow-up reveals normal nasal airway and facial growth in all patients. Mildly symptomatic patients with congenital nasal pyriform aperture stenosis may be treated expectantly, while severely symptomatic patients benefit from repair via the sublabial approach.

Cor pulmonale secondary to tonsillar and adenoidal hypertrophy: management considerations.

Eleven cases of cor pulmonale secondary to tonsil and adenoid hypertrophy and upper airway obstruction were reviewed. These patients presented with a spectrum disease ranging from mild, with only abnormal ECG or chest X-ray findings, to severe with hypercarbia, hypoxia, and right heart failure. One patient with severe disease suffered a postoperative respiratory arrest. We have successfully managed 4 patients with severe cor pulmonale with postoperative intubation and assisted ventilation. Hypoxia is the driving stimulus for respiration in patients with upper airway obstruction and hypercarbia. Relief of respiratory obstruction by tonsillectomy and adenoidectomy with postoperative oxygen administration may remove the hypoxic drive, resulting in respiratory arrest. Patients undergoing tonsillectomy and adenoidectomy for upper airway obstruction disease should be screened for cor pulmonale. Affected patients should be managed after surgery in an intensive care unit (ICU) environment with careful monitoring of the respiratory status. Patients with severe cor pulmonale can be successfully managed with planned postoperative intubation and mechanical ventilation to prevent respiratory arrest.

Ototoxicity of Vasocidin drops applied to the chinchilla middle ear.

Some widely used ototopical preparations are potentially toxic to the middle and inner ear. Vasocidin Ophthalmic Solution (sulfacetamide sodium and prednisolone sodium phosphate) has been advocated as an alternative agent that may have fewer toxic side effects in the treatment of otorrhea. Vasocidin was introduced into the bullae of nine chinchillas to investigate the effects on the middle and inner ear. The organ of Corti and stria vascularis were found to be entirely normal in 17 of the 18 temporal bones studied. Changes observed in the middle ears at one week included inflammation, hemorrhage, and effusion. Examination of specimens at four weeks revealed resolution of most of the inflammatory changes. The results of this experimental study indicate that Vasocidin causes reversible middle ear inflammation with little or no toxic effect on inner ear structures.

Bilateral posterior choanal atresia: a morphologic and histologic study, and computed tomographic correlation.

Bilateral posterior choanal atresia is an uncommon cause of respiratory obstruction in the newborn. Although the clinical syndrome and treatment options are well known, the abnormal histology has not been well described. Computed tomography (CT) is a useful tool in the radiologic diagnosis of choanal atresia, but has not been correlated with the histopathology. Two patients with CHARGE association (congenital heart defects, choanal atresia, retarded growth and development, hypogenitalism, and aural anomalies) and bilateral posterior choanal atresia were studied with CT. The atresia plates were removed at autopsy and sectioned in an axial plane for gross and microscopic study. The histopathology is described and correlated with the CT studies. These studies show that CT accurately defines the histopathologic abnormalities found in bilateral posterior choanal atresia.