Maxillary sinus mucocele: predisposing factors, clinical presentations, and treatment.

PURPOSE: Maxillary sinus mucocele (MSM) is uncommon lesion and has many presenting features. The aim of this study was to detect the possible predisposing factors, clinical characteristics, and to assess the efficacy of trans-nasal endoscopic treatment of this lesion. METHODS: This retrospective multicenter study was conducted on 36 patients with MSM, the diagnosis of the disease was based on computed tomographic criteria. The patients' history, presenting features, and surgical management were reviewed. All patients were followed up postoperatively for at least 3 years. RESULTS: Chronic sinusitis, previous surgery, allergic rhinitis, and nasal trauma may be implicated as predisposing factors for the disease. However, in some patients (56%) the cause may remain uncertain. MSM may present with unilateral cheek pain, heaviness, swelling, numbness, hemifacial pain, nasal obstruction, nasal discharge, and/or proptosis. All patients were treated with trans-nasal endoscopic marsupialization through the middle meatus, patients with large MSM showed bulged medial maxillary wall, and they needed to empty the fluid through inferior antrostomy to facilitate introduction of the instruments to the middle meatus. All patients reported resolution of their symptoms, and none required revision surgery through the follow-up period. CONCLUSIONS: MSM has several predisposing factors such as chronic sinusitis, previous surgery, allergic rhinitis and nasal trauma. However, some patients have no identifiable cause. The disease can present with a variety of symptoms which are usually related to their expansion and subsequent pressure on the surrounding structures. Trans-nasal endoscopic approach is an effective and safe method for treatment of the lesion.

Repair of submucous cleft palate with Furlow palatoplasty.

OBJECTIVE: Submucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI. METHODS: This prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy. RESULTS: Significant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory. CONCLUSIONS: Furlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity.

Furlow technique for treatment of soft palate fistula.

OBJECTIVE: Fistula of the palate is a common complication of palatoplasty, it leads to nasal regurgitation of fluids and hypernasality of speech. Its treatment is technically difficult due to paucity and fibrosis of palatal tissues. The aim of this study was to evaluate the efficacy of closure of soft palate fistula by using Furlow double opposing Z-palatoplasty. METHODS: Nineteen patients were subjected for repair of their soft palate fistulas using Furlow Z-plasty. Pre and postoperative speech analysis using auditory perceptual assessment, measurement of nasalance score using nasometric assessment, and measurement of velar movement using flexible nasopharyngoscopy were done. RESULTS: All cases showed complete closure of their fistulas at first attempt, with no operative or postoperative complications. Recurrence was not recorded in any case after a follow up period of at least 12 months. Significant improvement of speech quality and nasalance score was achieved. Flexible nasopharyngoscopy showed postoperative increase in velar movement which was not significant relative to the preoperative records. CONCLUSIONS: Treatment of soft palate fistula by using Furlow technique is an effective method as a primary treatment with a high success rate and a good functional outcome.

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management.

OBJECTIVE: Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management. METHODS: Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year. RESULTS: Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Down's syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms. CONCLUSIONS: Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.

Treatment of velopharyngeal insufficiency after cleft palate repair depending on the velopharyngeal closure pattern.

Velopharyngeal insufficiency (VPI) is a common problem after cleft palate repair; secondary surgery may be needed to treat this condition. Pharyngeal flap is usually selected for cases with sagittal closure pattern, and sphincter pharyngoplasty is used for cases with coronal closure pattern, whereas cases with circular closure pattern may be puzzling. The objective of this prospective study was to assess the efficacy of tailoring the surgical technique to the preoperative velopharyngeal closure (VPC) pattern and to determine the success of sphincter pharyngoplasty for cases with circular closure pattern.This study was conducted on 48 patients, who presented with postpalatoplasty VPI; the cases were classified into 3 groups according to the VPC: group A of coronal VPC was treated with sphincter pharyngoplasty, group B of sagittal VPC was treated with pharyngeal flap, and group C that exhibited circular VPC was treated with sphincter pharyngoplasty. Speech analysis, nasalance score, and nasopharyngoscopic data were recorded preoperatively and 6 months postoperatively. Also, snoring and sleep apnea were assessed.There were no significant differences between the groups regarding the speech, nasometric, and nasopharyngoscopic data. Although snoring was significantly higher after pharyngeal flap, there was no significant difference regarding apnea.Selection of the surgical procedure depending on the type of preoperative VPC pattern for treatment of postpalatoplasty VPI is an appropriate method. In case of circular closure pattern, sphincter pharyngoplasty is the operation of choice as it has a lower incidence of postoperative snoring than pharyngeal flap.

Epstein-Barr virus infection as a cause of cervical lymphadenopathy in children.

OBJECTIVE: Cervical lymphadenopathy is a common pediatric problem; reactive hyperplasia, specific infective agents, and malignancy are mainly the differential diagnosis. The aim of our study was to detect the prevalence of Epstein-Barr virus infection among children who complained of cervical lymphadenopathy and also to evaluate the clinical manifestations of the disease in pediatric patients. METHODS: One hundred and sixty children presented with cervical lymphadenopathy were subjected to Epstein-Barr Virus (EBV) serology testing. Cases that showed positivity to heterophile antibody test, and/or EBV-specific antibodies; IgM against viral capsid antigen (VCA-IgM) and IgG against viral capsid antigen (VCA-IgG) were evaluated clinically for manifestations of the disease. RESULTS: Twenty-four cases (15%) showed positivity to EBV serology, all of them had posterior cervical lymph nodes enlargement, 70.8% had fever, 66.6% had tonsillo-pharyngitis, 58.3% had splenomegaly, 25% had hepatomegaly, 41.6% had generalized lymphadenopathy, while skin rash was detected in 12.5%, and both palatal petechiae and palpebral edema were detected in 8.3%. CONCLUSIONS: EBV infection is not a rare cause of cervical lymphadenopathy in children. Posterior cervical lymphadenopathy in pediatric age group may represent a password for suspicion of EBV infection, while other clinical manifestations of the disease may include hepato-splenomegaly, skin rash, palpebral edema and palatal petechiae.

Acute mastoiditis: A one year study in the pediatric hospital of Cairo university.

BACKGROUND: Acute mastoiditis is a serious complication of acute otitis media especially in the pediatric age group. This study reports the authors' experience in the treatment of children admitted with acute mastoiditis to the Pediatric Hospital of Cairo University throughout the year 2007, also we aimed to evaluate our current management of this serious disease. METHODS: Nineteen children were included in this study, 11 females and 8 males, their ages ranged from 9 months to 11 years. All children were treated with intravenous antibiotic on initial admission, myringotomy was considered for cases that did not respond to medical treatment for 48 hours, while cortical mastoidectomy (with myringotomy) was reserved for cases that presented initially with subperiosteal abscess with or without post-auricular fistula, cases with intracranial complications and for cases that showed no response to myringotomy (after 48 hours). Follow up of the patients was carried out for at least 1 year. RESULTS: Medical management alone was enough in 5 cases (26%); all of them had erythematous tender mastoid on first presentation. Seven cases (37%) needed myringotomy; 2 of them showed no response and they needed cortical mastoidectomy and the other 5 cases responded well except for 1 case that developed post-auricular subperiosteal abscess 2 months later necessitating cortical mastoidectomy with no evidence of recurrence till the end of the follow-up period. Seven cases (37%) presented with subperiosteal abscess and they needed cortical mastoidectomy with myringotomy; they showed no recurrence till the end of the study. CONCLUSION: Conservative management is an effective method in the treatment of non-complicated acute mastoiditis, but myringotomy should be considered if there is no response within 48 hours. Cortical mastoidectomy should be used in conjunction with the medical management in the treatment of complicated cases.

Treatment of persistent post-adenoidectomy velopharyngeal insufficiency by sphincter pharyngoplasty.

OBJECTIVE: Persistent hypernasality after adenoidectomy is an infrequent problem in children with normal palate. However if it happened, it can render a child's speech unintelligible resulting in serious affection of social life. We aimed in this study to identify the causes of persistent post-adenoidectomy velopharyngeal insufficiency and to assess the efficacy of sphincter pharyngoplasty in the treatment of such problem. METHODS: This study was conducted on 18 patients complained of hypernasal speech following removal of their adenoids after variable periods of failed expected spontaneous improvement. Their hypernasality was rated as being mild, moderate and severe, all cases were subjected to conservative treatment in the form of speech therapy for 3 months to correct the problem, and patients that did not respond to speech therapy were subjected to surgical intervention in the form of sphincter pharyngoplasty. Velopharyngeal closure was assessed using flexible nasopharyngoscopy, while speech was assessed using auditory perceptual assessment and nasometry. RESULTS: Hypernasality was mild in 9 cases, moderate in 7 cases and severe in 2 cases. Flexible nasopharyngoscopy showed occult submucous cleft in 5 cases, short palate in 2 cases, and deep nasopharynx in 3 cases. Speech improvement was achieved in 8 cases after completion of speech therapy program (all had mild hypernasality with no anatomical palatal defects). Ten patients that had palatal defects were subjected to sphincter pharyngoplasty, 8 of them showed complete recovery, while 2 cases with severe hypernasality showed partial improvement of their speech. CONCLUSIONS: Persistent post-adenoidectomy velopharyngeal insufficiency may be due to anatomical abnormalities of the palate such as an occult submucous cleft, short palate or deep nasopharynx; such conditions may be overlooked during the preoperative preparation for adenoid removal. Speech therapy is an effective method in mild hypernasality especially if there is no anatomical abnormality, while surgical correction is usually needed in moderate and severe cases, and sphincter pharyngoplasty is a useful choice for those patients.

Nodular fasciitis of the external auditory canal in six Egyptian children.

OBJECTIVE: Nodular fasciitis of external auditory canal may mimic a malignant tumor due to its progressive course, so it was the aim of this study to focus on a new etiology for aural masses to avoid unnecessary aggressive treatment. STUDY DESIGN: Retrospective study on six children presented with aural masses that were diagnosed pathologically to have nodular fasciitis. METHODS: Presentation of the cases clinically, radiologically and pathologically was carried out. Surgical excision of the lesions was done through the external canal with follow up of the cases for 1 year. RESULTS: Recurrence was detected in two cases, one after 2 months and the other after 4 months. Re-excision was carried out without recurrence till the end of the follow up period. CONCLUSIONS: Proper diagnosis of this lesion is mandatory to avoid aggressive treatment (radical surgery and/or radiotherapy) as the disease has favorable prognosis with local excision.

Closure of anterior post-palatoplasty fistula using superior lip myomucosal flap.

OBJECTIVE: (a) Surgical repair of palatal fistulas are technically difficult due to excessive tissue fibrosis with high failure rate. (b) The aim of this study is to evaluate the efficacy of closure of anterior palatal fistula using myomucosal superior lip flap. METHODS: 33 cases with anterior palatal fistulas after cleft palate repair were subjected to closure in two-layers, the first is the oral mucoperiosteum hinge flap to reconstruct the nasal side and the second is a myomucosal flap from the inner surface of the superior lip to reconstruct the oral side. Follow up was carried out for 12 months. RESULTS: The fistulas were completely closed in 30 cases (91%) and partially closed in 3 cases (9%) due to necrosis of the tip of the flap. CONCLUSIONS: Closure of anterior palatal fistula by the use of superior lip myomucosal flap is a useful method with high success rate and no morbidity.