Objective tinnitus in children.

OBJECTIVE: To discuss the various symptoms and causes of objective tinnitus in children. STUDY DESIGN: Retrospective case review. PATIENTS: Five children who had audible signals emanating from their ears caused by audible spontaneous otoacoustic emissions, palatal myoclonus, arteriovenous malformation, and acoustic trauma. MAIN OUTCOME MEASURE: The tinnitus reported by the patients was linked to acoustic signals that could be measured objectively or heard by the examiner. RESULTS: Four of the five children had essentially normal hearing. The one child who demonstrated a hearing loss audiometrically was thought to have normal hearing sensitivity, but his intense roaring objective tinnitus appeared to mask his low-frequency thresholds. All five patients had measurable acoustic signals in the ear canal that matched the patients' descriptions of their tinnitus. CONCLUSION: The cases illustrate how the objective tinnitus was diagnosed and measured, how a treatment algorithm was applied, and the expected results of treatment. In addition, the cases provide support for the use of psychologic counseling throughout the examination and treatment of objective tinnitus in children.

Unilateral vs. bilateral supraglottoplasty for severe laryngomalacia in children.

OBJECTIVES: To study the efficacy of unilateral supraglottoplasty in comparison with bilateral supraglottoplasty for the treatment of severe laryngomalacia in children and to study factors that may be predictive of major complications or the need for a subsequent contralateral or revision procedure. DESIGN: Retrospective medical record review. SETTING: University tertiary care pediatric hospital. PATIENTS: One hundred six consecutive pediatric patients, aged 9 days to 18 years, who had undergone unilateral or bilateral supraglottoplasty for severe laryngomalacia. MAIN OUTCOME MEASURES: Resolution of clinically significant laryngomalacia, development of major complications (supraglottic stenosis or aspiration), and an association between study variables (demographics, medical comorbidities, synchronous airway abnormalities, sites of excision, and techniques of excision) and the need for subsequent contralateral or revision supraglottoplasty. RESULTS: We achieved a high success rate (95.7%), a low complication rate (8.5%), and observed the need for a contralateral procedure in 7 (14.9%) of the 47 patients who underwent initial unilateral supraglottoplasty. Two patients who underwent initial bilateral supraglottoplasty developed supraglottic stenosis. No significant association existed between our study variables and the development of complications or the need for contralateral or revision supraglottoplasty. CONCLUSIONS: Unilateral supraglottoplasty was associated with a high success rate, low complication rate, and the avoidance of supraglottic stenosis in our study population. The percentage of patients requiring a subsequent contralateral procedure was comparable to that reported in the literature, and no major complications were associated with the second operation in these patients. Therefore, unilateral supraglottoplasty seems to be a reasonable option for initial surgical management of pediatric patients with severe laryngomalacia.

A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient.

OBJECTIVE: To compare the use of ibuprofen with the use of acetaminophen with codeine for posttonsillectomy management. BACKGROUND: We were not satisfied with our traditional pain-management practice for tonsillectomy patients. We hoped to find a new approach for improved patient comfort and avoid scheduled, abusable drugs such as codeine. DESIGN: Intervention, prospective, randomized control trial. Follow-up was 1 month. SETTING: University referral center; institutional pediatric practice, ambulatory. PATIENTS: 110 children undergoing tonsillectomy with or without other procedures. Consecutive patients were offered participation. Enrollees were randomly assigned to one of two classes and analyzed with the initial assignment. No patients withdrew for adverse effects, although 12 in group 2 used codeine and 5 of those used acetaminophen, whereas 2 in group 1 received ibuprofen. INTERVENTIONS: Patients received either acetaminophen with codeine (group 1) or ibuprofen (group 2) for postoperative pain control. MAIN OUTCOME MEASURES: The main outcomes, determined before initiation of the study, were assessment of (1) postoperative bleeding, (2) pain, (3) efficacy of relief of pain by drug, (4) nausea, (5) emesis, (6) readmission to hospital, (7) average temperature, and (8) highest temperature after surgery. RESULTS: The only statistically significant difference is less nausea in patients receiving ibuprofen (p = 0.0049). Of note, no difference existed in postoperative bleeding, pain, or temperature control. CONCLUSIONS: Ibuprofen is at least as effective as acetaminophen with codeine for postoperative pain control in children after tonsillectomy.

Wegener's granulomatosis, acute laryngotracheal airway obstruction and death in a 17-year-old female: case report and review of the literature.

OBJECTIVE: To alert practitioners to the risk of sudden airway obstruction and death in patients with Wegener's granulomatosis. DESIGN: Case report and literature review. SETTINGS: University and Community hospitals. PATIENT: A 17-year-old white female. INTERVENTION: (1) evaluation and treatment for mental status changes over 2 months. (2) Evaluation and surgical biopsy of nasal septal perforation under general anesthesia at a university children's hospital. (3) Evaluation and observation at a community hospital 2 days later. (4) autopsy. RESULTS: Serology performed 3 days ante-mortem revealed (at 2 days post-mortem) cytoplasmic anti-neutrophil cytoplasmic antibody positive at 1:128. Autopsy was significant for microscopic fibrosis and granulomas in the kidneys and essentially total obstruction of the subglottis and upper trachea by a 3.5 x 1 x 1 cm mass of fibrosis and granulomas overlying circumferentially necrotic mucosa. This mass was centered on the crico-tracheal junction. CONCLUSIONS: Wegener's granulomatosis can lead to proliferative tissue growth with acute airway obstruction in the larynx and trachea, and death. Any patient with WG under age 20, as well as patients with WG and laryngotracheal symptoms (e.g. strider, hoarseness, wheezing) would benefit from evaluation of the airway.

Aneurysmal bone cyst of the maxilla: case report and review of the literature.

Aneurysmal bone cyst (ABC) is a rare benign lesion of the head and neck. A case of an ABC in a 12-year-old female is presented, the twentieth reported such case in the maxilla. Literature review shows ABC are common in the long bones; only 2% are in the head and neck. Of the 77 lesions in the head and neck found in the literature, 31 (40%) are in the mandible, 20 (26%) are in the maxilla (including this case) and the remainder mainly in the skull. Current recommended treatment is curettage with enucleation first if technically possible.

Laryngomalacia and intra-neural striated muscle in an infant with the Freeman-Sheldon syndrome.

Striated muscle cells within peripheral nerve trunks, a very rare dishistogenetic lesion, was found in the arytenoid submucosa of a ten and a half week old afroamerican male with the Freeman-Sheldon syndrome (craniocarpotarsal dysplasia) who presented with obstructive apnea. Laryngomalacia was confirmed endoscopically. Supraglottoplasty offered temporary relief of the obstruction. Our histopathological observation is puzzling and perhaps adds a new dimension to the appropriateness of 'dysplasia'. It remains to be seen whether the neuromuscular lesion is a coincidental finding, a mere curiosity or bears any clinical significance.

Pleomorphic adenoma (benign mixed tumor) of the trachea.

A 15-year-old "asthmatic" found to have a pleomorphic adenoma of the trachea was treated by staged CO2 laser excision. Primary tracheal tumors, the clinicopathologic features of mixed tumor in this rare location, and therapeutic options are briefly reviewed. Immunohistochemical stains for cytokeratin, S-100 protein, and glial fibrillary acidic protein are reliable methods of evaluating component cell types in pleomorphic adenoma, but immunohistochemical evidence has not resolved the issue of tumor histogenesis.

The evaluation of ear canal, middle ear, temporal bone, and cerebellopontine angle masses in infants, children, and adolescents.

Ear canal, middle ear, temporal bone, and CPA angle masses (except for cholesteatomas) are rare in the pediatric population. The physician needs to have a high degree of suspicion for such lesions if a child presents with ear pain unrelated to infection or otorrhea that fails to improve after treatment. A precise diagnosis needs to be made in these children and also in those with hearing loss, vertigo, and facial paralysis. The most useful imaging procedures for ear, temporal bone, and CPA masses are CT and MR imaging. With a suspected vascular lesion, a definitive diagnosis usually can be made by an imaging procedure or angiography. In all cases of mass lesions, except for some aneurysms and infections, a tissue diagnosis must be secured.

Tracheal granulation tissue. A study of bacteriology.

We prospectively examined 19 patients (21 laryngotracheal reconstructions) over a 6-month period to evaluate the bacteriology of granulation tissue present at the time of Teflon stent removal and at the first laryngoscopy several weeks later. The most frequently recovered isolates were viridans streptococci, Pseudomonas aeruginosa, nonhemolytic Streptococcus, and Staphylococcus aureus. All but one positive culture were polymicrobial. The amount of tissue did not correlate with the duration of stenting and the amount of granulation tissue and number of organisms decreased after stent removal. Further prospective study of the most appropriate antimicrobial therapy is needed.

Incidence of perforation with Goode T-tube.

Two groups of patients from the same era were retrospectively studied in Cincinnati and Chicago. In Cincinnati two subgroups were studied. The first group received myringotomy with insertion of a 'T'-shaped ventilating tube (75 patients, 140 ears, 147 insertions). Fifty-eight ears still had the tube in place, 31 had healed after spontaneous extrusion, 17 had healed after removal of the tube, 20 had persistent perforation after the tube was gone, 2 had a cholesteatoma, and 4 patients (7 ears) were lost to follow-up. The second set received myringotomy and insertion of a small grommet (Donaldson tube, 71 patients, 140 ears, 164 insertions) tympanostomy tube. None could be documented to still have the tube in place, 156 ears healed after spontaneous extrusion, none required removal, 3 ears had a persistent perforation after the tube was gone, none had cholesteatoma, and 5 patients (5 ears) were lost to follow-up. The perforation rate for the T-tube is 13.6% and for the grommet is 1.8% (P = 0.0005). In Chicago, 93 patients who received the Goode T style tube (175 ears, 175 insertions) prior to March, 1986 were evaluated. The degree of retraction of the tympanic membrane preoperatively was recorded. No ears still had the tube in place, 145 had healed after spontaneous extrusion or removal of the tube, 30 had persistent perforation 12 months after the tube was gone, 4 had a cholesteatoma, and 8 patients (15 ears) were lost to follow-up. The rate of perforation is 18.8% which is not statistically different from the Cincinnati rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhancement of expansion of guinea pig skin by local delivery of an anticontractile agent using a new bilumen expander.

We have shown previously that anticontractile agents used with tissue expanders provide significantly more rapid expansion in an animal model than in controls without these agents. We describe an improved method of delivery involving a perforated concentric envelope enclosing a tissue expander (type 2) in place of the single circumferential perforated catheter (type 1) used previously by us. Eleven guinea pigs received a type 1 expander and ten received a type 2 expander. The anticontractile agent theophylline was delivered in saline around each expander, and all the expanders from both groups were inflated to a similar pressure every three days for twelve days. Significantly greater expansion, in terms of total volume delivered to the expander, was noted using the type 2 expander. We conclude that the concentric device offers further improvement, probably as a result of more uniform distribution of the agent in the tissue around the expander.

Plunging ranula in an infant.

This unusual case extends the age range of persons with plunging ranula to include those with congenital neonatal submandibular masses. The congenital nature of plunging ranula has not been widely discussed. Clinical diagnosis can be reinforced by diagnostic imaging (CT, MRI) if the mass extends into or abuts the sublingual space. Definitive treatment (generally excision) leads to resolution of the mass and prevention of recurrence.

Calvarial bone grafting of facial defects.

Bony defects of the face continue to challenge the reconstructive surgeon. Traditional sources of autologous bone from the rib or pelvis have been associated with the limitations of pain at the donor site, the need for a second operative field, variable "take" of the graft with poor eventual survival and, ultimately, less than optimal reconstruction. Calvarial bone grafting provides a readily accessible source of bone from an inconspicuous donor site, usually within the same operative field. The morbidity is minimal. The calvarial bone graft is especially useful in repair of the frontal sinus, orbital floor, nasal and malar regions, as well as in certain instances of cleft palate with alveolar involvement.