Safety of electronic molecular resonance adenoidectomy.

Adenoidectomy is one of the most frequent operations in children. In order to reduce hospital stay costs, today, this procedure is performed as day surgery. Even though adenoidectomy is not considered risky, some minor complications may occur, the most important being bleeding (0.5-8% incidence). The surgical technique used can influence considerably postoperative pain and time to recovery. This aspect is essential in the management of day surgery patients, for whom the need of safe and rapid maneuvers associated with early recovery determines the choice of the surgical procedure. Recently, we developed a surgical technique based on the use of an electronic molecular resonance tool associated with bendable suction electrocautery. This study was carried out on 600 patients, divided into two groups, the first undergoing ablation using the molecular resonance tool and the second undergoing curette adenoidectomy. The two groups were homogeneous for age, sex, surgical indications, and grade of adenoid hypertrophy. The following parameters were considered: duration of surgery, importance of intraoperative bleeding, time to cicatrization, incidence of bleeding complications. Duration of surgery and intra- and postoperative bleeding were much lower in the first group than in the group undergoing traditional adenoidectomy. In addition, rhinopharyngeal complete cicatrization, defined as absolute absence of pseudomembrane, was much quicker in the first group, as assessed by postoperative endoscopy. Another major advantage offered by the molecular resonance tool is the accuracy of surgery performed under visual control in a practically bloodless field. To sum up, this method, thanks to its technical features and safety, is particularly indicated in children and in patients with coagulation disorders.

Acute mastoiditis: a 10 year retrospective study.

This retrospective study reviews our experience in the management of acute otomastoiditis over 10 years. During the study period we identified 40 cases in children aged 3 months-15 years with a peak incidence in the second year of life. Sixty per cent of them had a history of acute otitis media (AOM). All the children were already receiving oral antibiotic therapy. Otalgia, fever, poor feeding and vomiting were the most common symptoms, all the children had evidence of retroauricolar inflammation. Computerized tomography (CT) and magnetic resonance imaging (MRI) were used to support the diagnosis and to evaluate possible complications. Streptococcus pneumoniae was the most common isolated bacterium. All the patients received intravenous antibiotics, 65% of children received only medical treatment, 35% also underwent surgical intervention. Mean length of hospital stay was 12.3 days. Cholesteathoma was diagnosed in one child. We conclude from our study that acute otomastoiditis is a disease mainly affecting young children, that develops from AOM resistant to oral antibiotics. Adequate initial management always requires intravenous antibiotics, conservative surgical treatment with miryngotomy is appropriate in children not responding within 48 h from beginning of therapy. Mastoidectomy should be performed in all the patients with acute coalescent mastoiditis or in case of evidence of intracranial complications.

Monothermal air caloric test in children.

We compared the efficacy of bithermal (BAT) and monothermal cold (MCAT) and warm (MWAT) air caloric tests in identifying labyrinthine function anomalies in the child. At first, we established confidence intervals of normality for both monothermal tests in 40 children (22 males, 18 females) aged 6-14 years, clinically healthy and normal as previously shown by BAT. Subsequently, we compared the results of BAT with those of MCAT and MWAT performed in 46 children (22 males, 24 females) aged 6-14 years, affected by multiple labyrinthine diseases. These results confirmed that, as in the adult, MCAT alone should not be used in the evaluation of labyrinthine function in vertiginous patients. As to MWAT, we obtained good sensitivity and specificity with respect to BAT (83% and 90% for 90% probability; 78% and 92.5% for 95% probability). Sensitivity values increased or decreased depending on the disease causing vertiginous symptoms, with decreased or increased number of false negatives. In our opinion, MWAT cannot replace BAT for the study of labyrinthine function in children. MWAT alone can be used when vertigo is ascribable to vestibular neuritis or to endogenous disease (dysmetabolic, dyscrasic, dysendocrine).

In vitro stimulation of human tonsillar subepithelial B cells: requirement for interaction with activated T cells.

Human tonsillar subepithelial B cells, which are a marginal zone-equivalent B cell subset, respond readily to T-independent type 2 antigens, but not to polyclonal B cell activators in vitro. In this study, subepithelial (SE) B cells were induced to proliferate and mature into plasma cells when co-cultured with activated T cells. The response of SE B cells was not observed when co-cultures were carried out in transwell chambers or in the presence of blocking anti-LFA-1 antibodies, demonstrating the need for a close T-B cell interaction. The presence of soluble CD40 also prevented the B cell response in vitro suggesting a pivotal role of CD40-CD40 ligand interactions. The data are discussed in terms of the T cell dependence of marginal zone (MZ) B cell response and the possible existence of various MZ B cell subsets.

Heterogeneity of tonsillar subepithelial B lymphocytes, the splenic marginal zone equivalents.

The VH4 genes expressed by both resting and in vivo-activated subepithelial (SE) B cells from human tonsils were studied. Resting SE B cells were subdivided according to the presence (IgDlow) or absence (IgM-only) of surface IgD. CD27 was abundant on activated SE B cells and low on resting IgM-only B cells. Resting IgDlow SE B cells could be subdivided into CD27low and CD27high cell fractions. Resting IgDlow SE B cells displayed VH4 genes with a substantial number of mutations (13/29 of the molecular clones were mutated), whereas 25/26 of the clones from resting IgM-only SE B cells were unmutated. Moreover, mutated VH4 genes were detected mainly within the CD27high cell fraction of the IgDlow SE B cells. Several identical unmutated VH4DJH sequences (11/32) were found in different molecular clones from resting IgM-only SE B cells, suggesting local cellular expansion. Both unmutated (14/25) and mutated (11/25) sequences were found in mu transcripts of activated SE B cells. Extensive mutation was observed in the gamma transcripts of activated SE B cells. Therefore, SE B cells are heterogeneous, being comprised of B cells with mutated Ig VH4 genes, that are Ag-experienced B cells, and a subset of B cells with unmutated VH4 genes that are either virgin cells or cells driven by Ags that did not induce or select for V gene mutations.

Compared study of optokinetic and caloric nystagmus in children with unilateral hyporeflexia and other vestibular disorders.

The authors compare the nystagmus evoked by the caloric test and by two slow and fast optokinetic 'look' stimulations performed in 78 subjects subdivided into two groups and recorded by ENG: group 1 composed of 22 subjects with 'significative' unilateral hyporeflexia and group 2 composed of 56 subjects with important anomalies at the vestibular caloric test. The results can be summarized as follows: 1. the presence of unilateral vestibular hyporeflexia is not exceptional in the child: 22 over 140 cases (15.7%); 2. the comparison between the caloric test and the OKN test in the 22 subjects with significant unilateral hyporeflexia shows: slow and fast TAP homolateral to the side with labyrinthine deficit prevails in ten subjects (45.4%); TAP is inconsistency with respect to the hyporeflexic side (i.e. homolateral in one test and contralateral in the other) in seven cases (31.8%); TAP is contralateral in five cases (22.7%). Within the same group, STAP varies according to cases. 3. In group II, TAP values at the OKN test overlap considerably with respect to the caloric test (18 cases with a total TAP prevailing on the right side, 32.2%; 19 cases with divergent TAP, 33.9%; 19 cases with total TAP prevailing on the left side, 33.9%). 4. The data shown in group 1 with significant vestibular hyporeflexia can be correlated to the time elapsed between the last electronystagmography and that performed soon after disease onset. Since for ENG performed some days after vertigo onset (even though clinical examination is negative) shows a concordance of OKN TAP and the hyporeflexic side (as the mechanisms of central compensation are still being developed) and then when these mechanisms improve with time, an inconsistency of OKN TAP and hyporeflexic side and finally a contralaterality. We might rely on the comparison between OKN TAP and caloric test as a finding of the time distance from the vertigo onset (when unknown) and a rough prognostic sign. The only case of vestibular neuritis by us followed in time seems to confirm our assumption.

The air caloric test in children: subdivision and statistical analysis of the response.

Among a population of 200 children, suffering by dizziness that we examined in the ENT department of the G. Gaslini Institute of Genoa, we acquired and checked, through the statistical analysis, the data of an air caloric test (according to the standard stimulation method) performed in 20 children (resulted normal to neurological, ophtalmological and audiovestibuler examinations which included audiometry, tympanometry, spontaneous, positional and positioning nystagmus research, OKN and caloric tests) and subdivided into 10 s sequences. The statistical analysis of the results obtained showed the following: (1) in both cold and warm air caloric test, the response can be obtained already in the stimulation phase, requiring ENG recording to start at the beginning of stimulation; (2) even in children, response culmination occurs in a period ranging from 60 to 90 s from stimulation onset; therefore the Visual Suppression Test should be performed in this period to obtain more significant data; (3) in cold and warm test, considering SSCs, the response is constant and intense up to 130 and 110 s, respectively, from beginning of ENG recording. After these time ranges, the response is less intense and homogeneous, becoming poor and variable. In our opinion, this allows suspension of recording immediately after these periods without the risk of the excluding significant aspects of the response.

Comparison between air and water caloric tests in children.

The caloric test represents an essential part of each procedure evaluating vestibular function. The use of water has many contraindications: tympanic perforation, external otitis and mastoid diseases. Sometimes, nausea can make test execution very difficult. Several authors contributed to the study and diffusion of the caloric test for the evaluation of labyrinthine function using different types of otoalcorimeters. We compared two methods in the child--generally intolerant to the water test--and the results obtained were adapted to a mathematical model of air and water caloric nystagmus. Twenty-seven normal children, aged between 5 and 14 years, subdivided into three age groups (5-7, 8-10 and 11-14 years), underwent the water caloric test (250 cm3 at 31 and 43 degrees C for 40 s) and then the air test, together with another nine subjects undergoing only the air test (flow-rate 8 l/min at 25 and 49 degrees C) on different days. The comparison between the two stimulation methods showed a statistically significant difference (P < 0.002) between maximum slow speed component (max SSC) in degrees per second (degrees/s) of water (4.74 degrees/s) and air (2.98 degrees/s). The results of two caloric tests and the interindividual and intraindividual analysis of our electronystagmographic results are in agreement with the data obtained by other authors in studies on adults. Therefore, notwithstanding the differences between the two stimulation methods, the air caloric test can be applied in a larger number of cases, it is better tolerated and can thus be used even in children for the study of labyrinthine function.

Electronystagmography findings in child unilateral sensorineural hearing loss of probable viral origin.

We studied the labyrinthine function in a group of 72 children aged between 4 and 14 years affected by unilateral sensorineural hearing loss of probable viral origin. From the analysis of the results obtained we confirm the concomitance of cochlear and vestibular damage. However, there were no statistically significant differences between type of audiogram at onset of hearing loss and type of electronystagmography (ENG), while we found a direct correlation between the presence of vertigo or dizziness and type of ENG. Finally hearing recovery was influenced by the presence of vertigo or labyrinthine function alterations. The results of statistical analysis confirmed a significant statistical difference between patients with vertigo or dizziness (V(+)) and those without vertigo (V(-)) and also between patients with ENG 3 (subjects with spontaneous nystagmus or positional nystagmus and canal paresis ipsilateral to the cochlear lesion) and those with ENG 1 (subjects without spontaneous nystagmus or positional nystagmus and with normal vestibular reflex). In fact, hearing recovery was worse in V(+) group and in ENG 3 group.

Otoneurologic evaluation of child vertigo.

In this study 282 children with vertigo are subdivided (according to previous experiences) into three large groups: (1) vertigo and cochlear diseases; (2) vertigo as an isolated symptom; and (3) vertigo and C.S.N. diseases. Due to the difficult etiopathogenetic investigation of the patients from the second group, the authors focused on that group as they are less studied, are without associated symptoms (deafness--first group; CNS diseases--second group) and where vertigo appears as an idiopathic and an isolated symptom. A careful anamnestic, clinical and instrumental analysis leads to the following observations: (1) in decreasing order of frequency we find the third group, followed by the first and finally by the second; (2) in spite of the overall lower incidence of the second group, this latter includes the paroxismal benign vertigo (PBV) which is overall the second most frequent vertiginous form (after vertigo due to cranial trauma). In this group the authors underline the reasonably high incidence of the iatrogenic syndromes, insisting on the need of their accurate prevention of these risks; (3) the authors confirm that, nowadays, a reliable etiopathogenetic cause of the apparently isolated vertigo (except for the ascertained iatrogenic forms) cannot be identified. Moreover, in spite of its frequency, PBV is the less known form of vertigo, of which we cannot give a certain diagnosis and which can be identified only the the exclusion of all the other known forms through instrumental and clinical observations.

The study of optokinetic 'look' nystagmus in children: our experience.

Seventy health children underwent an OKN trial. The authors have chosen to perform only four tests (slow and fast clockwise and counterclockwise OKN) taking into account (in agreement with several international studies) four parameters: sTAP, fTAP, sTSAP, fTSAP (where s and f indicate the velocity of the shifting target slow or fast, TAP is total asymmetry percentage of the SSC--speed of slow components--and TSAP is total asymmetry percentage of saccades). They carried out the statistical analysis of the results, which did not show peculiar difference between child and adult OKN. The result of the test was independent of the side first tested and of sex. The authors have tried to identify the normal range of values more suitable to the study of child OKN; on the basis of the calculation of the 95% percentile the normality range was wider than the range assumed for adults. The authors have also tried to subdivided the results for three different groups of age (I = 3-7 years; II = 8-11 years; III = 12-14 years) in order to observe the degree of OKN maturation with age. From the results obtained the maturation of OKN pathways seems to occur in the 7th year of age for the slow movements; the findings related to the fast movements are more doubtful and need further analysis. Finally, although the number of saccades interposed to the tracings depends on enormous variations unrelated to age, sex and first side tested, our data show their higher incidence during the slow test.

Subepithelial B cells in the human palatine tonsil. II. Functional characterization.

This study investigates the main functional features of subepithelial (SE) B cells and compares them with those of purified germinal center (GC) and follicular mantle (FM) B cells isolated from the same tonsils. Unlike FM B cells, SE B cells failed to produce polyspecific antibodies in vitro; unlike GC B cells, SE B cells expressed high levels of Bcl-2 and failed to undergo spontaneous apoptosis in vitro. The most striking function of SE B cells was their ability to produce IgM antibodies to T cell-independent type-2 (TI-2) (but not to TI-1) antigens (Ag). These antibodies could not be detected when both FM and GC B cells were stimulated with TI-2 Ag in vitro. Moreover, B cells isolated from peripheral blood were unable to mount a response to TI-2 Ag. The latter finding is consistent with the observation that B cells with the phenotypic features of SE B cells were virtually absent in the peripheral blood and emphasizes the notion that SE B cells belong to a subset of non-recirculating B cells. SE B cells were by far superior to FM B cells in mixed lymphocyte reaction (MLR) stimulation of allogeneic T cells in vitro, although they were not as efficient as dendritic cells (DC). In order to stimulate T cells efficiently, SE B cells had to be exposed to anti-mu antibody, a treatment which induced expression of activation markers such as CD80, CD86, CD69 and CD39, usually absent in resting SE B cells. CD80 and CD86 molecules expressed by SE B cells participated in the chain of events required to promote the proliferation of allogeneic T cells as demonstrated by inhibition tests with the appropriate mAb. The expression of CD80 and CD86 by anti-mu-treated SE B cells was not, however, the sole explanation for their good antigen presenting capacities since the exposure of FM B cells to anti-mu antibody also induced expression of these surface structures. Nevertheless, these cells failed to become good MLR stimulators. Collectively, the above data contribute further to the characterization of a distinct subset of tonsillar B cells which resemble, both phenotypically and functionally, the B cells of the splenic marginal zone.

Study of labyrinthine function in children using the caloric test: our results.

We studied caloric responses in a group of 42 healthy children aged between 4 and 14 years and compared the results with those obtained with the same method and equipment in a control group of 57 healthy adults at the Methodist Hospital Electronystagmography Laboratory at Houston (Texas). The average response in children appeared to be rather low. The confidence regions for unilateral weakness (UW) and directional preponderance (DP) measures were much wider in children than in adults. The confidence limit for bilateral weakness (BW) was lower in the children. The confidence limit for the fixation index (FI) in the children, however, was close to that in adults.

Production rate and composition of cerumen: influence of sex and season.

The production rate and composition of cerumen have been studied in 11 participants (5 men and 6 women), 25 to 42 years old. The cerumen was obtained in January, May, July, and November to investigate the possible influence of the season. Only the triglyceride content decreased from November to July. Sex was not a factor, which supported the hypothesis that sex hormones play a minor role in the production rate of the lipid component of cerumen.