Correlation of findings at direct laryngoscopy and bronchoscopy with gastroesophageal reflux disease in children: a prospective study.

OBJECTIVE: To correlate direct laryngoscopic and bronchoscopic findings with the presence of positive test results for gastroesophageal reflux disease (GERD) in children. DESIGN: Prospective collection of structured data. SETTING: An academic pediatric otolaryngology department. PATIENTS: Seventy-seven consecutive patients who underwent direct laryngoscopy and bronchoscopy between June and October 1999. INTERVENTIONS: During direct laryngoscopy and bronchoscopy, descriptions of 7 laryngeal and 6 cricotracheal findings were recorded on a 3-point scale (i.e., absent, mild, or severe). Medical records were later reviewed to obtain results of the following tests, if they were part of the record: gastric scintiscan, 24-hour pH probe monitoring, upper gastrointestinal tract series, and esophageal biopsy. MAIN OUTCOME MEASURES: Correlation of mucosal abnormalities with the presence or absence of a positive test result for GERD. RESULTS: Fifty (65%) of 77 patients had GERD diagnosed with at least 1 positive test result, 21 (27%) had no clinical symptoms and no positive GERD test results, and 5 (7%) had clinical symptoms but no positive test results. There were significant differences for total laryngeal and cricotracheal scores (P<.001) between the groups with positive and negative results. Significant differences were as follows: in the larynx-large lingual tonsil (P<.001), postglottic edema (P<.001), arytenoid edema (P<.001), ventricle obliteration (P =.03), and true vocal fold edema (P = .001), and in the cricotracheal region-general edema and erythema (P =.003) and blunting of the carina (P<.001). Severe arytenoid edema, postglottic edema, or enlargement of lingual tonsil were pathognomonic of GERD. CONCLUSION: Many direct laryngoscopic and bronchoscopic findings correlate well with the diagnosis of GERD as determined by using other tests.

Complications in pediatric tracheostomies.

OBJECTIVE: To examine complications of pediatric tracheostomy. STUDY DESIGN: Retrospective. METHODS: Chart review of children undergoing tracheotomy or laryngeal diversion between 1990 and 1999. RESULTS: Charts of 142 children were examined. Average age was 2.64 years (standard deviation [SD], 4.73 y) at surgery. Duration of tracheostomy was 2.08 years (SD, 1.72 y) for those decannulated, 3.12 years (SD, 2.5 y) for those still with a stoma, and length of follow-up for the whole group was 4.14 years (SD, 8.69 y). At last follow-up, 56% had a tracheostomy, 29% had none, and 15% had died; one death was tracheostomy-related. Three percent had intraoperative complications, 11% had complications before the first tracheostomy tube change, and 63% had complications after the first tube change. Thirty-four percent had a trial of decannulation; 85% of these were successful. Fifty-four percent of those decannulated had complications. Number of complications was not related to duration of follow-up. In-hospital mortality was congruent to mortality predicted by PRISM (Pediatric Rate of Mortality) scores. CONCLUSIONS: Forty-three percent had serious complications involving loss of the tracheostomy airway (tube occlusion or accidental decannulation) or requiring a separate surgical procedure. Deaths directly attributable to tracheostomy complications occurred in 0.7%.

Incidence of reflux in young children undergoing adenoidectomy.

OBJECTIVE: To compare the incidence of gastroesophageal reflux disease (GERD) in children under 2 years of age who have symptomatic adenoid hypertrophy requiring surgical removal or who have otitis media with effusion requiring ventilation tube insertion without adenoidectomy. STUDY DESIGN: Retrospective chart review. SETTING: An academic pediatric otolaryngology unit. PATIENTS: All children under age 2 undergoing adenoidectomy (Ad group) between January 1998 and May 2000 were compared with children in the same age range having ventilation tube insertion without adenoidectomy (VT group). MAIN OUTCOME MEASURES: Whether a diagnosis of GERD was made, how it was made, GERD treatment, and resolution of symptoms were compared. RESULTS: There were 95 children in the Ad group and 99 in the VT group. GERD incidence was significantly higher in the Ad group where it was 42% versus 7% in the VT group (P < .001). In the Ad group, 88% of children age 1 or less had GERD, and 32% of those older than 1 had GERD diagnosed. In the VT group, 14% of patients age 1 or less and 2% of those older than 1 had a diagnosis of GERD. CONCLUSIONS: Children under age 2 with symptomatic adenoid enlargement requiring adenoidectomy have a significantly higher incidence of GERD than children in the same age group presenting with otitis media requiring ventilation tube insertion.

Success rates in paediatric tympanoplasty.

OBJECTIVE: To determine if the success of paediatric tympanoplasty is dependent on certain criteria, which are determinable prior to surgery. DESIGN: Retrospective chart review. SETTING: An academic paediatric otolaryngology department. PATIENTS: Seventy-seven patients who had undergone tympanoplasty with or without ossicular reconstruction, but without mastoidectomy, between April 1997 and May 1999. MAIN OUTCOME MEASURES: Status of the repaired tympanic membrane at last follow-up visit measured by otoscopic examination and with tympanometry. RESULTS: Eighty-nine tympanoplasties were performed during this period. The age range was 2.9 to 22 years. The success rate was 75% overall. For patients younger than 11 years (n = 43), the success rate was 82%, and for those 11 to 18 years (n = 44), it was 74%, which was not significantly different. In 18 patients 7.5 years or younger, the success rate was 79%. Perforation location, size, presence of myringosclerosis, status of the other ear or nose, history of the perforation, surgical approach, middle ear findings, canal packing, and gender were not shown to be significantly different between successful and unsuccessful tympanoplasty groups. CONCLUSION: These young patients had a good success rate post-tympanoplasty, which we believe reflects less severe disease. These results mitigate against delaying tympanoplasty in young children.

Persistent cerebrospinal fluid otorrhea: a case of Munchausen's syndrome by proxy.

A case is presented of a young child who initially presented with recurrent bacterial meningitis 1 year after significant head trauma and was found to have cerebrospinal fluid (CSF) leakage into the middle ear. Surgical procedures were devised to attempt to stop this abnormal flow, but inexplicably clear otorrhea biochemically identical to CSF persisted for weeks. The child's mother was apparently soaking the surgical dressings with CSF obtained through a lumbar drain and confessed to this activity after she was found to have tampered with an intravenous catheter. This activity resulted in a prolonged hospital stay and several presumably unnecessary procedures. Munchausen's syndrome, typified by intentional mimicry of symptoms of serious illness backed by plausible medical history, is well-described. Rarer is the syndrome by proxy, where parents and/or caregivers, by falsifying histories, fabricating laboratory evidence, or deliberately generating bodily lesions, cause unneeded diagnostic and therapeutic procedures to be performed on their young victims. This form of child abuse is hidden by the perpetrator's apparent concern and involvement in the care of the victim. The literature is reviewed, this form of abuse is discussed, and the role of communication of suspicion between the various health care workers is stressed. The medical and social settings in which this disorder is prevalent are covered. Early detection of this entity is essential in rescuing the victim from life-threatening abuse and in obtaining appropriate therapy for the abuser.

Cochlear nerve activity after intense sound exposure in neonatal chicks.

1. Single-neuron behavior in the cochlear nerve of neonatal (3-day-old) chicks was examined after exposure to a 120-dB SPL pure tone (0.9 kHz) for 48 h. Exposed animals were tested after 0 days or 12 days of recovery. Nonexposed chicks, age-matched to the exposed animals, formed two control groups. 2. Spectral response plots were obtained from each cell. These plots described the neuron discharge rates in response to 1,767 tone burst stimuli, each with a unique frequency-intensity combination. The tone bursts were presented at frequencies between 0.1 and 4.5 kHz and for intensities between 0 and 100 dB SPL. From these plots the characteristic frequency (CF), CF threshold, and sharpness of tuning (Q10 dB) were derived for each cell. Frequency response-area functions at selected stimulus levels and rate-intensity functions at the CF were also constructed from the spectral response plots. In addition, spontaneous activity was determined. Data were obtained from 903 cells. 3. Neuron activity in the control cells revealed no differences between CF thresholds, Q10 dB, or spontaneous activity in the two age groups. However, age differences at all frequencies were noted in the rate-intensity functions. 4. A frequency-dependent loss in CF threshold was observed in the 0-day recovered cells. The threshold shift (relative to age-matched control cells) was 55-65 dB between 0.8 and 1.5 kHz, but only 10-15 dB between 0.1-0.4 kHz and 2.5-3.5 kHz. The exposed cells showed no loss in frequency selectivity (Q10 dB) at < 0.5 kHz, whereas above this frequency an increasing deterioration in tuning was noted. Spontaneous activity in the 0-day cells was suppressed across the entire range of CFs. The rate-intensity function of exposed cells had a steeper growth rate than that of control cells. 5. At 12 days of recovery, CF threshold, Q10 dB, and spontaneous activity all recovered to the levels exhibited by age-matched control cells. However, the rate-intensity function for cells with CFs between 0.8 and 1.0 kHz showed abnormal growth and higher discharge rates at saturation than the control cells. Outside of this frequency range the rate-intensity functions of control and exposed cells were similar to each other. 6. Recovery of function in the sound-damaged chick ear is accompanied by almost complete repair of the basilar papilla. The tectorial membrane, however, retains a major defect and only the lower layer of this membrane regenerates. An important observation in this presentation was the abnormal rate-intensity functions (in the 12-day recovered cells) reported for frequencies served by that region of the sensory epithelium where the tectorial membrane defect was found. This observation may be related to sustained structural damage to the short hair cell region of the papilla and/or alterations in the efferent control of papilla function mediated by the short hair cells.

The effects of exposure to intense sound on the DC endocochlear potential in the chick.

Chicks were exposed to an intense pure tone (0.9 kHz, 120 dB SPL) for 48 h. The DC endocochlear potential was measured with a microelectrode inserted into scala media in six separate groups of animals between 0 and 12 days post exposure. Similar data were obtained from seven groups of unexposed control chicks between 2 and 15 days of age. One to nine animals were tested in each control or exposed group. The results in the control chicks revealed that the EP at 2 days of age (6.7 mV) was 36% of the mature value (15.2 mV) noted at 6 days of age. In the exposed animals, at 0-days recovery, the EP showed a 63% reduction relative to that measured in age matched control chicks. The level of EP in the exposed animals quickly recovered, and by 3 and 6 days post exposure exhibited a loss of only 7 and 3 percent relative to the age-matched controls. The recovery of EP was plotted against the recovery of evoked potential thresholds reported by others, and the time-course of the recovery functions were very similar. This relationship suggested that recovery of auditory function in the chick was highly correlated with the restoration of the EP. Damage to the tegmentum vasculosum and its capacity to secrete potassium, as well as the shunting of current through the damaged basilar papilla, are considered as mechanisms for the reduction of EP loss in the exposed ear.

Recovery of auditory function and structure in the chick after two intense pure tone exposures.

Groups of neonatal chicks were examined in three experimental conditions that differed in the age and number of times they were exposed to a pure tone of 0.9 kHz at 120 dB SPL for 48 h. Several animals were exposed once at 2 or 16 days of age, while others were subjected twice to the above stimulus, first at 2 days and then at 16 days. Evoked potential measures of threshold shift, obtained at 0, 12 or 26 days post-exposure, were used to determine the degree of hearing loss and recovery. The average threshold loss in the mid-range frequencies was about 57 dB at 0 days for all three conditions. This level was reduced to about 15 dB in all three groups at 12 days of recovery, while in birds exposed once at 2 days, but allowed 26 days to recover, the post-exposure thresholds returned to pre-exposure levels. Scanning electron microscopic analysis of cochlear structure was conducted in groups of similarly exposed and recovered animals. Twelve days post-exposure, the structural analysis revealed regeneration of a single honeycomb-like tectorial membrane layer in both the once and twice-exposed cochleae. However, damage to, and repair of, the tectorial membrane after the second exposure revealed the production of a second honeycomb layer in about half the animals examined. The results indicated that chicks retain the capacity to repair receptor epithelium damage and recover considerably from hearing loss after multiple exposures to intense sound.

Tracheo-gastric fistula following gastric pull-up.

Tissue damage from gastric acid may be more prevalent than currently believed following gastric pull-up. An intense anti-acid medical regimen should be instituted peri- and postoperatively. In cases where significant peptic ulcer disease exists preoperatively, an alternative means of reconstruction following laryngo-pharyngo-esophagectomy should be considered.