Battery ingestion in children.

INTRODUCTION: Ingestion of batteries by children became more frequent in recent years, due to the increasing accessibility of electronic toys and devices to children. Due to their electrochemical composition, impacted batteries in the esophagus may cause an extensive damage. Following the removal of a battery, the post-esophagoscopy management is still controversial. CASE PRESENTATION: An otherwise healthy 8 year-old boy presented to the pediatric emergency room 3h after the unintentional swallowing of a lithium battery. On examination, the patient was diaphoretic and tachypneic. Plain PA chest film revealed a 2.5 cm diameter radiopaque round object in the upper esophagus. The patient was scheduled for an urgent rigid esophagoscopy which was performed 2h after admission. Esophagoscopy findings included an impacted lithium battery in an advanced emptying process at a level of 17 cm from the incisor teeth, with a 3rd degree ulcerative esophagitis. It was not possible to visualize either the distal esophagus or the stomach. A nasogastric tube was not inserted because of a significant risk for esophageal perforation if bluntly passed. Post-operative medical therapy included fasting, administration of intravenous antibiotic therapy, antacids, and steroids. Flexible esophagoscopy superior to the level of the mucosal injury performed one day later, revealed erosive esophagitis, without evidence of perforation. Upper digestive tract gastrografin swallow test performed 2 days after esophagoscopy did not demonstrate a leak from the esophagus, and oral feeding was carefully re-initiated. Treatment was discontinued the following day. Follow up on days 10 and 14 revealed a healthy child with normal swallowing. DISCUSSION: Battery ingestion-related injury results from direct pressure necrosis, local electrical currents and alkali leakage. Signs and symptoms of ingested battery are related to impaction duration, size of battery, battery content and peristaltic waves of the esophagus. Appropriate imaging studies should be performed to maximize identification of the foreign body before esophagoscopy. Esophageal stenting and adjuvant medical therapy (steroid therapy, antibiotic therapy and anti-reflux therapy) have a low evidence level of clinical benefit following caustic injuries from impacted batteries and spillage of their content to the esophagus. A judicious management should be tailored in each patient. Increased public and health personnel awareness is necessary to diminish the incidence of battery ingestion.

Nasopharyngeal cysts.

INTRODUCTION: Nasopharyngeal cysts are uncommon, and are mostly asymptomatic. However, these lesions are infrequently found during routine endoscopies and imaging studies. In even more rare cases, they may be the source for unexplained sinonasal symptoms, such as CSF rhinorrhea, visual disturbances and nasal obstruction. PURPOSE OF REVIEW: This presentation systematically reviews the different nasopharyngeal cysts encountered in children, emphasizing the current knowledge on pathophysiology, recent advances in molecular biology and prenatal diagnosis, clinical presentation, imaging and treatment options. SUMMARY: With the advent of flexible and rigid fiber-optic technology and modern imaging techniques, and in particularly prenatal diagnostic techniques, nasopharyngeal cysts recognition is more common than previous times and requires an appropriate consideration. Familiarity with these lesions is essential for the pediatric otolaryngologist.

Middle ear pressure change as a function of body position.

OBJECTIVE: To verify and assess immediate middle ear (ME) pressure changes as a function of body position. STUDY DESIGN: A prospective clinical trail. PATIENTS AND METHODS: Twenty-six adult volunteers having 52 normal, healthy ears had tympanometric ME pressures measured in an upright and recumbent positions. Recordings were obtained immediately after positioning and after 3 minutes. The main outcome measure was the pressure difference between upright and recumbent measurements, that is, positional ME pressure change. RESULTS: All ME pressure recordings were within (-)100 to (+)55 mmH(2)O. An instant and significant (P < .001) pressure elevation was recorded in all ears once position changed from upright to recumbent. The average pressure increment was 19 mmH(2)O. Once a recumbent ear was repositioned upright it demonstrated an immediate pressure drop and regaining the initial ME pressure. Assuming the volume of a normal ME cleft as 8 mL and following Boyle's law, an ME volume alteration of about 17 microL was required to induce such pressure change. CONCLUSIONS: Positional pressure changes were within the range of normal daily ME pressure variations. The instantaneous pressure changes and reversibility may be explained by filling and emptying of blood vessels within the ME cleft, following gravity causing an alteration of the aerated volume. Individual differences of pressure change may follow variability of ME cleft volume, its surface, and vessel density.

Oropharyngeal injuries in children.

BACKGROUND: Oral cavity and oropharyngeal injuries are common among pediatric patients seen in emergency rooms for head and neck trauma. The appropriate treatment of such injuries is often controversial. PATIENTS AND METHODS: Audit of 6 months' admissions to the pediatric emergency room in a secondary care referral center. Sixty-four patients were treated for various injuries. Charts were reviewed for relevant data. RESULTS: Description of distribution of types and sites of injuries and discussion of treatment recommendations. CONCLUSIONS: Most of oropharyngeal injuries heal without any intervention and therefore can be left untreated after being diagnosed. However, in certain injuries, treatment is indicated for better outcome results.

Acute otitis media and mastoid growth.

CONCLUSIONS: This study implies that the hypothesis that acute otitis media (AOM) in infancy inhibits the growth of the mastoid system cannot be accepted. OBJECTIVE: To establish a relationship between AOM in children and their mastoid pneumatization development. PATIENTS AND METHODS: Lateral Schüller mastoid radiographs (LMRs) were measured in two groups of children at ages 2-11 years. Group A (n=116) had a history of recurrent AOM; group B (n=108) had no such history. Patients were treated in a private clinic. Data were analysed at Tel Aviv University. The patients had their LMR taken and measured planimetrically. LMR areas on left and right sides were compared in each group and age and were tested for possible differences using the paired Student's t test. When no left/right difference was detected, the values were averaged. Groups A and B were compared at different ages using two-tailed two-sample unequal variance and correlation coefficients. RESULTS: The analyses show that the LMR area became gradually and significantly larger with age in group A (R2=0.858; p<0.05). It did not develop significantly in group B.

Cochlear nerve size evaluation in children with sensorineural hearing loss by high-resolution magnetic resonance imaging.

PURPOSE: To determine differences in size of cochlear nerves among subjects with deafness due to connexin 26 (Cx26) mutations, subjects with deafness of unknown origin, and normal hearing subjects by sagittal high-resolution magnetic resonance (HRMR) imaging of the temporal bone. MATERIALS AND METHODS: Cross-sectional and surface areas and volumetric measurements of the cochlear nerve and modiolus were made on HRMR images of the internal auditory canal (IAC) and inner ear in the 3 groups of children (groups 1, 2, and 3). Three-way comparisons of in vivo cochlear nerve measurements on HRMR imaging were made among 17 children with sensorineural hearing loss (SNHL) and no obvious etiology for the hearing loss (group 1), 7 children with profound SNHL due to a Cx26 mutation (group 2), and 10 normal hearing children (group 3). RESULTS: Children with profound SNHL of unknown cause and children with profound SNHL due to a connexin mutation displayed hypoplastic cochlear nerves as compared with normal controls. HRMR imaging of the temporal bone was accurately delineated potential problems with cochlear nerves in 2 of 17 instances where high-resolution computed tomography did not do so. CONCLUSIONS: Accurate and specific measurements of the cochlear nerve and related structures is possible on HRMR imaging of the temporal bone. The size of the cochlear nerve is mildly hypoplastic in children with profound SNHL of unknown causes or children with a deafness-causing Cx26 mutation. HRMR imaging is superior to high-resolution computed tomography in the investigation of profound SNHL in children.

Modified endoscopic swallowing test for improved diagnosis and prevention of aspiration.

Laryngopharyngeal sensation is important in the normal process of swallowing, it is often impaired after neurological events and it has been common practice in such an occurrence to order non-oral tube feeding to prevent aspiration. This study assesses a novel approach to the evaluation of the laryngopharyngeal sensation that allows for improved triage of aspiration risk and more lenience towards oral feeding. This is a case series with follow-up period ranging from 6 to 24 months. Forty patients with neurological deficiencies were tested by a modified laryngopharyngeal sensation study that included evaluation of both supra and infra-glottis. All patients had impaired supra glottic sensation but had good infra glottic sensation that enabled cough protection. All had received oral feeding. Main outcome measure is incident aspiration pneumonia. Twenty-two patients maintained oral feeding without any evidence of aspiration. Eighteen patients had some aspirations associated with cough, and were maintained on modified oral feeding. Out of these 18 patients, four patients (10% of the entire group) developed aspiration pneumonia. The presented procedure identified patients with impaired supraglottic sensation but preserved good infra glottic sensation. This observation enables safe oral feeding in most patients and therefore offers a better quality of life for these individuals.

Cell adhesion molecules and cytokines in middle ear effusions in children with or without recent acute otitis media.

OBJECTIVES: We sought to compare the levels of cytokines and cell adhesion molecules in middle ear effusions (MEEs) of children with (group 1) or without (group 2) acute otitis media (AOM) within 3 months of obtaining MEE and to correlate these levels with hearing loss. DESIGN AND SUBJECTS: MEE were collected from children (49 and 51 children composed groups 1 and 2, respectively) with otitis media with effusion (OME) undergoing tube placement who had an audiogram performed preoperatively. MEE was assessed as serous or mucoid. Cytokines and cell adhesion molecules were measured by enzyme-linked immunosorbent assay. Data were analyzed with the Student t test, chi(2) test, and the Pearson correlation test. RESULTS: Concentrations of interleukin (IL)-1, IL-6, and vascular cell adhesion molecules (VCAM) were greater in the MEE of the children in group 1 compared with those of group 2 children. (P < 0.001 for IL-1 and IL-6; P < 0.05 for VCAM). The concentrations of IL-1, IL-6, VCAM, and E-selectin were greater in serous than in mucoid MEE. (P < 0.05). Concentrations of IL-6 correlated with the concentrations of the other 2 cytokines and the 3 cell adhesion molecules. Only concentrations of IL-6 in MEE correlated with the degree of hearing loss (P < 0.002). CONCLUSIONS: The inflammatory response leading to OME involves multiple cytokines regardless of an AOM episode in the 3 months before obtaining MEE. IL-6 is an important cytokine in the pathogenesis of OME.

Is secretory otitis media a single disease entity?

The outcome of 809 children who had middle ear effusion (MEE) was correlated with their age and medical history and the bacteriologic and cytologic findings of the MEE. Three groups emerged. Group A (n = 384) had a medical history of relatively recent acute otitis media (AOM) with a peak prevalence of 2.6 years of age, and its MEE was hypercellular (mostly polymorphonuclear leukocytes) with a 24% rate of positive bacteriologic culture. In contrast, the peak prevalence of group B (n = 280) was approximately 5 years of age. Its MEE followed no otologic medical history and was bacteriologically sterile with relatively few cells (mostly lymphocytes typical of viral infections). Group AB (n = 145) resembled group B except that they had a history of AOM some years before hearing loss onset. Altogether, the clinical features of group A are statistically distinguishable from those of groups B and AB in most respects. These findings explain the bimodal peak prevalence distribution that was found in many available epidemiological studies of secretory otitis media (SOM) and that was also seen in our data. It appears that SOM should neither be termed nor treated as an otitis media, but as a sequela of either bacterial AOM (group A) or of insidious, asymptomatic, probably viral otitis media (groups B and AB). Our data do not support antibiotic treatment for SOM (otitis media with effusion)--especially not in chronic cases.