Mastoid subperiosteal abscess in children: drainage or mastoidectomy?

OBJECTIVE: To evaluate the management of mastoid subperiosteal abscess using two different surgical approaches: simple mastoidectomy and abscess drainage. METHOD: The medical records of 34 children suffering from acute mastoiditis with subperiosteal abscess were retrospectively reviewed. In these cases, the initial surgical approach consisted of either myringotomy plus simple mastoidectomy or myringotomy plus abscess drainage. RESULTS: Thirteen children were managed with simple mastoidectomy and 21 children were initially managed with abscess drainage. Of the second group, 12 children were cured without further treatment while 9 eventually required mastoidectomy. None of the children developed complications during hospitalisation, or long-term sequelae. CONCLUSION: Simple mastoidectomy remains the most effective procedure for the management of mastoid subperiosteal abscess. Drainage of the abscess represents a simple and risk-free, but not always curative, option. It can be safely used as an initial, conservative approach in association with myringotomy and sufficient antibiotic coverage, with simple mastoidectomy reserved for non-responding cases.

Incidence of non-infectious 'acute mastoiditis' in children.

OBJECTIVE: The temporal bone may be the first involved site in cases of systemic disease, and may even present with acute, mastoiditis-like symptomatology. This study aimed to evaluate the incidence of such non-infectious 'acute mastoiditis' in children. MATERIALS AND METHODS: Retrospective chart review of 73 children admitted to a tertiary referral centre for acute mastoiditis. RESULTS: In 71 cases (97.3 per cent), an infectious basis was identified. In the majority of cases (33 of 73; 45 per cent), the responsible bacteria was Streptococcus pneumoniae. However, histopathological studies revealed a non-infectious underlying disease (myelocytic leukaemia or Langerhans' cell histiocytosis) in two atypical cases (2.7 per cent). CONCLUSION: 'Acute mastoiditis' of non-infectious aetiology is a rare but real threat for children, and a challenging diagnosis for otologists. A non-infectious basis should be suspected in every atypical, persistent or recurrent case of acute mastoiditis.

Results of endoscopic assisted probing for congenital nasolacrimal duct obstruction in older children.

PURPOSE: To evaluate the results of lacrimal probing with the use of nasal endoscopy and identify the anatomical anomalies responsible for the symptoms in older children. METHODS: Fifty-two eyes of 40 children with congenital nasolacrimal duct obstruction underwent primary probing of the lacrimal duct under general anaesthetic in conjunction with nasal endoscopy. Patients followed up for at least 6 months. Cure was defined as complete resolution of symptoms or minimal symptoms brought on by cold or wind. RESULTS: The age range was 12-126 months. In 30/52 (57.7%) eyes the symptoms were attributed to a single mechanical obstruction. Seven eyes had canalicular stenosis. Three eyes had upper nasolacrimal duct obstruction. Nine eyes had narrow duct and nine eyes had atresia of the distal end of the duct. Two eyes had only intranasal abnormalities. In 16/52 (30.76%) eyes a combination of anomalies was responsible for the symptoms. Nine eyes had canalicular stenosis in association with: either a membrane at the valve of Hasner in four, or a narrow duct in three, or intranasal anomalies in two. Two eyes had punctual stenosis and narrow duct. Two eyes had narrow duct and tight inferior turbinate. Three eyes had abnormal openings in association with stenotic ducts. Six (11.54%) eyes had functional blockage. With the use of endonasal endoscopy, intranasal anomalies identified in 12 eyes and treated in nine. One eye had large inferior conchae. One eye had inferior concha adherent to lateral nasal wall. One eye had redundant nasal mucosa. Three eyes had tight inferior turbinate. Three had abnormal openings. In three eyes the probe went submucosally. The overall success rate was 84.6% (44/52 eyes). Eight eyes remained unchanged. Endoscopically treated cases contributed to the overall success by 17.31%. CONCLUSION: Multiple anatomical anomalies within the lacrimal system and abnormalities of the nose are quite common in older children. Lacrimal probing remains the primary treatment and nasal endoscopy is a useful adjunct to probing increasing the success rate of the procedure.

Etiological diagnosis of bilateral, sensorineural hearing impairment in a pediatric Greek population.

Early diagnosis, evaluation and treatment of childhood deafness are essential for a child's normal growth. Etiological diagnosis of hearing loss makes prevention, family scheduling and more effective therapy feasible goals. Etiological assessment of sensorineural deafness still remains difficult although recently with the progress of genetics it has become more efficient. In this retrospective study, the etiology of bilateral, sensorineural hearing loss with indication for hearing aids has been studied in 153 hearing impaired children. Etiological diagnosis was based on family and patient record, physical, audiological and laboratory examinations. Among the 94 children who completed the diagnostic protocol etiological groups revealed the following distribution: non-hereditary acquired hearing impairment was present in 36 children (38%) and hereditary was present in 44 (47%) children. The etiology remained unknown in 14 (15%) children. Non-syndromic autosomal dominant type accounted for 13 (29% of hereditary hearing loss) children, non-syndromic autosomal recessive type for 21 (48%) children and syndromic deafness for 10 (23%) children. Modern diagnostic methods, such as genetic testing, help diminish the number of cases with hearing impairment of unknown etiology, for the benefit of children who receive early and appropriate medical, audiologic, genetic and educational counseling based on the etiology of their hearing loss.

Prelingual nonsyndromic hearing loss in Greece. Molecular and clinical findings.

Mutations in the gene encoding the gap-junction protein connexin 26 (GJB2) on chromosome 13q11 have been shown as a major contributor to prelingual, sensorineural, nonsyndromic deafness. One specific mutation, 35delG, has accounted for the majority of the mutations detected in the GJB2 gene in Caucasian populations and is one of the most frequent disease mutations identified so far with highest carrier frequency of 3,5% in the Greek population. In a collaboration with the major referral centers for childhood deafness in Greece, patients were examined by an extensive questionnaire to exclude syndromic forms and environmental causes of deafness and by allele-specific PCR for the detection of the 35delG mutation. The 35delG mutation was found in 32.1% of the alleles in 173 unrelated cases of prelingual deafness: 50 homozygotes and 11 heterozygotes. Individuals heterozygous for the 35delG mutation were further analyzed by direct genomic sequencing of the coding region of the GJB2 gene, which revealed R184P and 486insT mutations in single alleles. We conclude that the 35delG GJB2 mutation is responsible for one third of prelingual, sensorineural deafness in Greece, which is higher than the usually quoted 20% for Caucasian populations.

The change in the acoustic admittance phase angle: a study in children suffering from acute otitis media.

Middle ear mechanics, in normal and in pathological conditions, is the subject of this research, with acoustic impedance measurements as the cornerstone. Previous studies have established the importance of admittance-phase tympanograms, mainly in frequencies higher than the conventional 226 Hz. The purpose of the present study was to record how acute otitis media (AOM) affects the middle ear system and function by evaluating the recordings of the change in phase angle parameter (deltatheta) provided by an automated tympanometer using the sweep-frequency technique. Multifrequency and conventional tympanograms were obtained from 70 children suffering from AOM on consecutive visits. Values of deltatheta from these subjects were compared to normative data previously acquired in our Department. It appears that changes in the mechanical status of the middle ear after AOM are reflected in abnormal deltatheta values, despite the normal findings of conventional tympanometry. A positive history of AOM did not seem to influence the behaviour of the middle ear. In most cases, abnormal deltatheta values coexisted with abnormal values of resonance frequency (RF), i.e. the frequency at which mass and stiffness of the middle ear are in balance, and total susceptance (deltaB) reaches 0mmhos and the converse. The deltatheta seems to be an important indicator of middle ear mechanical status that can record changes occurring in the system after AOM and undetected by low probe-tone tympanometry.

Hearing loss in speech-language delayed children.

An infant begins to communicate with his/her environment from the first months of life. However, true words do not appear until the age of 12-15 months, following a rather predictable sequence. Delay or failure of normal language development is not a rare situation in childhood and may be due to a variety of reasons. Among these, hearing undoubtedly plays a leading part in the language acquisition process. The purpose of this study was to assess the percentage of hearing-impaired children in a group of phenotypically healthy children presenting with speech-language delay. Between March 1993 and March 1999, 726 speech-language delayed children were examined in our department. In 72 of them, various diseases or syndromes had already been diagnosed and so they were excluded from the study. The remaining 654 apparently healthy children entered the study and underwent a thorough audiological assessment for determination of their hearing thresholds. Eighty-seven children (13.3%) showed various degrees of hearing loss. Most of them (55 children, 8.4%) suffered from sensorineural hearing impairment, while in 32 children (4.9%) a conductive hearing loss was discovered. The increased prevalence of hearing impairment found in our population mandates a thorough hearing evaluation for every case of speech-language delay, even for those children who show no evidence of other handicaps. This will help in the early diagnosis of hearing loss, allowing proper management to be instituted as early as possible.

Evoked otoacoustic emissions--an approach for monitoring cisplatin induced ototoxicity in children.

OBJECTIVES: Cisplatin chemotherapy is associated with an increased risk of ototoxic changes. The incidence of hearing loss after the 1st cisplatin-infusion session is only scarcely mentioned in the international literature. With increasing survival rates, prevention and/or early detection of ototoxicity are important for providing management options. The predictive value of pure-tone audiometry in early detection of ototoxicity has been questioned, particularly in the higher frequencies. Otoacoustic emissions appear to be more sensitive to cochlear insult than the conventional pure-tone audiometry. The aims of our study was (a) to define the extent of hearing damage in children after the 1st cisplatin-infusion session (50 mg/m(2)); and (b) to compare the efficacy of otoacoustic emissions (transient evoked otoacoustic emissions, distortion-product otoacoustic emissions) with that of pure-tone audiometry as methods of audiological monitoring. METHODS: Baseline audiometric (0.25-8 kHz) and otoacoustic emission testing (transient evoked otoacoustic emissions, distortion-product otoacoustic emissions) was conducted in 19 children, 12 of whom met the criteria for inclusion in the final study. Comparisons were performed between baseline measurements and those recorded after the 1st cisplatin course. Transient evoked otoacoustic emissions were analyzed in terms of emission level and reproducibility as a function of frequency (0.8-4 kHz). Distortion-product otoacoustic emissions were obtained as DP-grams and I/Q functions at 4,6 and 8 kHz. The DP-gram amplitude, the dynamic range and the detection thresholds from the I/Q functions were determined for each child. RESULTS: Threshold changes from baseline were founded to be statistically significant from 4-8 kHz in 50% of the children (P<0.01). Transient evoked otoacoustic emissions revealed a significant decrease in the emission level and in the reproducibility at the highest frequency tested (4 kHz, P<0.01), reflecting the results seen in pure-tone audiometry. Distortion-product otoacoustic emissions demonstrated a significant threshold shift, a reduced dynamic range and a decreased amplitude in the frequencies >3 kHz (P<0.05). Furthermore, DP-gram amplitude also reduced significantly at 3 kHz (P<0.05) without any similar change in pure-tone audiometry. CONCLUSIONS: A significant high-frequency hearing loss is identified in children even after one low-dose cisplatin-infusion session. As ototoxicity screening tools DP-grams were extremely sensitive and superior to pure-tone audiometry and/or transient evoked otoacoustic emissions. Their use is recommended for regular monitoring of cochlear function, aiming in prevention of permanent damage. Some suggestions for reducing the potential for cisplatin ototoxicity (chemoprotective agents, gene therapy, inhibition of apoptosis) are also discussed.

Incidence of hearing loss among children presented with speech-language delay.

Infants' first attempts to communicate with their environment begin shortly after birth. However, real words appear by age of 12-15 months. Any delay in expressing their needs verbally beyond this age is defined as speech delay and may be associated with a variety of pathological conditions. The aim of this study is to investigate the incidence of hearing impairment in those children presented with speech delay. Ninety-one speech-delayed children were audiologically assessed between March 1993 and March 1995. In 25 out of 91 children (27.4%) a moderate to severe hearing loss was detected, either sensorineural or conductive. The increased incidence of hearing impairment found in this group mandates a thorough hearing evaluation for any case of speech-language delay.

Towards a universal newborn hearing screening.

Hearing loss is a common problem which, if remaining undetected during early childhood, could affect the patient's linguistic and mental abilities permanently. Although recommended, mass hearing screening has so far been problematic or even impossible due to several reasons. The available otoacoustic emission devices appear to be effective tools for universal hearing screening. The aim of this study is to evaluate the reliability and practicability of a new device for recording click-evoked otoacoustic emissions (cEOEs) on a pediatric population. Sixty children aged between 6 days and 14 years were evaluated audiologically both by auditory brainstem responses (ABR) and otoacoustic emissions. The latter were obtained by using the well-known ILO88v3.92 otoacoustic analyser and a new, portable device ('Echocheck', Otodynamics Ltd, UK). Sensitivity and specificity of cEOEs recorded by 'Echocheck'was found to be 93% and 91%, respectively, when compared to ABR results. Additionally, 'Echocheck' recordings were proved to be much easier to perform, needing considerably less time in comparison with those of the ILO88 system. In our opinion, 'Echocheck' as well as all similar portable devices--screeners--may represent a much-desired solution for implementing universal hearing screening programmes.

Comparison of neonatal transient evoked otoacoustic emission responses recorded with linear and QuickScreen protocols.

Linear and QuickScreen (non-linear) transient evoked otoacoustic emission (TEOAE) protocols were compared in terms of standardized clinical parameters in order to define the protocol producing recordings with the highest signal quality. Neonatal responses (520) were obtained from three different screening sites. The linear recordings were evoked by 69 and 75-dB p.e. SPL clicks. All responses were post-windowed by a 3.5- to 12.5-ms window, chosen by time-frequency analysis as the segment representing 97.35 per cent (linear) and 95.6 per cent (quick) of the total cumulative spectral energy. Evidence from hearing loss cases and the high similarity between the profile contours of the QuickScreen and the linear normal recordings have strongly suggested that a linear response evoked by a 75-dB p.e. SPL stimulus and post-processed by a 3.5 to 12.5 window is free of stimulus artefacts. The data indicate that the 75-dB linear protocol produces higher signal to noise ratios at 2.0, 3.0, and 4.0 kHz, higher wave reproducibility, and lower TEOAE noise values than the QuickScreen protocol.

Otoacoustic emissions--an approach for monitoring aminoglycoside induced ototoxicity in children.

OBJECTIVES: The early detection of hearing impairment caused by ototoxic drugs, such as aminoglycosides, has been the aim of research world-wide. Histopathological studies have shown that the outer hair cells are the most susceptible cochlear components to injury from ototoxic drugs like aminoglycosides. Otoacoustic emissions reflect the functional status of the outer hair cells and constitute the only non-invasive means of objective cochlear investigation. The aim of this study was to evaluate the potential of otoacoustic emissions in early identification of aminoglycoside-induced cochlear dysfunction. In addition, a comparison with pure-tone audiometry or auditory brainstem responses was performed in order to determine if this test might provide a more reliable method of monitoring early ototoxic insults to the cochlea. METHODS: Twenty four children receiving gentamicin (4 mg/kg once daily) for 6-29 days were included in the study. Eleven children received gentamicin for up to 7 days (group A), while 13 underwent longer-term therapy lasting 8-29 days (group B). Hearing was serially monitored using transient evoked otoacoustic emissions and pure-tone audiometry (0.25-12 kHz) or auditory brainstem responses for younger or uncooperative children. Transient evoked otoacoustic emissions data were analysed in terms of emission amplitude and response reproducibility as a function of frequency. RESULTS: All patients yielded a normal baseline audiometric assessment upon hospital admission. For group A patients no significant changes in hearing levels were observed either by pure-tone audiometry (P = 0.2), auditory brainstem responses (P = 0.3) or transient evoked otoacoustic emissions (mean response: P = 0.06, reproducibility by frequency: P > 0.05). For group B patients no significant changes in hearing levels measured by pure-tone audiometry (P = 0.1) or auditory brainstem responses (P = 0.4) were observed. Transient evoked otoacoustic emissions however revealed a statistically significant decrease in the mean response level (P = 0.017) and in the reproducibility over the whole frequency spectrum (1 kHz: P = 0.0057, 2 kHz: P = 0.0247, 3 kHz: P = 0.0134, 4 kHz: P = 0.0049, 5 kHz: P = 0.0019). CONCLUSIONS: The findings suggest that transient evoked otoacoustic emissions are an extremely sensitive measure of the early effects of aminoglycoside-induced injury to the peripheral auditory system. Therefore, their use is recommended for regular monitoring of cochlear function, in the presence of potentially toxic factors, aiming at prevention of permanent damage.

Prognostic value of multiple-frequency tympanometry in acute otitis media.

Multiple-frequency tympanometry (MFT) and conventional 226-Hz tympanometry were performed in 86 ears of children affected by acute otitis media (AOM) after therapy. In a 3-month follow-up period, the recurrence rate of AOM and persistence of middle-ear effusion in these children were evaluated in comparison with the early results of the two methods, as well as the relation of MFT findings to the possibility of development of AOM sequelae. It seems that abnormal resonant frequency values and recordings by MFT right after an episode of AOM indicate persistence of changes in the mass and stiffness balance of the middle ear, not demonstrated by conventional tympanometry, that could be responsible for a higher probability of AOM sequelae.

Otoacoustic emission-based hearing screening of a Greek NICU population.

The pressing need for early identification of hearing-disabled children has led to the development of several neonatal hearing screening programmes world-wide. Today otoacoustic emissions represent a widely used methodology for identification of neonatal hearing impairment. The purpose of the present study is to determine the sensitivity and specificity of click-evoked otoacoustic emissions (cEOAEs) in a Greek NICU population and compare the cEOAE data to the final hearing status of these children. A total of 438 ears of 223 neonates at high risk for hearing impairment were tested with both brainstem response audiometry (ABR) and cEOAEs. In 107 neonates the final hearing status was determined by using behavioural and playtone audiometry, at an age greater than 2 1/2 years. The sensitivity and specificity of the cEOAEs were found to be 90 and 92.4% when compared to ABR results and 90.9 and 91.1% when compared to the children's hearing status, respectively. Click-EOAEs have been proved to be highly effective in determining whether or not hearing impairment really exists. Since conventional ABR does not meet the requirements for large scale screening programmes, the cEOAEs represent a reliable alternative.

Profound hearing loss and presence of click-evoked otoacoustic emissions in the neonate: a report of two cases.

Evoked otoacoustic emissions using click stimulus (cEOEs) were recorded in 450 consecutive children over a 12-month period. Of this group, 102 were babies treated in neonatal intensive care unit (NICU), classified as High Risk neonates according to the criteria of the Joint Committee on Infant Hearing. Audiologic examination in the latter was completed by auditory brainstem responses (ABR). Two of the neonates showed a profound hearing loss accompanied by strong cEOEs. The two cases are described and discussed together with the possibilities and limitations of transient evoked otoacoustic emissions in the auditory screening of the neonatal population. Despite the reported rare possibility of pure retrocochlear disorders, when cEOEs are used for neonatal screening purposes there is an actual risk of missing a profound hearing loss. Nevertheless, the use of cEOEs in combination with ABR may contribute to the differential diagnosis between cochlear and retrocochlear lesions.

Evaluation of acoustic reflectometry in detecting otitis media in children.

Accurate detection of middle-ear effusion in children is not only useful but also necessary for diagnosis, management and follow-up of otitis media. A relatively new device, the Acoustic Otoscope (model 101, ENT Medical Devices) has been introduced for detecting middle-ear fluid in children. We tested 158 ears and the diagnosis was confirmed by acoustic admittance, acoustic reflex and pneumatic otoscopy. We propose 4.5 as a better breakpoint (the number on the vertical scale of the instrument which is the lower limit indicating middle-ear effusion) than 4.0 which is proposed by the manufacturer. In our results the 4.5 breakpoint maximizes both positive and negative predictive values (83 and 82% respectively) with satisfactory sensitivity and specificity (86 and 79% respectively) in detection of otitis media. Our clinical experience with this instrument, during the past 2 years, has led us to conclude that it is simple, non-invasive and objective. Unlike tympanometry, it requires no hermetic seal and is effective even if the child is crying. However, it is not sensitive enough when there are bubbles or negative pressure in the middle ear. When the user is aware of the flexibility of the instrument's breakpoints (in our opinion this is an advantage of the device) for different uses and different populations, the reflectometer often reduces the need for tympanometry and confirms the otoscopic examination.