Biological conditions affecting chronic inflammation in upper airways in children.

PROBLEMS/OBJECTIVES: A child's immune system cannot depend on a memory-type immune response and it also induces cytokine responses less efficiently. Biological conditions like allergy or cystic fibrosis, immune deficiency or gastrooesophageal reflux can induce and maintain background inflammation in children's upper airways, making newborns and children more susceptible to upper airway infections and inflammations. This paper will describe in brief how allergy, cystic fibrosis, immune deficiency, nasal and paranasal anatomical variants, and gastro-oesophageal reflux (GOR) can affect the immune and inflammatory responses in upper airways and how they could interfere with immunity development and maturation in children. METHODOLOGY: Literature review. RESULTS: Chronic inflammation induced by infection, allergy, cystic fibrosis or immune deficiency is multifactorial in origin and is strongly influenced by physiological, immunological, anatomical, environmental and, above all, genetic parameters. Finally, the direct role played by nasal and paranasal anatomical variants and GOR is also discussed. CONCLUSIONS: These conditions should be screened systematically in all children presenting chronic clinical features of upper airway inflammation.

Specific medical and surgical treatment for chronic inflammatory diseases in children.

Treatment for chronic inflammatory conditions in children should take into account the specific pathophysiological and clinical processes underlying these disorders. These guidelines provide a framework for both the medical and surgical treatment of chronic inflammatory diseases such as otitis media, allergic rhinitis and chronic rhinosinusitis, chronic inflammation of tonsils and adenoids, and laryngitis. In addition, the role of vaccinations and immunomodulatory therapies is discussed. Whenever possible, the evidence levels for specific treatments comply with the Oxford Levels of Evidence.

Apertura pyriformis stenosis in the newborn.

Apertura pyriformis stenosis in the newborn. Respiratory distress in the newborn can have a variety of aetiologies, the best known of which are cardiac and pulmonary diseases. Major nasal airway obstruction is probably often overlooked when acute desaturation of the neonate requires reanimation procedures, although it is well established that the baby is an obligate nose breather at birth. Nasal airway stenosis or atresia could account for a number of unexplained deaths in the delivery room. In the differential diagnosis of major nasal airway obstruction in the newborn, choanal atresia is by far the most common aetiology. However, a few cases of pyriform aperture stenosis have been reported. One child presenting this pathology was recently treated at the Brussels University Children's Hospital. Unexpectedly, the baby survived until 3 months without any medical support but had severe feeding problems. The diagnosis was confirmed by naso-sinusal CT scan. Surgery was performed at 4 months through an unusual endonasal approach which seems to be less traumatic than the classical sublabial approach. The post-operative course was satisfactory. The 9-month-old patient does not now show residual breathing problems. The presentation will focus on this unusual case.

Thyroid alar cartilage graft in paediatric laryngotracheal reconstruction.

OBJECTIVE: To evaluate the potential indications of thyroid alar cartilage (TAC) graft in the paediatric laryngotracheal reconstruction (LTR) population based on observations obtained in a case series of 27 consecutive infants referred to our tertiary care center. METHODS: Thyroid alar cartilage grafting was performed for limited Myer grade II and grade III subglottic stenosis requiring a single-stage laryngoplasty and for laryngeal enlargement after translaryngotracheal resection of endolaryngeal tumors. The evolution of the grafted area was evaluated prospectively during endoscopic follow-up. RESULTS: Twenty-five patients (92.5%) were successfully extubated after a mean of 5.1 days. No perioperative or postoperative complications were observed. The mean duration of graft harvesting was 7.7 min. Follow-up of the grafted area revealed one case of partial necrosis without prolapse into the lumen. The mean duration of graft epithelialization was 18.1 days (range: 12-30 days). Development of granulation tissue was observed in eight patients (32%) with a mean duration of granulation tissue persistence of 61.5 days (range: 7-155 days). Endoscopic follow-up did not demonstrate any pharyngolaryngeal asymmetry or feeding difficulties. CONCLUSION: This study demonstrated that the use of thyroid alar cartilage grafting is feasible for pediatric laryngotracheal reconstruction. The indications of thyroid alar cartilage graft should be reserved for moderated subglottic stenosis. The use of TAC reduced the operative time and cosmetic sequelae significantly. The healing of the grafted area was similar to those obtained with other types of graft. The TAC removal did not induce laryngeal deformation but longer follow-up is necessary to confirm this.

Embryology and epidemiology of cleft lip and palate.

Craniofacial anomalies, in particular cleft lip and palate, are major human birth defects with a worldwide frequency of 1 in 700 and substantial clinical impact. This article reviews the embryology of the face, lip, and palate to enhance the understanding of the pathogenesis of these lesions, with particular attention to the period of susceptibility during gestation, complexity, and the factors that may influence their development. It includes an overview of the prevalence and environmental and genetic causes of cleft lip-with or without cleft palate- and cleft palate.

Initial assessment of a neck mass in children.

OBJECTIVE: To propose national recommendations for the initial assessment of a mass in the neck in children. METHODS: Comprehensive review of the available literature and consensus discussion with national experts in the field. RESULTS: Consensus guidelines are proposed concerning the work up of children presenting with a mass in the neck.

Iodine-123 alpha-methyl-l-tyrosine single-photon emission tomography for the visualization of head and neck squamous cell carcinomas.

The uptake of iodine-123 alpha-methyl-l-tyrosine (IMT) in the primary tumours and metastatic lymph nodes of squamous cell carcinoma of the head and neck was examined with single-photon emission tomography (SPET). Eleven patients with biopsy-proven carcinomas were studied prior to any therapeutic action. The evaluation of cervical lymph node involvement was based on the findings of physical examination, computed tomography and magnetic resonance imaging, and in six patients on the histological data relating to tissue samples obtained by fine-needle lymph node aspiration or surgical intervention. SPET imaging was performed 10 min after the injection of 130-170 MBq IMT using a triple-head gamma camera equipped with medium-energy collimators. High-quality IMT SPET depicted the primary tumour in 10 of 11 patients (sensitivity: 91%). Tumours located in the larynx were visualized more clearly than those located in the mouth or oropharynx. The mean tumour-to-background ratio was 2.35 (range: 1.6-3.1) for laryngeal tumours and 1.67 (range: 1.2-2.2) for mouth and oropharyngeal tumours. Metastatic cervical lymph nodes were involved to various degrees in 8 of the 11 patients. Among these eight patients there were 16 sites, nine of which were detected by IMT SPET (sensitivity: 56%). If the IMT SPET findings were recorded per side of the neck, the sensitivity was 64%. Five of the seven missed metastatic lymph nodes were smaller than 15 mm. The mean tumour-to-background ratio of the scintigraphically visualized lymph nodes was 1.81+/-0.51 (range: 1.39-2.77). Asymmetric physiological submandibular salivary gland IMT uptake led to false-positive lymph node assessment in three patients. This study indicates the potential use of IMT SPET as a metabolic imaging modality in patients with head and neck squamous cell carcinoma.

Assessment of adenoid size in children by fibreoptic examination.

In order to investigate the relationship between the size of the adenoid and upper respiratory symptoms in children, fibreoptic examination of the nasal cavity and nasopharynx was performed in 817 children. The size of the adenoid was classified into three categories according to the distance between the vomer and the adenoid tissue. There was a significant relation between the size of the adenoid and the complaints of nasal obstruction (P < 0.001) and of snoring (P < 0.001), but not with the presence of purulent sinusitis. In the whole population, the size of the adenoid correlated well with the results of tympanometry (P < 0.001), but this does not hold in all age groups. This study has confirmed adenoid hypertrophy as a common aetiological factor in children with the complaints of nasal obstruction and snoring. The enlargement of the adenoid only partially explains the occurrence of otitis media with effusion. The introduction of the flexible fibrescope in the examination of the nasal cavity and nasopharynx in children is of great clinical value, especially in the selection of children for adenoidectomy. It is a minor invasive examination well tolerated by most children, giving more information than a lateral skull radiograph and avoiding unnecessary radiation.

The kinetics of the cytologic and rhinomanometric changes in the nose after challenge with allergen.

The objective of these experiments was to study the dynamics of the cytologic and rhinomanometric nasal reaction after allergen challenge. For this purpose a micro-suction system was developed to repetitively and atraumatically collect nasal secretions. Outside of the pollen season, four patients allergic to grass pollen were challenged with phosphate buffered saline (PBS) and, two weeks later, with grass pollen. Six control subjects were challenged with PBS only. Repetitive nasal secretion samplings over three days and rhinomanometry (PAR) were performed. Analysis of samplings taken before allergen challenge proved the atraumatic character of the micro-suction and provocation methods. Coupling the obtained dynamic data of nasal cytology and PAR, the following observations could be made: 1) Higher number of eosinophils in patients in the absence of antigen, compared to controls, suggesting a constitutional characteristic of atopy. 2) A close temporal association between cytological and clinical events occurring during the late phase of the allergic reaction. Nasal obstruction seems to be correlated with the influx of eosinophils rather than with their absolute concentration.

Toxicity of polybrominated biphenyls (PBBs) in Domestic and laboratory animals.

The composition, environmental fate, and effects of the polybrominated biphenyls (Firemaster BP-6 or FF-1) involved in the accidental contamination of cattle feed in Michigan in 1973 are reviewed. Toxic effects referred to in this report are limited to those occurring in domestic and laboratory animals and include general toxicity, neurobehavioral toxicity, immunotoxicity, reproductive toxicity, mutagenicity and carcinogenicity. The absorption, distribution, biotransformation and elimination of these polybrominated biphenyls are discussed along with the interactions with other chemicals and drugs.

Amino sugar sensitivity in Escherichia coli mutants unable to grow on N-acetylglucosamine.

Studies were conducted on two mutants of Escherichia coli that lack either glucosamine-6-phosphate deaminase or N-acetylglucosamine-6-phosphate deacetylase and which accumulate glucosamine-6-phosphate or N-acetylglucosamine-6-phosphate, respectively, when grown in the presence of N-acetylglucosamine. The addition of 10(-4) to 10(-5)mN-acetylglucosamine to these mutant strains caused a rapid and complete inhibition of growth on substrates that enter the catabolic pathways at or below the level of fructose-6-phosphate. Growth on glucose was inhibited to a lesser degree, whereas only minor inhibition occurred when the pentoses were used as substrates. Growth on gluconate was found to be totally unaffected by these levels of N-acetylglucosamine. The objective of this investigation was to determine the nature of this "amino sugar sensitivity" phenomenon and the conditions under which it could be overcome. It was found that this amino sugar sensitivity was abolished when an exogenous source of pentose such as uridine was included in the culture medium. Experiments are described indicating that the accumulated amino sugar phosphate metabolites interfere with an early step in hexose metabolism of both mutants, resulting in a pentose deficiency and consequent inhibition of growth on certain substrates.