The use of pulse transit time in pediatric sleep studies: A systematic review.

As a surrogate measure of blood pressure, pulse transit time (PTT) is commonly used in studies investigating arterial function and respiratory sleep disturbance. A systematic search of the literature was conducted with the aim of reviewing the usefulness of the technique within pediatric sleep studies. All studies that used PTT as a diagnostic tool during sleep in infants, children or adolescents were considered. The search yielded 425 articles, of which 21 full-text articles met inclusion criteria, the majority reporting on obstructive sleep apnea (OSA). PTT was used alongside polysomnography (PSG) in all studies. Several studies supported the potential of PTT to detect central apneic events in both infants and children and obstructive events in children, with implications for use as a screening tool for OSA, albeit with some limitations. Only one study validated PTT against blood pressure (BP), and only against systolic arterial pressure (SAP), showing significant negative correlations between PTT and SAP. PTT tracked well against BP and heart rate (HR) over acute cardiovascular perturbations in several studies. PTT is simple to execute, cost-efficient to run, and more tolerable than alternatives to measuring continuous BP in children. However its potential as a core clinical tool remains to be determined.

Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial.

Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.

Gabapentin for Perioperative Analgesia in Otorhinolaryngology-Head and Neck Surgery: Systematic Review.

OBJECTIVE: Recent research has investigated the role of gabapentin in perioperative pain relief in otorhinolaryngology-head and neck surgery. This review aims to identify whether sufficient evidence exists for the routine use of gabapentin in the perioperative setting. DATA SOURCES: MEDLINE, Cochrane CENTRAL, EMBASE, and Google Scholar. REVIEW METHODS: A comprehensive systematic search was performed with keywords for articles up to November 2015. The systematic review included all randomized, placebo-, and active-controlled trials investigating the role of perioperative gabapentin for pain in otorhinolaryngology-head and neck surgery. The studies were assessed for risk of bias and selected and reviewed by the main author. Selected trials were required to have data in the form of pain intensity scores, analgesic consumption, adverse effects, or return to normal function. RESULTS: A total of 14 randomized controlled trials were included, of which 4 had an active control. The placebo-controlled trials included 4 for tonsillectomy, 3 for rhinology, and 3 for thyroidectomy. These studies were not suitable for meta-analysis. Trial quality involving gabapentin in tonsillectomy surgery is variable. The higher-quality studies reported significantly reduced analgesic consumption in the gabapentin groups, with the effect on pain scores less clear. There was a significant benefit, within the first 24 hours, in pain and analgesic consumption as compared with placebo favoring the gabapentin groups following rhinologic and thyroid surgery. CONCLUSION: Overall, gabapentin appears to have a significant beneficial effect on perioperative pain relief and analgesic consumption in otorhinolaryngology-head and neck surgery procedures within the first 24 hours.

Natural history of snoring and other sleep-disordered breathing (SDB) symptoms in 7-year-old New Zealand children: a follow-up from age 3.

PURPOSE: We aimed to examine the natural history of snoring and associated symptoms in a community sample of New Zealand children at ages 3 and 7 years, and identify factors associated with habitual snoring at age 7 years. METHODS: Parent/s of children (n = 839) who completed the community survey about their child's sleep and breathing at age 3 years were re-contacted via mail 4 years later when children were aged 7 years. Parents were asked to complete a follow-up questionnaire which included items relating to their child's sleep and health, and family demographic information. There was a 54.8% (n = 460) response rate. RESULTS: At follow-up, habitual snoring was prevalent in 9.2% of the sample, similar to the 11.3% reported at age 3 years. However, habitual snoring status changed over time; 36.2% (n = 21/58) remained habitual snorers; 63.8% (n = 37/58) were no longer snoring habitually, while 5.3% (n = 21/397) had started habitual snoring since the initial survey. Overall, the reported severity of SDB-related symptoms decreased over time, regardless of initial habitual snoring status. Nonetheless, habitual snoring at follow-up was significantly associated with mouth breathing, sleeping with the neck extended, sweating profusely, night waking, and parent-reported child irritability. CONCLUSIONS: Our findings highlight the dynamic nature of SDB, where habitual snoring and related symptoms can develop, remain present, or resolve at different times, over early-mid-childhood years. Given the dynamic nature of habitual snoring over the early childhood years, pediatricians should continue to screen for snoring and sleep apnea on an annual basis throughout childhood.

Head and neck fascia and compartments: no space for spaces.

An accurate understanding of the arrangement of cervical fascia and its associated compartments is essential for differential diagnosis, predicting the spread of disease, and surgical management. The purpose of this detailed review is to summarize the anatomic, clinical, and radiological literature to determine what is known about the arrangement of cervical fascia and to highlight controversies and consensus. The current terminology used to describe cervical fascia and compartments is replete with confusing synonyms and inconsistencies, creating important interdisciplinary differences in understanding. The term "spaces" is inappropriate. A modified nomenclature underpinned by evidence-based anatomic and radiologic findings is proposed. This should not only enhance our understanding of cervical anatomy but also facilitate clearer interdisciplinary communication.

Cervical fascia: a terminological pain in the neck.

Although understanding the cervical fascia and its arrangement is an important part of anatomical, surgical and radiological training, it is inconsistently described in textbooks, which makes its study challenging and interdisciplinary communication confusing. This review examines the recommended textbooks for trainees of these disciplines in order to identify areas of agreement and controversy. Not only were the terms used variably between texts, but also key aspects of the anatomical descriptions associated with similar terms differed, contributing further to the confusion.

Pulse transit time and assessment of childhood sleep disordered breathing.

OBJECTIVES: To compare nocturnal polysomnography (PSG) with pulse transit time (PTT) recordings and structured clinical assessments and assess the reliability of these methods as a surrogate for the apnea-hypopnea index (AHI; calculated as the number of apneas/hypopneas per hour of total sleep time) and to test the associations between the clinical assessments and sleep disordered breathing (SDB). DESIGN: Prospective observational study. The parents of 51 children and adolescents filled out a questionnaire on SDB and the participants underwent examination. Scores from questionnaire and examination items were weighted according to their association with SDB. A total clinical score was assigned combining questionnaire and examination scores. SETTING: Hospital pediatrics department. PATIENTS: Children and adolescents aged 5 to 17 years undergoing standard PSG with the addition of PTT as part of a clinical investigation for SDB. MAIN OUTCOME MEASURES: The AHI and associations between the AHI and PTT arousal index (PTT-AI) and questionnaire, examination, and total clinical scores. RESULTS: We found a significant correlation between the AHI and PTT-AI (r = 0.55; P < .001). The relationship between the AHI and PTT-AI was stronger when the AHI was greater than 3. We also found significant correlations between the PTT-AI and the total clinical score (r = 0.38; P = .008) and the examination score (r = 0.44; P = .002) but not the questionnaire score (r = 0.23; P = .12). There was an association between the AHI and examination score in particular when the AHI was greater than 3. CONCLUSIONS: Pulse transit time shows promise as a screening test for SDB associated with an AHI greater than 3. For less severe SDB, the validity of using the PTT to separate these conditions from primary snoring has not been demonstrated in a clinical setting.

Surgical anatomy of the chorda tympani: a micro-CT study.

PURPOSE: Iatrogenic injury of the chorda tympani is a well-known complication of middle ear surgery, yet few studies have investigated the intraosseous course of the nerve. The aim of this study was to accurately delineate the posterior canaliculus in the temporal bone, particularly its relationship to the tympanic annulus, which is critical during the insertion of subannular ventilation tubes. METHODS: Forty temporal bones from 27 cadavers (15 male, mean age 75 years, 13 bilateral) were scanned using a micro-CT scanner, and standardised 3-D multiplanar reconstructions were generated using a software platform. The posterior canaliculus was measured in relation to reproducible bony landmarks. RESULTS: In 6 (15%) specimens, the chorda tympani originated from the facial nerve outside the skull and in 34 (85%) from within the facial canal at a mean of 3.2 ± 1.8 mm above the stylomastoid foramen. The posterior canaliculus was 12.3 ± 3.8 mm long and converged on the tympanic sulcus cranially. It entered the middle ear at 62 ± 10% of the height of the tympanic membrane. CONCLUSIONS: This novel micro-CT study defines the precise anatomy of the posterior canaliculus housing the chorda tympani and provides data that may help the otologic surgeon protect the nerve from iatrogenic injury.

Yeast colonization of voice prostheses: pilot study investigating effect of a bovine milk product containing anti-Candida albicans immunoglobulin A antibodies on yeast colonization and valve leakage.

OBJECTIVES: Our goals were to determine whether a bovine milk product containing anti-Candida albicans immunoglobulin A antibodies ("immune milk") could reduce the adherence of C albicans to voice prosthesis silicone in vitro, and whether administration of the milk could reduce C albicans colonization and voice prosthesis damage in vivo. METHODS: An in vitro assay of C albicans attachment to silicone was developed with radiolabeled C albicans. A pilot crossover in vivo trial, over 3 periods of 3 months, was also undertaken for 4 patients with voice prostheses, comparing daily administrations of immune milk and a control milk product. The prosthesis valves were replaced at each changeover and were assessed for wet weight of removable biofilm, yeast numbers in removable biofilm, valve leakage, and valve damage. RESULTS: Immune milk inhibited C albicans adherence to silicone in vitro. However, in a small clinical pilot study, this effect was not replicated. CONCLUSIONS: There is scope to further investigate the topical use of immune milk for management of voice prosthesis biofilms.

Childhood hearing and its relationship with tinnitus at thirty-two years of age.

OBJECTIVES: Tinnitus is associated with hearing loss in adulthood, often resulting from noise or age, but it is not known whether children's hearing and/or middle ear health predispose them to tinnitus in adulthood. METHODS: The participants were members of the Dunedin Multidisciplinary Health and Development Study, born in Dunedin, New Zealand, between April 1972 and March 1973. The base sample consisted of 1,037 children. Otitis media was assessed at 5, 7, and 9 years of age; audiometry and tympanometry findings were recorded at 11 years of age, and a detailed description of the tympanic membrane was made at 15 years of age. At 32 years of age, 970 of the 1,015 living study members (96%) answered questions about tinnitus. RESULTS: Children who had otitis media and a raised audiometric threshold went on to experience more tinnitus in adulthood than did those without middle ear disease or those who had otitis media without a raised threshold. In those who had recovered from otitis media, audiometric threshold elevation at lower and higher frequencies was associated with experiencing tinnitus in adulthood. Neither childhood otitis media alone nor elevated thresholds alone predicted adult tinnitus. CONCLUSIONS: Childhood otitis media with an associated hearing loss in the low and high frequencies was associated with a greater probability of experiencing tinnitus in adulthood.

Tympanomastoidectomy: planned second-look tympanotomy.

OBJECTIVE: To review the outcome following surgery for cholesteatoma/retraction pocket disease where second-look tympanotomy was recommended for selected patients. DESIGN: Retrospective outcome analysis following canal wall down mastoid surgery for cholesteatoma/retraction pocket disease. SUBJECTS: The study included 158 patients (163 ears) operated on between 1993 and 2003. Data were collected on the recommendation for second-look tympanotomy, the findings at second-look tympanotomy, and hearing threshold. RESULTS: Second-look tympanotomy was recommended for 36 patients, 32 had surgery, and 30 were free of residual disease. The respective mean pre- and postoperative bone conduction threshold was 8.9 dB and 18 dB for single-stage surgery and 15.8 dB and 16.8 dB for second-look tympanotomy. The mean preoperative air-bone gap (0.5, 1, 2, 4 kHz) was 27.1 dB for single-stage surgery and 27.9 dB for staged surgery. The 1-year air-bone gap was 24.6 dB and 28.6 dB, respectively. CONCLUSION: Planned second-look tympanotomy demonstrated excellent early disease control and allowed management of the middle ear pathology.

Personality and perception of tinnitus.

OBJECTIVES: Tinnitus has high prevalence and a wide range of etiologies and of impacts on sufferers. Our objective was to develop understanding of the role of personality in the perception of tinnitus in the general population. As a theoretical basis for this, we combined elements of a general model of signal detection with the ideas of ignition (development) and promotion (neural transmission) of tinnitus, and considered plausible roles for personality factors within this conceptual framework. DESIGN: We interviewed a birth cohort of 970 people aged 32 yr sampled from the general population. On the basis of questioning, we divided them into three groups, those without tinnitus, those with occasional tinnitus (including those with transient tinnitus of very brief duration), and those who experienced tinnitus most of the time. We also established how annoying or distressing the tinnitus was, and assessed personality using the Multidimensional Personality Questionnaire. RESULTS: Tinnitus was experienced rarely by 38.2% and half the time or more by 6.8% of those studied. Men and women did not differ in the amount of tinnitus reported, but women were more likely to find it annoying. People from lower socioeconomic backgrounds were more likely to report tinnitus. People with tinnitus were more socially withdrawn, reactive to stress, alienated, and less Self-Controlled. People who were more annoyed by tinnitus were more socially withdrawn, and men were more stress reactive and alienated. CONCLUSIONS: Our interpretation of the findings is that personality influences the persistence of tinnitus by influencing the tendency to be aware of it. Consideration of personality factors may improve the ability to tailor tinnitus therapies, and the concept of awareness may benefit treatment outcomes by showing tinnitus sufferers a means of internalizing the locus of control over their symptoms.

Childhood hearing is associated with growth rates in infancy and adolescence.

It is known that shorter stature is associated with sensorineural hearing loss; and that cochlear development is associated with activity of IGF 1, as are many important aspects of neurodevelopment. We hypothesized that this relation might be extrapolated to a normally hearing group, and that the strongest relation between hearing level and growth rate would be in late puberty, when serum IGF-1 levels are highest. We examined the statistical relation between childhood hearing threshold and rate of growth in height at different times during the life course up to age 32. We found mixed support for the hypothesis. The strongest relations were observed in late puberty, at the ages which previous research shows are associated with the highest serum concentrations of IGF-1 in males and females, but also in infancy and early childhood. The association between hearing and height is present in a normally hearing, general population sample, and is associated with growth in late adolescence. Our findings support the idea that childhood hearing threshold may be predictive of IGF-1 mediated developmental characteristics.

Variation in the normal hearing threshold predicts childhood IQ, linguistic, and behavioral outcomes.

Childhood hearing level varies considerably within the range considered normal. Four classes of outcome were investigated for associations with hearing thresholds in this range: ability to identify speech in noise, neurocognitive ability, linguistic ability, and behavior. The research was conducted in a general population cohort of 711 children with mean hearing threshold of 15 dB HL or better. Some outcomes: speech in noise, intelligence, and certain linguistic abilities, were predicted in both boys and girls; effects were stronger in girls. In girls only, poorer hearing predicted worse behavior. These effects remained after statistical control for childhood socioeconomic status and otitis media. Variability in normal hearing, due to causes other than otitis media, is associated with the listening, language, and neurocognitive abilities of children, and the behavior of girls. We suggest that these effects may be present for three reasons, cochlear insults, neurodevelopmental factors, and psychological factors. We discuss how these may interact to produce the effects observed.

The effects of childhood otitis media on the acoustic reflex threshold at age 15.

Previous research has found that childhood otitis media leads to elevated adulthood acoustic reflex thresholds because of worsened audiometric thresholds in the stimulation ear, and abnormality of the tympanic membrane in the ear from which acoustic reflexes were measured. To confirm and expand this finding, our research utilized longitudinal data from 631 general-population-sampled children assessed between ages 5 and 15. Otitis media was assessed to age 9, audiometric thresholds were measured at age 11, and otoscopy and acoustic reflex thresholds testing were performed at age 15. Our findings support the earlier research, in that acoustic reflex threshold was higher in those with the worst experience of childhood otitis media. However, this was directly mediated not by audiometric threshold in the ear to which the stimulus was delivered, but by the amount of tympanic membrane abnormality in both the stimulus and probe ears. This appeared to have an effect independent of audiometric threshold. Furthermore, only those who suffered the worst, persistent, binaural childhood otitis media showed raised acoustic reflex thresholds.

Changes in behavior and attentional capacity after adenotonsillectomy.

The objective of this study was to quantify behavioral and attention capacity changes in children aged 4-11 y before and 3 mo after adenotonsillectomy (A/T). Overnight cardiorespiratory recordings were performed in 61 "behaviorally normal" children 1 wk before A/T. Tests of sustained attention using visual and auditory continuous performance tests (CPT) were completed by children 1 wk before and 3 mo after A/T. Behavioral Assessment Scales for Children (BASC) and a sleep questionnaire were completed by the parent/s at these same times. Results from overnight cardiorespiratory recordings showed that the children had mild sleep-related breathing disorders (SRBD) preoperatively with a mean apnea/hypopnea index of 3.0/h and a movement awakening index of 2.5/h. The majority had parent-perceived sleep and breathing difficulties that significantly improved post-A/T. BASC T scores for externalizing and internalizing behaviors improved post-A/T, e.g., behavioral symptom index mean pre-A/T was 56.2 (95% confidence interval, 52.8-59.6) compared with 50.9 (48.5-53.5) post-A/T. Some measures indicative of impulsivity and attentiveness obtained from the visual CPT before surgery, improved post-A/T, but no change was observed in any auditory CPT measures. Our data confirm improvements in subjective measures of sleep problems in children treated for SRBD and strengthen the notion of treating the disorder, not only related to the obvious clinical condition but also to the underlying sleep problems and adverse effects on daytime behavior and attention.

Non-culture-based analysis of bacterial populations from patients with chronic rhinosinusitis.

Middle meatus aspirates from patients with chronic rhinosinusitis were analyzed by bacterial culture, denaturing gradient gel electrophoresis (DGGE), and antibiotic sensitivity techniques. DGGE detected a greater bacterial diversity than culture methods. Although resistance to antibiotics was low, there was evidence of changes in the composition of the bacterial microbiota over time, and the presence of noncultured bacteria was demonstrated.