Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients.

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.

Penetrating injuries of the visceral compartment of the neck.

Penetrating injuries of the visceral compartment of the neck are uncommon but potentially life threatening. A retrospective review of patients who sustained penetrating trauma to the laryngotracheal complex was conducted at the Level I trauma center of the University of Louisville Hospital in Kentucky. Sixteen patients were identified and their records reviewed for type of injuries, treatment, complications, and 1-year follow-up. The majority of patients were men who sustained injuries that were violent in nature. Zone II of the anterior neck was the most commonly injured area, with the trachea (69%), esophagus (38%), and larynx (31 %) the most commonly injured structures. Although 31% underwent angiograms, only 13% showed vascular injuries. Eighty-one percent of the patients had injuries involving more than 1 major structure of the neck. Neck exploration was performed in 81% of the patients and tracheotomies in 75% as well as repair of the trachea (50%), larynx (31%), and esophagus (38%). There is significant mortality associated with these injuries (13% in our study), and many of the patients have long-term sequelae such as dysphagia, hoarseness, and prolonged tracheotomy.

Otolaryngologic clinical patterns in pediatric infectious mononucleosis.

PURPOSE: Classic infectious mononucleosis (IM) is uncommon in children; therefore, the incidence of severe pharyngotonsillitis complicating the infection is not well established. This study was undertaken to better define the management of complications with special emphasis on the use of parenteral steroids and the role and timing of surgical management. MATERIALS AND METHODS: A retrospective review of all cases of IM encountered between January 1989 through December 1993 was undertaken. RESULTS: There were 109 patients admitted with IM. Sixty patients (55%) were admitted for severe pharyngotonsillitis. Twenty-nine patients in this subgroup were felt to have symptoms of severe upper airway obstruction and were treated with parenteral steroids. Surgical intervention was required in three patients. CONCLUSION: The study shows a higher incidence of admissions for severe pharyngotonsillitis complicating IM than reported in the adult literature. It suggests that routine use of parenteral steroids is indicated in cases of severe upper airway obstruction and may decrease the need for surgical intervention.

Priorities in the management of penetrating maxillofacial trauma in the pediatric patient.

Penetrating facial trauma is uncommon in children; a large series published by Cooper et al revealed that only 1% to 2% of the total population of infants and children admitted for trauma during their study period had a diagnosis of penetrating trauma to the head or neck. Little has been published specifically addressing these injuries in the pediatric population. The records of 20 patients treated for penetrating facial injuries at Kosair-Children's Hospital in Louisville, Kentucky from January 1991 through December 1994 were reviewed. The location, mechanism and extent of injury, as well as the diagnostic and management practices used in patient treatment, were collected. Categorizing the injuries relative to the involvement of one or more facial zones helped guide diagnostic studies and therapeutic intervention and predict associated injuries. This article evaluates the authors' method of management and any differences in management between pediatric and similarly injured adult patients.

Embolization as the definitive treatment of epistaxis in the pediatric patient.

Epistaxis occurs often in children, but these patients are seldom hospitalized. Two cases of intractable epistaxis, which were definitively treated with internal maxillary artery embolization, are presented with an algorithm for management of similar cases.

Eustachian tube dysfunction and its sequelae in patients with cleft palate.

The incidence of middle ear disorders in patients with cleft palate deformities was determined in a retrospective review of 110 children with palate or palate and lip involvement. Ages ranged from 2 months to 18 years and included patients with associated abnormalities such as Pierre Robin syndrome and Treacher Collins syndrome. Clinical manifestations of eustachian tube dysfunction were found in 79% in the form of effusions, retraction pockets, adhesions, and ossicular erosion. Only two patients had confirmed cholesteatoma formation. Despite the low incidence of acquired cholesteatoma in these patients, the frequent occurrence of other disorders that affect hearing warrants early and aggressive otologic management to prevent long-term sequelae.

Peripheral hearing loss following head trauma in children.

The purpose of this prospective study was to determine the incidence and type of hearing loss occurring in children who suffered head injuries. Fifty children admitted to the neurosurgical service after sustaining head trauma were studied. Neurologic, otologic, and audiologic evaluations were performed. Diagnostic studies included skull roentgenograms and computerized tomography scans. A 32% incidence of conductive hearing loss and a 16% incidence of high-frequency sensorineural hearing loss was found in this group. All patients with temporal bone fractures had conductive hearing losses, but the presence of a skull vault fracture did not correlate with the presence, type, or degree of hearing loss. In addition, there was no correlation between either cause of injury, loss of consciousness, or Glasgow Coma Scale scores and the presence, type, or degree of hearing loss. There was a significant incidence of both sensorineural and conductive hearing loss in this series of patients, which indicates that close audiologic and otologic follow-up is necessary for all head injury patients.

Michel's anomaly, type I microtia and microdontia.

Michel's anomaly is an extremely rare cause of congenital sensorineural hearing loss. We present a 2-1/2 year old white female with this inner ear defect associated with type I microtia and microdontia. Assessment of anatomic structures of the ear is critical in an infant with abnormal auditory brainstem responses to determine whether a structural lesion is present and the most appropriate rehabilitative approach available.

Diagnosis and management of acute laryngeal trauma.

Retrospective chart analysis was carried out on 13 patients presenting to the trauma service at the Humana Hospital University in Louisville, from January, 1984 through December, 1987 with a diagnosis of acute laryngeal injury. The most common cause of injury was blunt trauma suffered in a motor vehicle accident. Stridor was the most common presenting symptom and the thyroid cartilage was the most common site of fracture. Seven patients underwent immediate open exploration and repair, three underwent tracheostomy without exploration, and three were treated conservatively with voice rest, humidity, and steroids. All 13 patients had a favorable result. The purpose of this paper is to review the findings of our study and to discuss diagnostic and management recommendations for laryngeal trauma.

Are we teaching medical students what they need to know?

If our broad goal for undergraduate education is to prepare students for residency and the eventual practice of medicine, the specific knowledge and skills we teach should reflect those that will be required of them to perform well as residents and practicing physicians. To determine and compare priority goals and objectives, we surveyed otolaryngology educators, a representative group of physicians in practice, and a representative group of residents. Participants were asked to evaluate the level of knowledge and skills necessary for students to attain in various areas of otolaryngology by ranking each item by a score of 0 to 3 according to its required depth of knowledge or skill. A rank "order of importance" was developed based on mean scores. The highest-ranking areas of knowledge were otitis media, airway obstruction, tonsillitis, and croup/epiglottitis, whereas the highest-ranking skills were history and physical examination of the head and neck, throat cultures, and use of the otoscope and pneumatoscope. The lowest-ranking areas of knowledge were voice disorders and ear deformities, whereas the lowest-ranking skills were interpreting electronystagmograms and stapedial reflex testing. We review the findings of our survey and comment on their role in undergraduate curriculum planning for otolaryngology.

Otolaryngologic problems in cardiac transplant patients.

Cardiac transplantation is now a well-accepted treatment for selected patients who have end-stage heart disease. Of the 38 patients who underwent cardiac transplants at our center from August 1984 through August 1987, 27 received consultation for otolaryngologic problems. Eleven patients had sinonasal complications; 8 had laryngotracheal complications; 4 had otologic complications; 2 had oropharyngeal complications; and 2 had a combination of more than one of the above complications. Of these otolaryngologic disorders, 63% were infectious in etiology. Development of otolaryngologic infections generally did not correlate with either higher doses of maintenance immunosuppression or with treatment of an acute rejection episode, which requires increased immunosuppression. Otolaryngologists should be aware of the sinonasal, laryngotracheal, oropharyngeal, and otologic disorders that can occur in cardiac transplant patients.

Diagnostic and therapeutic efficiency in croup and epiglottitis.

Croup and epiglottitis continue to be potentially life-threatening diseases in children. Early distinction is imperative as definitive treatment differs significantly. To determine the correlation of various clinical features, x-rays, and laboratory tests with diagnosis and management planning, a retrospective chart analysis of 194 children with croup (N = 169) and epiglottitis (N = 25) was performed. The clinical history and physical findings were most important in differential diagnosis. Patient age, lateral neck x-ray, and white blood count (WBC) strongly correlated with diagnosis. Counter immunoelectrophoresis (CIE) results did not alter therapy. No blood cultures were positive unless the patient had: WBC over 15,000 with more than 10 stabs, WBC over 20,000, or WBC with more than 20 stabs. Ampicillin resistant H. influenzae occurred in 21% of positive blood cultures. Capillary blood gases did not correlate with clinical need for intubation. It is suggested that a selective evaluation of patients with epiglottitis and croup can be performed in a more cost-effective manner without sacrifice in patient care.