The utility of nasopharyngeal culture in the management of chronic adenoiditis.

OBJECTIVES: To examine the utility of nasopharyngeal culture in the management of children with chronic adenoiditis to determine if it results in a change in antibiotic therapy. METHODS: Retrospective chart review of pediatric patients managed for chronic adenoiditis, being defined as cough, postnasal drip, and congestion for over three months with endoscopic evidence of nasopharyngeal purulence with normal anterior rhinoscopy and middle meati. Standard treatment was defined as amoxicillin clavulanate or amoxicillin clavulanate ES-600 in non-penicillin allergic patients, and cefuroxime or clarithromycin for penicillin allergic patients. Nasopharyngeal culture results and antibiotic prescriptions were reviewed to look for a change from the standard. RESULTS: Of 207 patients diagnosed with chronic adenoiditis, 198 had nasopharyngeal cultures (119 male, 79 female, mean age 3.7 years). The most common organisms isolated were Streptococcus pneumoniae sensitive to penicillin in 40 cultures (20.2%), S. pneumoniae intermediate or resistant to penicillin in 26 (13.1%), Moraxella catarrhalis in 27 (13.6%), Haemophilus influenzae in 57 (28.8%), and Staphylococcus aureus intermediate or resistant to penicillin in 26 (13.1%). 13.3% of S. aureus isolated was methicillin resistant. 103 (52.0%) children required different antibiotics from the standard, and 26 (13.1%) had no antibiotics prescribed based on a negative culture. Of the 87 children suspected to have upper airway reflux, 25 (28.7%) had negative cultures. Of the 135 patients with follow-up, 50 (37.0%) reported resolution and 50 (37.0%) reported improvement of their symptoms. CONCLUSION: Nasopharyngeal culture has significant utility in the choice of antibiotics for children with chronic adenoiditis.

Management of supraglottic dysgenesis presenting as laryngomalacia.

Laryngomalacia is a common source of stridor and can lead to significant upper airway obstruction and feeding disturbances in infants. We describe a unique case of supraglottic dysgenesis presenting as laryngomalacia featuring a prominent "s-shaped" epiglottis with both posterior edges fused to the right aryepiglottic fold/arytenoid complex. Although this anomaly is not accounted for in any of the current laryngomalacia classification schemes, modified laser supraglottoplasty was a satisfactory approach leading to successful decannulation. Laryngeal embryology and possible timing of the pathogenesis of this rare occurrence are reviewed as well.

A prospective study of the effect of gastroesophageal reflux disease treatment on children with otitis media.

OBJECTIVES: To demonstrate improvements in validated quality-of-life measures for otitis media and gastroesophageal reflux disease (GERD) and an objective score for pediatric reflux obtained by fiberoptic laryngoscopy after treatment with antireflux precautions and therapy in children diagnosed as having either recurrent acute otitis media or otitis media with effusion and GERD. DESIGN: Prospective, before-and-after intervention study. SETTING: Hospital-based pediatric otolaryngology practice. PARTICIPANTS: Population-based sample of 47 patients (mean age, 19.5 months). INTERVENTION: Standard antireflux therapy for 2 consecutive 12-week periods. MAIN OUTCOME MEASURES: Otitis Media 6-Item quality-of-life survey, Infant GERD Questionnaire-Revised, GERD Symptom Questionnaire for Young Children, Pediatric Reflux Finding Score, and speech awareness threshold. RESULTS: Follow-up data were available for 37 patients. Mean (SD) change scores for Otitis Media 6-Item quality-of-life survey were 1.6 (1.1) at visit 2 and 1.5 (1.1) at visit 3 (P < .001 and P = .004, respectively). Change scores were significantly improved for Infant GERD Questionnaire-Revised and GERD Symptom Questionnaire for Young Children at visit 2 and for Infant GERD Questionnaire-Revised at visit 3. Mean (SD) change scores for the Pediatric Reflux Finding Score were 6.4 (4.9) at visit 2 and 8.0 (7.2) at visit 3 (P < .001 and P = .03, respectively). Hearing loss was significantly improved following therapy, as were laryngeal findings of reflux on fiberoptic laryngoscopy. Otitis media was considered by the examining physician to be clinically improved in 28 of 37 children (76%; 95% confidence interval, 60%-87%) at visit 2 and in 6 of 10 children (60%; 95% confidence interval, 31%-83%) at visit 3. Nine children (19.1%) required myringotomy tube placement. CONCLUSIONS: Children with otitis media with effusion or recurrent acute otitis media and GERD have improved quality of life following treatment with antireflux therapy. Control of gastroesophageal reflux may play a role in the management of otitis media and avoidance of tympanostomy.

Laryngomalacia: a classification system and surgical treatment strategy.

Laryngomalacia, the most common congenital laryngeal anomaly, is not a single disease entity but rather a variety of entities along a spectrum of underlying pathophysiologies. Based on our study of 10 children who were surgically treated for laryngomalacia in an urban tertiary care center, we have developed a system of classifying laryngomalacia on the basis of its different underlying pathophysiologic processes. Type I laryngomalacia is characterized by a foreshortened or tight aryepiglottic fold. Type 2 disease is defined by the presence of redundant soft tissue in the supraglottis. The type 3 designation applies to cases caused by other etiologies, such as underlying neuromuscular disorders. While the three types are not mutually exclusive, each should be considered as a separate disease entity with a final common clinical presentation. Each type requires a specific approach to surgical repair.

Chiari Type I malformation and upper airway obstruction in adolescents.

Chiari Type I malformation is characterized by cerebellar tonsil herniation through the foramen magnum. Manifestations may include new-onset upper airway obstruction. We describe two patients who had bilateral vocal cord paralysis and Chiari Type I malformation. These cases highlight the importance of suspecting a neurologic abnormality such as Chiari malformation in new-onset upper airway obstruction and/or bilateral vocal cord paralysis in adolescents in the absence of an obstructive lesion, though the development of cranial neuropathies or radiographic evidence may be delayed. Establishing a proper diagnosis is critical as Chiari I malformation can be treated with neurosurgical decompression, with possible improvement.

Treatment of pediatric sinusitis.

The successful management of RS in children relies on careful diagnosis, recognition of causative factors, and judicious yet adequate antibiotic usage. Refractory cases will require surgical therapy, with adenoidectomy as the first-line intervention and ESS reserved for those cases refractory to adenoidectomy. This overall approach will improve quality of life and prevent complications in children with RS.

Optimizing the diagnosis of gastroesophageal reflux in children with otolaryngologic symptoms.

OBJECTIVES: Although many children with otolaryngologic (ENT) symptoms are being treated for gastroesophageal reflux (GER), how to diagnose GER in children with primarily or exclusively ENT symptoms has yet to be determined. This study compares the incidences of pathologic GER in the upper verses the lower esophagus in a cohort of children with ENT symptoms that were screened for GER. METHODS: The results of extended dual channel intraesophageal pH probe monitoring obtained from 14 infants and 14 children with ENT symptoms were retrospectively analyzed. The percent of total monitoring time that the pH was less than 4, reflux index (RI) was determined. The upper limits of normal distal and proximal esophageal RI were based on published data. To evaluate our results, upper esophageal reflux (UER) was also determined in 27 infants and children without ENT or pulmonary symptoms, who had normal lower esophageal reflux (LER) values. RESULTS: Mean upper esophageal RIs in the infants and children with normal LER were similar to previously published values for control infants and adults. Four (29%) of the ENT infants, 11 (79%) of the older ENT children, and 54% of the entire cohort had increased esophageal acid exposure. However, nine (60%) of the 15 pediatric ENT patients with GER had pH abnormalities limited to the upper esophagus. CONCLUSIONS: Standard distal pH probe monitoring alone gives a false negative result in a substantial proportion of the infants and children with ENT symptoms being evaluated for GER. Beyond its value in clinical practice, UER testing should be employed in research studies that evaluate the impact of GER therapy on ENT symptoms.

Perioperative adenotonsillectomy management in children: current practices.

OBJECTIVE: To determine the current practices of preoperative evaluation, surgical techniques, and postoperative treatment of pediatric adenotonsillectomy. STUDY DESIGN: Forty-one-item survey measuring the frequency of different evaluations, procedures, and treatments performed, including selected case scenarios, with all items scored on a five-point ordinal scale ranking frequency. METHODS: The entire membership of the American Society of Pediatric Otolaryngology (ASPO) and active fellows and members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) residing in New York state were anonymously surveyed through mail-in questionnaires. RESULTS: History alone was the most frequent modality for diagnosing both adenoid enlargement and obstructive sleep apnea. The most common preoperative laboratory test ordered before an adenotonsillectomy is a complete blood cell count; ASPO members ordered fewer preoperative laboratory tests than AAO-HNS members. Unipolar cautery is the most frequently used tonsillectomy technique, and curettage followed by cautery is the most popular adenoidectomy technique. Steroids are the most common intraoperative medication administered during an adenotonsillectomy, and office visits remain the most frequently used methods of assessing adenotonsillectomy patients postoperatively. CONCLUSIONS: Although there are statistically significant trends uncovered by the survey, the results reflect a lack of consensus regarding adenotonsillectomy management. Further randomized controlled trials or large-scale outcomes projects are much needed to evaluate critically the current practices of pediatric adenotonsillectomies. Additional efforts may also be required to use the information from these studies in effecting changes in actual practice patterns, moving us toward a more evidence-based paradigm of treating pediatric adenotonsillar disease.