Management of acute otitis media caused by resistant pneumococci in infants.

OBJECTIVES: To assess the clinical outcome and risk of failure after oral vs. intravenous treatment in otitis media caused by penicillin-resistant pneumococci. To determine the possible correlations between pneumococcal minimal inhibitory concentration (MIC) to penicillin and clinical outcome. DESIGN: Retrospective study of 156 cases collected between 1993 and 1995. Mean follow-up: 5 months. Setting. Two tertiary academic medical centers in Paris, France. PATIENTS AND METHODS: Pneumococcus was isolated from 191 of 570 ear samples obtained from children with otitis media and shown to be penicillin-resistant in 156. Medical history, antibiotic therapy during the previous 3 months and day-care center attendance were reviewed. For the current episode microbiologic characteristics of the isolated strains, type of treatment, therapy efficacy and clinical outcome were analyzed. Patients were predominantly young (76.3% were <1 year old) and bacteriologic samples were taken mainly because of previous treatment failure. RESULTS: Among 156 children with pneumococcal penicillin-resistant otitis media, 72.2% attended day-care centers, 71.8% had been previously treated with aminopenicillin and 52.5% with cephalosporins. Failure of previous empirical oral therapy was noted in 84% (one-third of these had been receiving amoxicillin-clavulanate). Patients treated intravenously had had a more protracted otitis but no greater number of previous episodes of acute otitis media than those receiving oral therapy. Acute mastoiditis occurred in 4 infants resulting in mastoidectomy. Oral treatment (mainly with high dose amoxicillin,120 to 150 mg/kg/day) and intravenous therapy (cephalosporin or glycopeptide) had been used in 59 and 41%, respectively. Mean duration of therapy was 10.7 days. Three failures (1.9%) and 10 recurrences (6.4%, average 28 days) occurred. No statistical difference was found between intravenous and oral therapy with respect to risk of recurrence. A high penicillin MIC value was correlated with previous antibiotic treatment but not with clinical outcome. CONCLUSIONS: Oral therapy appears to be as effective as intravenous therapy for the treatment of penicillin-resistant pneumococcal otitis media. Intravenous treatment should not necessarily be dictated by the penicillin susceptibility value but should be considered in cases of failure to thrive, persistent otitis or other complications.

[Cysts of the lacrimal tracts in the newborn infant]. / Kystes des voies lacrymales chez le nouveau-né.

At birth, a thin membrane often remains at the distal end of the nasolacrimal duct in the inferior meatus. The rupture is spontaneous during the first month of life. Sometimes this impatency can lead to a symptomatology usually limited to an uni or bilateral dacryocystitis. Exceptionally a cyst can develop in the nasolacrimal passageways. The authors describe three cases of intranasal occurrences, two of which brought about an obstructive dyspnea. Twelve cases have been described in the literature. This affliction predominantly occurs in young girls. Whenever the nasal obstruction is isolated, it is important to eliminate any other cause of intranasal tumor, especially an encephalocele, before any surgical intervention. Computerized tomographic scan is indispensable in order to eliminate any connection with the intracranial space. Magnetic resonance imaging appears promising. For the authors, the treatment must be surgical and must be kept simple. It consists in a cyst excision.

Tracheal rupture in a newborn during a complicated delivery. Diagnosis and surgical repair.

Rupture of the trachea is an exceptional obstetrical lesion. The infant reported in this paper, at 1 hour of age, developed respiratory distress with pneumomediastinum, bilateral pneumothorax and subcutaneous emphysema. This resulted from the fact that the trachea had ruptured, within 1 cm of the carina, during the difficult delivery. When the child was 23 days old, operation proved necessary because extubation was not feasible. The stenotic portion of the trachea was resected and continuity restored by end-to-end anastomosis. The tracheal lumen at the site of the anastomosis proved normal by bronchoscopic examination 4 months after the operation. There is only one similar case in the literature. The etiology of this rupture is discussed.

Laryngeal ultrasonography in infants and children: a new way of investigating. Normal and pathological findings.

Ultrasound of the larynx appears as a new way of imaging the larynx in infants and children. The normal sonographic anatomy is briefly described. The pathological findings of this method, its advantages and its drawbacks are discussed. It appears to be a very interesting method for functional disorders and space-occupying lesions.

[Balloon dilatation of tracheobronchial stenoses in children. Apropos of 4 cases]. / Dilatation au ballonnet des sténoses trachéobronchiques du nourrisson. A propos de 4 cas.

Long-lasting tracheal tubing in newborns and infants, associated with repeated tracheobronchial aspiration, is sometimes complicated by tracheal and/or bronchial stenoses. Many therapeutic methods have been described to treat this condition: use of dilatators, laser, surgery, insertion of prosthetic material. Dilatation with an angioplasty balloon has been recently described for the treatment of various stenoses. The authors report about 3 cases of acquired tracheobronchial stenosis which were successfully treated with this method, and 1 case of complex tracheal stenosis (with a double inflammatory and congenital nature) which required both dilatation and surgery. The technique is described. There is no morbidity and no mortality in this non-randomized series. Balloon dilatation is a simple and effective method, which may be proposed as a first-intention treatment for acquired tracheobronchial stenosis in newborns and infants.

[Severe subglottic hemangioma in the infant: corticotherapy, intubation or surgery?]. / Hémangiomes sous-glottiques graves du nourrisson: corticothérapie, intubation ou chirurgie?

In the case of sub-glottic hemangioma, with serious immediate or cortico-resistant dyspnea, it is not always possible to wait for the growth of the laryngo-tracheal skeleton and the spontaneous involution of the angioma. On the basis of a series of 25 cases, we propose in these serious forms the following therapeutic escalation: very high dose corticotherapy, with betamethasone at 0.12 to 0.48 mg/kg/day for 15 days, followed by a degressive treatment over 6 weeks to 3 months; intubation to overcome a difficult stage in the event of aggravation of the angioma with a rhinopharyngitis. Embolization and the use of the laser proved unsatisfactory in the extensive forms of angiomas. In the event of failure of the preceding treatment, we perform a tracheotomy, the duration of which can be reduced by the surgical exeresis of the angioma with a widening of the larynx.

Aryepiglottic fold excision for the treatment of severe laryngomalacia.

Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.

[Congenital perilymphatic fistula in children]. / Fistules péri-lymphatiques congénitales chez l'enfant.

We report twenty case of perilymphatic fistulae in children. A fistula was discovered in every case where the cochlear aqueduct is larger than normal on high resolution CT scan of the temporal bone. The surgical treatment of these fistulae allowed only a significant improvement of hearing in the cases were an asymmetry or a dilatation of the cochlear aqueducts and a fluctuating deafness coexisted. Unfortunately these improvements do not look permanent.

[Our current experience with subglottic hemangioma in infants. Apropos of 29 new cases]. / Notre expérience actuelle des hémangiomes sous-glottiques du nourrisson. A propos de 29 nouveaux cas.

The authors report 29 cases of sub-glottic hemangioma in infants. Symptomatology was dominated by laryngeal dyspnea and the diagnosis was made on direct laryngoscopy. The symptomatology and endoscopic appearance enabled two groups to be distinguished: non obstructive hemangiomas (11 infants) and obstructive hemangiomas (18 infants). For non obstructive hemangiomas, the authors recommend close surveillance in combination with short term steroid therapy was prescribed from the start. In the event of failure of steroid therapy (8 infants) naso-tracheal intubation and selective embolization was carried out and gave the best results. In 4 infants failure of the above treatments led to tracheostomy.

[Tracheotomy in children. Apropos of 144 cases]. / Trachéotomie chez l'enfant. A propos de 144 cas.

For a long time pediatric tracheotomy has had a poor reputation. Its indications are incontestably restricted in view of improvements in anesthesia and pediatric intensive care. We analysed 144 cases for the period 1976-1986. While very few peri-operative complications were noted, thanks to a rigorous technique, a review of which may be worthwhile, secondary complications such as tube obstruction, accidental displacement and superinfection of the lower airways were often fatal. These could be prevented by better training of both the families and also hospital staff. On average, these children had a tracheostomy for one year. There were few difficulties associated with removal of the tracheostomy tube.

[Mastoidectomy and seromucous otitis]. / Mastoïdectomie et otite séro-muqueuse.

Twenty-nine children presenting with chronically recurring serous otitis media, or with serous otitis media complicated by retracted eardrum, underwent either unilateral or bilateral mastoidectomy. For 23 of the children (26 surgical cases) whose follow-up extended over a sufficiently long period of time, results were assessed by otoscopic eardrum inspection, audiometry, and tympanometry. Long-standing recovery of serous otitis media, accompanied by a return to normal of the tympanic membrane, the tympanometric and audiometric parameters, was achieved in 2/3 of cases. These data compare well with results obtained by other authors, and they are telling as regards the efficacy of mastoidectomy for stabilizing the inflammatory process and restoring normal tubal function, in some cases of chronic serous otitis media.

[Subglottic stenosis and gastroesophageal reflux]. / Sténoses sous-glottiques et reflux gastro-oesophagien.

The authors report the cases of ten children treated for sub-glottic laryngeal stenosis, in the Department of Pr. Narcy in Hospital Robert-Debre. Medical treatment of the laryngeal stenosis had failed in these cases. Treatment, most often surgical, of the gastro-oesophageal reflux present in these ten cases enabled these children to be cured. A review of the literature stresses the role and responsibility of gastro-oesophageal reflux in laryngeal pathology. Based on their experience, the authors suggest: systematic investigation for gastro-oesophageal reflux during management of laryngeal stenosis, especially when laryngeal inflammation is encountered; the adoption of an interventionist attitude vis-a-vis gastro-oesophageal reflux which would seem to have an important pathogenic role in certain laryngeal stenoses.

[Severe congenital laryngeal stridor. Endoscopic surgical treatment]. / Stridor laryngé congénital sévère. Traitement chirurgical endoscopique.

Congenital laryngeal stridor or laryngomalacia is a congenital disease causing an usually shrill and solitary inspiratory noise, sometimes associated with disorders of deglutition and dyspnea when crying. Most often, the symptoms spontaneously disappear before the age of two. However, some cases are very severe, with permanent dyspnea, leading to tracheal intubation or tracheotomy. To avoid the risks of prolonged tracheotomy in infants, a new surgical technique has recently been described, beside epiglottectomy and hyomandibulopexy, now abandoned. This is simple endoscopic section and resection of the ary-epiglottic folds. Preliminary results in 15 patients seem to show the superiority of this so-called epiglottoplasty technique. Except in one case with supraglottic oedema attributed to a major gastro-esophageal reflux, all patients recovered from their dyspnea with this procedure. Extubation usually was rapidly feasible and the post-operative period was uneventful. The patients are kept in hospital for 2 to 5 days, and an antibiotic and anti-reflux treatment is recommended. This procedure is advocated as a treatment of choice of "laryngomalacia" with severe dyspnea.

[Effect of the surgical treatment of cleft palate on pathology of the middle ear. Apropos of 49 cases]. / Influence du traitement chirurgical des fentes vélo-palatines sur la pathologie de l'oreille moyenne. A propos de 49 cas.

The presence of middle ear disease was analyzed in 49 patients with soft palate cleft, and more particularly the influence of surgical repair and early therapy. Clinical examination, impedancemetry and audiometry carried out preoperatively and at follow up more than 3 months after surgery showed that although surgical closure of cleft provokes some improvement (40% of cases) some degree of seromucous otitis persisted in most patients, with a very partial positive influence of early surgery. Other physiopathologic factors are involved in the genesis of seromucous otitis, which cannot be cured by early surgery for soft palate cleft alone.