Ototoxicity of common topical antimycotic preparations.

OBJECTIVE: To determine the ototoxic effects of five commonly used topical antimycotic agents-clotrimazole, miconazole, nystatin, tolnaftate, and gentian violet-in the guinea pig. DESIGN: A controlled animal study in which the ototoxicity of commonly used topical antifungal agents was investigated by measurement of hair cell loss. METHODS: Several readily available topical antimycotic preparations were instilled into the middle ears of female Hartley guinea pigs over a 1-week period. Two weeks after the last instillation, the animals were euthanized. An active control group was treated with neomycin to confirm the adequacy of the treatment in delivering a known ototoxin; an untreated control group defined the normal distribution of hair cells. The temporal bones were removed, and the cochleas were fixed and dissected. The basilar membranes were examined under the scanning electron microscope. A map of hair cell survival was made for each row in segments of each turn. RESULTS: The untreated control animals had no discernible hair cell loss in the two lower turns. In the apical turn and sometimes the third turn, loss of hair cells was a common finding, this is a known effect of aging in this species. The animals treated with neomycin had damage consistently in the basal turn, sometimes extending into the second turn, as well as the expected hair cell loss in the apical turn. Clotrimazole, miconazole, or tolnaftate did not cause any hair cell loss in the first two turns. Hair cell loss in the third and fourth turns was similar to that of the untreated control group. Likewise, nystatin exhibited no evidence of ototoxicity. Of note, however, the preparation used in this study left a persistent residue in the round window niche. Of the first four animals treated with gentian violet, three developed pronounced behavioral signs of vestibular damage, and three demonstrated extensive middle ear inflammation and extensive new bone growth. Hair cell counts were not attempted because the extreme bone growth interfered with successful perfusion and dissection. CONCLUSIONS: Extrapolating from guinea pigs to humans requires caution. However, it is likely that guinea pigs are, if anything, more susceptible to topical ototoxins than are humans. The specific antimycotics clotrimazole, miconazole, and tolnaftate appear to be safe. Gentian violet has the potential for severe damage. The persistent residue left by the nystatin preparation is cause for concern and is a reminder that both the active ingredient and vehicle must be considered in evaluation of safety.

Surgical management of obstructive sleep apnea in children with cerebral palsy.

OBJECTIVES: To evaluate the surgical management of obstructive sleep apnea in children with cerebral palsy. STUDY DESIGN: Retrospective review of 27 children with cerebral palsy who underwent surgical treatment for obstructive sleep apnea. METHODS: Charts were reviewed. Data gathered included primary complaint, coexisting illnesses, initial procedure performed, age at initial surgery, number of days the child was monitored postoperatively in the intensive care unit, notation of postoperative respiratory distress and management, and outcome. RESULTS: Nineteen children underwent adenotonsillectomy for initial treatment of obstructive sleep apnea. Three of these children also had a uvulectomy. Six children had an adenoidectomy alone as their initial procedure. Neither uvulopalatopharyngoplasty nor tracheostomy was performed as an initial procedure. Mean follow-up was 34 months. Seventy-six percent of these children have not required any further surgery. Of the six children who have undergone further surgery, one has required a revision adenoidectomy, and another underwent a tonsillectomy and uvulectomy 2 months after the initial adenoidectomy. Four children ultimately required a tracheotomy. CONCLUSIONS: Eighty-four percent of these children were successfully managed without a tracheotomy. We recommend tonsillectomy and/or adenoidectomy for initial surgical treatment of obstructive sleep apnea in children with cerebral palsy.

Pediatric tracheostomy: a changing procedure?

In 1982, the experience with tracheostomy at The Children's Hospital of Philadelphia was reported for 1971 through 1980. We have now reviewed 450 cases for the period from 1981 through 1992, and compared the characteristics of these cases with those in the previous review. Long-term follow-up was available on 83% of cases, and the median follow-up was 2.96 years. Patients received a tracheostomy for airway obstruction (38%), chronic ventilation (53%), or multiple indications (9%). The mean duration of tracheotomy (adjusted for death and loss to follow-up) was 2.13 years. The tracheostomy-related mortality was 0.5%, and the nontracheostomy-related mortality was 22%. Nineteen percent of patients had complications in the first postoperative week, and 58% had 1 or more late complications. In comparison with the previous study from our institution, there was a great increase in long-term tracheostomy and a continuing trend away from tracheostomy for short-term airway management. Better monitoring and improvements in parental teaching may have contributed to a decrease in tracheostomy-related mortality.

Development of the paranasal sinuses in children with sinus disease.

In a previous report, the authors defined the normal development of the paranasal sinuses. Landmarks and dimensions relevant to functional endoscopic sinus surgery were measured on the computed-tomography images of 145 children who were free of significant sinusitis. The present study compares those normal values to the same measurements in 235 cases of sinus disease. No significant difference was found between normal and diseased groups in any of the 10 dimensions originally reported or in six derived measures. There appears to be no association between sinus disease and any of these dimensions. The previously reported norms are applicable to cases of pediatric sinus disease.

Bilateral sternocleidomastoid tumors of infancy.

The sternocleidomastoid tumor of infancy (STOI) is a relatively uncommon condition. Typically, it presents as a firm, well circumscribed mass within the sternocleidomastoid muscle (SCM) in infants 1-8 weeks of age and may be associated with torticollis. This condition must be considered in any infant with a lateral neck mass. The diagnosis can often be made clinically, but unusual presentations may present diagnostic challenges. Although bilateral involvement is rare, it does occur. The second reported case, a 2-week old female with bilateral STOIs and torticollis, is reported. Although many of the characteristics of the masses suggested the condition, the bilateral nature added uncertainty to the clinical impression, and magnetic resonance imaging (MRI) was used to confirm the diagnosis. The clinical presentation and management of the STOI are reviewed, and the unusual features of this case are discussed.

Periauricular cysts and sinuses.

Periauricular cysts, sinuses, and fistulas occur commonly in the pediatric population. They arise from developmental defects of the first branchial cleft and first branchial arch. In most instances the diagnosis and management of these conditions are straightforward, but exceptional presentations sometimes occur. Failure to recognize these unusual cases may result in inadequate treatment and subsequent recurrence, and even if the correct diagnosis is made, surgical management of these lesions may be complicated. A series of 15 cases of periauricular congenital lesions is reviewed, of which three cases illustrating a diagnostic or surgical challenge are presented. The embryology, presentation, and management of these anomalies are discussed. This is one of the largest series of first branchial cleft anomalies reported in the literature, and our paper uniquely discusses first branchial cleft anomalies and preauricular sinuses together, with an emphasis on the surgical management of facial nerve, external ear, and middle ear involvement.

Complications of frontal sinusitis in adolescents: case presentations and treatment options.

Frontal sinusitis in adolescents can be a serious condition because of the severity of potential complications and rapid progression of disease. These complications may arise as a result of extension of the infection intracranially, to the frontal bone, and to the orbit. Infection may spread hematogenously or by direct extension. A series of seven adolescent patients with complications of frontal sinusitis is presented. Surgical options are necessitated by the location and extent of infection and include trephination, frontal sinus obliteration, and craniotomy. Recent advances in endoscopic sinus surgery have provided surgeons another access to the frontal recess. However, a combined otolaryngological/neurosurgical approach is essential for patients with intracranial complications.

Nontuberculous mycobacterial cervical adenitis.

Granulomatous inflammation is a common finding in pathologic evaluation of surgically excised chronic lymphadenopathy in children. Confusion exists regarding diagnosis and management of these lesions. Over a 10-year period at The Children's Hospital of Philadelphia, a total of 81 children were identified with biopsy-confirmed granulomatous lesions of the head and neck, with nontuberculous mycobacteria (NTM) accounting for 67 of the cases. The typical presentation was that of a nontender mass in the cervicofacial area present for weeks to months, unresponsive to antimicrobials. All underwent surgical excision, which was curative in 54 patients; 13 children required additional procedures. This paper reviews NTM, its typical clinical presentation, difficulty in diagnosis, and the methods of treatment.

Development of the paranasal sinuses in children.

The development of computed tomography and functional endoscopic sinus surgery has improved diagnosis and management of sinusitis. It has also renewed interest in the developmental anatomy of the paranasal sinuses. There are significant differences between adult and pediatric sinus anatomy, and to safely perform functional endoscopic sinus surgery in children, the surgeon must be aware of these differences. To define the developmental anatomy of the paranasal sinuses, we analyzed 145 computed tomograms from patients under 18 years of age. The study emphasized landmarks at the level of the maxillary sinus ostium. In addition, distances and angles from the nasal spine to various points in the sinuses were determined. The structures were identified and traced on a digitizing tablet. Means and standard deviations were calculated for each measure as a function of age. This study can aid a better understanding of sinus development in children and provide guidance to the endoscopic sinus surgeon.

The effects of gelatin film stents in the middle meatus.

Controversy exists regarding the management of the middle meatus after pediatric functional endoscopic sinus surgery (FESS). To prevent adhesions following pediatric FESS, gelatin film stenting of the middle meatus has been recommended. The effects of stenting, however, have not been established. Fifty-one children with similar degrees of bilateral sinus disease had a gelatin film stent placed in one middle meatus on completion of FESS, while the opposite meatus was not stented. Two to three weeks later at the time of a second, staged procedure, the sides were compared for the presence of the stent, adhesions, granulaion tissue, and patency of the maxillary sinus ostia. In 11 children the postoperative findings were more severe in the side without the stent, whereas in 29 children they were more severe in the stented side. There was no difference between the sides in 11 children. Although gelatin film stenting benefits some children, it should not be used routinely following pediatric FESS but should be reserved for children who are predisposed to develop adhesions or have poor prognostic factors, such as immunodeficiency and ciliary dyskinesia.

Dexamethasone in adenotonsillectomy.

Edema contributes substantially to the postoperative discomfort and morbidity of adenotonsillectomy. In a double-blind study, 58 children undergoing adenotonsillectomy were given a single intraoperative dose of either dexamethasone or saline. The steroid markedly affected the postoperative course in the first day after surgery. According to parental reports, the percentage of patients vomiting was reduced from 48 to 4%. Severe throat pain was reported in 57% of controls and only 20% of dexamethasone patients. Twice as many steroid patients as controls tolerated some soft food on the first postoperative day. It appears that dexamethasone can greatly improve patient diet and comfort after adenotonsillectomy.

Depression in children after tonsillectomy.

Postoperative depression has been reported in adults undergoing open heart surgery and mastectomy. Tonsillectomy is a commonly performed procedure and can be associated with significant morbidity including pain, difficulty swallowing, dehydration, and bleeding. While adults may be able to express their feelings about the postoperative course, children often are unable to express themselves. Because postoperative depression may manifest itself in unusual behavior that is dismissed as "expected," it may go unrecognized. We present three case reports in which the child demonstrated signs of depression following tonsillectomy. We believe that depression following tonsillectomy occurs more frequently than has been recognized. We describe the diagnosis and management of posttonsillectomy depression to increase the otolaryngologist's awareness of this entity.

Effect of anesthetic gas on middle ear fluid.

Tympanometry was performed before (preoperative) and after (intraoperative) the administration of inhalation anesthesia including nitrous oxide and halothane on 109 children undergoing myringotomy with pressure equalization tube insertion. A total of 213 preoperative tympanograms were compared with their intraoperative counterparts and the presence or absence of middle ear effusion at myringotomy. When preoperative tympanograms were consistent with pneumatized middle ears, intraoperative findings demonstrated a mean middle ear pressure increase of +147 daPa. When preoperative tympanometry suggested middle ear effusion, less than 1% demonstrated intraoperative tympanometric changes and/or findings at surgery that would support anesthesia clearing middle ear effusion. Preoperative tympanometric data were poor predictors of the presence or absence of effusion at myringotomy. The relationship between inhalation anesthetics (i.e., nitrous oxide and halothane) and middle ear fluids, and the reliability of tympanometry to predict middle ear effusion are discussed.

Congenital tracheal stenosis. The otolaryngologist's perspective.

Congenital tracheal stenosis is a rare congenital anomaly, with less than 70 reported cases in the literature. The presenting signs and symptoms of stridor, recurrent pneumonia, and respiratory distress are commonly seen in other conditions. The rarity of congenital tracheal stenosis and the diverse presentations make accurate early diagnosis difficult and frequently lead to inappropriate treatment. We treated three patients with congenital tracheal stenosis who presented with different sites of stenosis. Each patient displayed different symptoms and required individualized management. The treatment of congenital tracheal stenosis depends on identifying the site and extent of the stenosis. We reviewed the embryogenesis and treatment of this abnormality and developed a new classification system that will aid in the management of congenital tracheal stenosis.

Tracheobronchomalacia in children.

Tracheobronchomalacia (TBM) is an important cause of airway distress during infancy, but it generally resolves as the airway enlarges. To assess the origin and natural history of TBM, a chart review and telephone survey were conducted for 50 patients with TBM at the Children's Hospital of Philadelphia (Pa). This study revealed that TBM is a relatively common airway abnormality and is found on 15% of all diagnostic bronchoscopies. Prematurity, low birth weight, bronchopulmonary dysplasia, and prolonged ventilation predispose patients to the most severe symptoms. In our study, a tracheotomy with continuous positive airway pressure was required by 75% of the premature infants and 25% of the full-term infants with TBM. Seventy-one percent of all patients underwent decannulation without any other surgical intervention and remained nearly asymptomatic. Some patients could not undergo decannulation because of other airway lesions. In most instances, TBM is a self-limited disease that resolves without surgery.

Endoscopic assessment in children with tracheotomies.

Pediatric tracheotomy is a safe procedure, and the tube can be maintained for a prolonged period. There are, however, few guidelines regarding the endoscopic assessment of the airway following tracheotomy. From January 1988 through December 1989, the Division of Otolaryngology of The Children's Hospital of Philadelphia (Pa) performed tracheotomies on 81 patients. Thirty-two children had direct laryngoscopy and bronchoscopy at the time of the procedure, 1 week later, and at 6-month intervals for a minimum of 18 months. Four children had normal airways while 21 had intraluminal stomal granulomas, 16 had development of subglottic stenosis, nine had collapse of the anterior tracheal wall, and three had development of distal tracheal granulations. Sixteen children had multiple lesions. Anatomic changes occur in the airways of the majority of children with long-term tracheotomies, and endoscopic evaluation is an essential part of their care.

Intramuscular hemangioma of the head and neck.

Intramuscular hemangiomas (IMH) are uncommon tumors in the head and neck region, occurring most often in the trunk and extremities. Preoperative misdiagnosis is common because of the deep location of these tumors. Ten recent cases of head and neck IMH are presented, five of which involve the masseter muscle--the most frequent site of involvement in the head and neck. Masseter IMH occurred almost exclusively in the pediatric age group. The clinical presentation, radiographic and histologic findings, treatment, complications, and outcome of these patients are presented. The vital role of preoperative diagnosis using magnetic resonance imaging (MRI) is discussed, as well as a review of the natural history of IMH and indications for surgical intervention.