Inflammatory torticollis in children

Acute torticollis is commonly seen in the pediatric emergency department. It often results from an inflammatory process that irritates the cervical muscles, nerves, or vertebrae. Posturing of the head occurs with unilateral spasm of the sternocleidomastoid muscle such that the child will position the head with the occiput rotated to the affected side and the chin rotated to the contralateral side. We recently treated 26 children who presented to the emergency department with acute nontraumatic torticollis. The most common causes were upper respiratory infection, sinusitis, otomastoiditis, cervical adenitis, and retropharyngeal abscess or cellulitis. Four patients had subluxation of the atlantoaxial joint as a result of the inflammatory process. Children with acute torticollis need careful evaluation for either overt or occult otolaryngologic infections. Computed tomography and magnetic resonance imaging are helpful in determining the cause of the acute torticollis and in ruling out rotatory subluxation of the atlantoaxial joint.     

The ENT manifestations of HIV infection in children

This study identified the ENT symptoms of 66 HIV infected children over an 8 year period (1986-1993) at Great Ormond Street Hospital for Children. The incidence, nature and age of onset of ENT symptoms were investigated; 91% of the children had ENT symptoms, the most common being cervical lymphadenopathy, oro-oesophageal candidiasis and otitis media. The HIV infected children suffered from the common ENT diseases of childhood. They also presented with specific conditions such as diffuse parotid swelling. Therefore, their clinical features differed from HIV infected adults as well as non-infected children. An increasing incidence of paediatric HIV infection was demonstrated by the study. Most were due to vertical transmission. ENT surgeons are likely to see more HIV infected children in future, either with the usual ENT diseases of childhood (to which they seem more susceptible) or with HIV-specific conditions. Although the diagnosis of HIV may be known, the ENT condition could be the initial presentation suggestive of immunodeficiency.     

Pediatric deaths due to otolaryngologic causes: a population-based study in Massachusetts, 1990-2002

OBJECTIVE: To identify the most common otolaryngologic causes of mortality in the 0 to 19 age group in the state of Massachusetts and to estimate the pediatric otolaryngologic mortality rate based on population data. STUDY DESIGN: Population-based retrospective cohort study. METHODS: The Massachusetts State Registry of Vital Records and Statistics electronic database was searched for all otolaryngology related causes of death from 1990 to 2002 for children aged 0 to 19. The individual death certificates were then reviewed, and a database of otolaryngology related pediatric deaths was created. RESULTS: A total of 59 otolaryngology related deaths were identified in the pediatric population from 1990 to 2002. Eighty-one percent of deaths occurred because of airway compromise caused by infection, anatomic obstruction, or congenital anomaly. The remaining 19% of deaths occurred because of aspiration, nonairway infections, and malignant neoplasms. Ninety-five percent of deaths in the children under age 10 were caused by airway compromise. Six of seven deaths (86%) in the age 15 to 19 group occurred because of malignant neoplasms. The overall mortality rate caused by otolaryngologic causes was estimated to be 0.28 per 100,000 population. CONCLUSIONS: The overall mortality rate for otolaryngology related deaths is low in the pediatric population. The vast majority of deaths are caused by airway compromise, primarily because of laryngotracheobronchitis or other upper airway obstruction. In older children (ages 15-19), malignant head and neck neoplasms are the leading cause of otolaryngology related deaths.     

HIV protocol for the pediatric otolaryngology office

With the increasing awareness and concern over the transmission of human immunodeficiency virus (HIV) to health care providers, the development of a reasonable approach to patient care is necessary with those suspected of or documented as being HIV-positive. Children are all too frequently the innocent victims of this deadly disease and will often require the services of the otolaryngologist for evaluation, diagnosis, and treatment. In order to provide appropriate care for these children and reduce the risk of possible contamination of health care professionals or other patients a protocol was established for the Pediatric Otolaryngology Division of Children's Hospital at Washington University. This protocol is discussed in detail with explanation of rationale and alternatives.     

Otolaryngology and infectious disease team approach for outpatient management of serious pediatric infections requiring parenteral antibiotic therapy.

Children with community-acquired serious otolaryngologic infections are conventionally hospitalized for parenteral antibiotic therapy. However, effective and safe outpatient therapy is desirable since it is less traumatic and less costly. During a 24-month period outpatient parenteral antibiotic therapy, usually once daily i.m. ceftriaxone, was evaluated in 41 children with serious otolaryngologic infections (acute mastoiditis, complicated otitis media, severe external otitis and severe sinusitis with orbital or periorbital involvement). Daily visits and compliant capable parents were considered essential for outpatient management. Diagnosis, plan for management and daily follow-up evaluations were carried out in cooperation by otolaryngology and infectious disease specialists. Nineteen children (45%) were treated initially in the hospital and 22 children (55%) were treated entirely as outpatients. The mean duration of outpatient treatment, using once daily i.m. ceftriaxone was 5.7 days (range 1-13). The overall clinical cure rate was 98% and no serious side effects were observed. One case of sinusitis-orbital cellulitis relapsed during therapy. Most patients and parents returned to normal life activities within 72 h from starting outpatient therapy. Our data suggest that many children with serious otolaryngologic infections can be managed successfully and safely as outpatients by a combined team of otolaryngology and infectious disease specialists.     

Stomatological lesions seen in HIV virus infection. II. Histopathological and ultrastructural studies

Buccal lesions observed in the clinical setting of human immunodeficiency virus (HIV) infection constitute a diverse group of pathological entities. Several are related to the opportunistic infections observed in association with HIV infection. "Hairy leukoplakia" is a recently described benign lesion that is presumably related to infection by Epstein-Barr virus (E.B.V.). Kaposi's sarcoma is seen somewhat frequently in the oral cavity, especially involving the palate of HIV infected patients. We have observed this lesion 19 times in this location. The diagnosis is usually relatively straight-forward. Both vascular inflammatory and more typical sarcomatous morphology sub-types are present. The salivary glands may show an important lymphoplasmocytic infiltration which is unusual in that associated epithelial changes are not observed. The salivary glands seem to be a seat of the lymphocytic infiltration seen in other organs during the course of HIV infection. As for the changes encountered in the lymph nodes in HIV infection, they represent different stages in the evolution of a dynamic process, which progresses from hyperplasia to atrophy of the lymph nodes.     

HIV and communication

The human immunodeficiency virus (HIV) continues to plague many countries across the globe, including the United States, Africa, China and India. Children and adults have been infected with HIV, and both populations can present with communication disorders that coexist with the presence of the virus. The purpose of this paper is to present an overview of HIV and a discussion of the types of conditions that impact communication in both pediatric and adult populations. Persons living with HIV may present with disorders in the areas of language, phonology, voice and swallowing. Given the advances in pharmacological management of HIV, speech-language pathologists need to be knowledgeable of how medications can impact communication and swallowing. Also, since HIV crosses the blood-brain barrier and impacts all aspects of an infected person's life, speech-language and hearing professionals need to be members of the interdisciplinary teams that assess and manage patients living with HIV. Specific information regarding communication disorders in the pediatric population and research issues that warrant continued investigation will be addressed. LEARNING OUTCOMES: The reader will become aware of the ways in which a speech-language pathologist or audiologist may become involved with a patient infected with HIV or AIDS. The reader will learn the specific manners in which HIV and AIDS may affect the speech, language, hearing, and swallowing of pediatric and adult patients, as well as the appropriate intervention philosophies.     

Upper airway obstruction due to tonsillar lymphadenopathy in human immunodeficiency virus infection

Head and neck manifestations of human immunodeficiency virus (HIV) infection are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodigestivetractcandidiasis, and parotidlymphadenopathy and cysts. Recurrent otitis media and chronic sinusitis have been noted in the pediatric HIV population. We describe a patient with HIV-associated tonsillar and adenoid lymphadenopathy and upper airway obstruction. Pathologic analysis of the tonsillar tissue revealed severe lymphofollicular hyperplasia similar to that of other lymphoid tissue in HIV infection. The importance of symptomatic treatment of the airway obstruction is stressed.     

Grisel's syndrome: a case report and review of the literature

Grisel's syndrome is non-traumatic atlantoaxial subluxation (AAS) secondary to an inflammatory process in the upper neck. It is a rare condition that occurs almost exclusively in children and has been associated with upper cervical infections and otolaryngologic procedures. A case of AAS secondary to an upper cervical infection is presented. Potential sequelae can be severe; early diagnosis and treatment of Grisel's syndrome can prevent tragic outcome.     

ENT presentations in children with HIV infection

Illnesses of the ear, nose and throat (ENT) are common in children with human immunodeficiency virus (HIV) infection. We reviewed the case files of 107 HIV seropositive children in the paediatric HIV unit at St Mary's Hospital. The prevalence, age of onset and type of ENT disease were reviewed. We also determined sex distribution, maternal country of origin and mode of transmission of HIV. Fifty per cent of the HIV children had ENT illnesses. Fifty-five per cent of the children presented with their first ENT symptom before age 3 years with 98% of the children having ENT manifestations by age 9 years. The commonest ENT diseases were cervical lymphadenopathy (70%), otitis media (46%), oral candidiasis (35%) and adenotonsillar disease (31%). HIV transmission was vertical in 90%. Maternal country of origin was Africa in 70% and the UK in 13%. Compared with previous studies, the proportion of HIV children with ENT problems appears to have decreased. Although our figures report a similar ENT symptom profile, the age at onset of these symptoms has increased.     

Head and neck manifestations of the acquired immunodeficiency syndrome in children

The head-and-neck manifestations of HIV infection in children are very different from those in the adult population. Recurrent bacterial and viral infections are common manifestations, and persistent sinusitis or otitis media should make the otolaryngologist suspicious of HIV infection if the child has been exposed to the virus. Other common problems include mucocutaneous and esophageal candidiasis, recurrent herpes I and II and zoster infections, parotid swelling, and cervical lymphadeopathy.     

HIV infection in children--impact upon ENT doctors

The global epidemic of HIV infection remains appalling. By 2001, there were an estimated 1.4 million HIV-infected children, with 4.5 million deaths. In the UK, paediatric cases are clustered around population centres where there are high concentrations of infected immigrant adults, and to a lesser extent, areas where IV drug abuse is common. The highest incidence remains in London and the southeast. With the national redistribution of immigrant and refugee families, any doctor in any specialty may expect to be involved with children who are HIV positive, or have clinical AIDS. The majority of children are infected vertically, i.e. infection of the infant from an infected mother in the pre-, peri-, or post-natal periods. Rates of transmission vary from 15-20% in the developed countries. Children with HIV infection may have their primary presentation to ENT doctors, who should have appropriate thresholds for suspecting the diagnosis. The most common presenting features include persistent generalised lymphadenopathy, hepatosplenomegaly, chronic/recurrent diarrhoea, poor growth, and fever. Fifteen to twenty percent of untreated children will present with an AIDS-defining illness by 12 months, typically with Pneumocystis pneumonia at approximately 3-4 months of age. Seventy percent of perinatally infected children will exhibit some signs or symptoms by 12 months Without treatment, the median age to progression to AIDS is approximately 6 years, and 25-30% will have died by this age. The median age of death is approximately 9 years. Children may also present with repeated/unusual ear infections, sinus disease (inc. mastoiditis), tonsillitis, orbital/peri-orbital cellulitis, oral candidiasis, and dental infections. Infections with streptococcus pneumoniae and group A streptococcus are common, and often progress to severe systemic infection with an appreciable mortality. Infections may be due to unusual pathogens such as Pseudomonas, 'typical' and atypical Mycobacteria, Candida, Aspergillus, etc. Fungal infections of the sinuses (inc. Aspergillus and Rhizopus spp.) may be particularly devastating, with rapid spread to involve bone and the central nervous system. Another classical presentation, which may present to ENT doctors, is that of bilateral parotid enlargement, especially in children who are 'slow progressors', many of whom also have Lymphoid Interstitial Pneumonitis (LIP). A major attitudinal change has occurred due to advances in 3 main areas: (i) the multidisciplinary management of the infected mother (inc. counselling, antenatal screening, elective caesarean section, advising against breast feeding, etc.), (ii) the prevention of vertical transmission, using anti-retroviral therapy to the infected mother during pregnancy, and to the potentially infected infant in the first weeks of life, and (iii) major advances due to the advent of highly active anti-retroviral treatment. With effective use of these measures, transmission rates may be reduced to <2%. None of the measures though, affect a cure, and it will still be many years before the development of effective vaccines. ENT doctors may be referred children already known to be HIV-positive. Knowing how to talk to infected children (and their parents) is full of potential pitfalls, and requires careful forethought. Many infection-control policies have required considerable rethinking due to the AIDS epidemic. This has especially been the case with respect to needle-stick injuries, post-exposure prophylaxis, sterilization and re-use of equipment, and safe approaches to surgery.     

Current treatment for human immunodeficiency virus infection

Treatment of human immunodeficiency virus (HIV) infection can prolong survival and enhance the quality of life in affected patients, although neither immune reconstitution nor cure can be achieved. Zidovudine is now the only licensed treatment. It is effective but sometimes toxic. Zidovudine decreases the incidence of opportunistic infections but does not prevent them, and concurrent prophylaxis against Pneumocystis carinii pneumonia should be given to those patients at greatest risk of this infection. Most patients should have serial CD4+ T-cell determinations to assess their degree of immunodeficiency. Many investigational anti-HIV agents are being studied, and future treatments are likely to use multiple agents in combination or in sequence over many years.     

Immunocytochemical identification of HIV (p24) antigen in parotid lymphoid lesions

Antibodies to specific human immunodeficiency virus (HIV) polypeptides are important laboratory markers of HIV infection. We have used an antibody to the major structural gag protein p24 of HIV-1 virus to immunochemically localize this capsid antigen in lymphoid cells from seven of eight patients at risk for HIV infection and who presented with parotid lymphadenopathy and lymphoepithelial cysts of the parotid gland. A clinicopathological assessment of these two manifestations as they relate to HIV infection is also presented.     

Parotid swelling during human immunodeficiency virus infection

In Europe and in the United States, bilateral parotid gland swelling has been observed as a sign of human immunodeficiency virus (HIV) infection in children, but it has not been associated with HIV infection in adults. We observed a chronic parotid gland swelling in nine HIV-seropositive patients during a nine-month period in Kinshasa, Zaire. Parotid gland enlargement was bilateral in seven patients (78%), slightly painful in seven patients (78%), and painless in two patients (22%). No evidence of inflammation was observed around Stensen's duct. One of the two patients in whom a parotid gland biopsy was performed had a malignant lymphoma of the large-cell, histiocytic type. In the other patient, the parotid gland showed normal morphology with minor inflammation. Among 284 adults and 40 children with symptomatic HIV infection, chronic parotid gland enlargement was observed in none of the patients. However, two (0.7%) of the adults presented with an acute pyogenic parotitis. Further studies are needed to determine whether parotid gland enlargement is associated with HIV infection.     

Tuberculosis in the upper aerodigestive tract and human immunodeficiency virus coinfections

OBJECTIVE: To describe the clinical manifestations of tuberculosis in the upper aerodigestive tract. DESIGN: Retrospective chart analysis. SETTING: Srinagarind Hospital, Department of Otolaryngology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. METHODS: A review of medical records of patients diagnosed with mycobacterial infection of the upper aerodigestive tract between January 1991 and December 2000. MAIN OUTCOME MEASURES: Presenting symptoms, clinical findings, pathologic findings, pulmonary involvement, and outcome of treatment. RESULTS: Forty-five patients presented with upper aerodigestive tract tuberculosis. The nasopharynx was involved in 23 patients, the larynx in 16, the tonsils in 6, and the soft palate in 1. One patient had tuberculous infections in both the nasopharynx and tonsils. The mean duration of symptoms before diagnosis was 2.1 months. The pathologic findings included caseous granuloma and/or positive acid-fast bacilli (AFB) in 39 cases and chronic granulomatous inflammation with negative AFB in 6 cases. Pulmonary tuberculosis was found in 19 of the 36 patients who underwent radiography. A positive serologic test for human immunodeficiency virus (HIV) infection was found in 4 of 26 patients. These 26 patients, who received a full course of treatment, responded well. CONCLUSION: The most common site of tuberculosis in the head and neck involved the cervical lymph nodes and nasopharynx. Upper aerodigestive tract tuberculosis is difficult to differentiate from carcinoma; thus, tissue biopsy is necessary for a definite diagnosis. Chest radiography and screening for HIV infection are recommended in all patients with upper aerodigestive tract tuberculosis.     

The role of 24 h pH-recording in pediatric otolaryngologic gastro-esophageal reflux disease

The purpose of this study was to investigate the role of 24 h pH monitoring for the diagnosis of otolaryngologic including rhinologic manifestations of gastro-esophageal reflux (GER) in children and if possible to correlate the results with the efficacy of medical treatment. This is a retrospective study of 72 children from January 1997 to December 1999. The children were separated into three groups according to the main symptoms (although association of symptoms was frequent): rhinologic (n=28), laryngotracheal (n=28) and pharyngeal-otologic (n=16). With the classical gastroenterologic criterion (> or =4.2% of total time at pH < 4), the pH monitoring was positive in 56% of the patients. However, this criterion does not seem to be sensitive for otolaryngologic gastro-esophageal reflux disease (GERD) because multiple daytime short reflux episodes are often involved. Indeed, the pH monitoring was positive in 75% of the patients (82% in the rhinologic group) when a number of 40 episodes in 24h was also taken into account. The success rate of medical treatment was about 80% in case of positive pH recording. This study underlines that GER is an important factor in pediatric otolaryngologic diseases.     

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): an indication for tonsillectomy

Children with obsessive compulsive disorder or tic disorders that are associated with streptococcal infections (Group A beta-hemolytic) in the oro-pharyngeal region are given the diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Tonsillectomy has been reported to resolve the neuro-psychiatric symptoms in these children.We have a case of a 9-year-old boy who was seen in our clinic with multiple recurrent streptococcal infections of the oro-pharyngeal cavity. He also exhibited neuro-psychiatric symptoms including agitation, hyperactivity, and tics. These symptoms followed his recurrent infections.Tonsillectomy was performed and in one year follow-up the patient did not have any recurrent streptococcal infections, and his neuro-psychiatric symptoms resolved completely. Guidelines for medical and surgical management of recurrent strep infections in the face of PANDAS are reviewed.     

Practice of pediatric otolaryngology: results of the future of pediatric education II project

OBJECTIVES: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. METHODS: Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age <18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people. CONCLUSIONS: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.