Endoscopic endonasal repair of bilateral choanal atresia in a 1200 g preterm infant: Is it feasible? (With video)

IntroductionBilateral choanal atresia (CA) is a rare congenital anomaly, that causes neonatal respiratory distress. No consensus exists regarding the most appropriate surgical approach in low-birth weight preterm infants.Case reportWe present (with video) the case of a male born at 29 weeks' gestation, 1200 g, affected by bilateral CA. He was successfully treated with an endoscopic transnasal approach performed on day 4 of life which allowed a very early extubation. Otologic instruments and 2.7 mm wide endoscope were used to be able to operate in very narrow nasal cavities. Thulium LASER® was used to limit bleeding. At the follow-up visit, four months after surgery, the neochoana was widely patent.DiscussionIn low-birth weight preterm infants, endoscopic transnasal surgery (ETS) may be considered technically not feasible or with a high risk of early restenosis. With early ETS, we were able to avoid the morbidity of a prolonged intubation and sedation.ConclusionBilateral CA is a life threatening and challenging clinical entity, particularly difficult to treat in low-birth preterm infants. Early surgery to reduce intubation and sedation is preferable, but requires experienced teams with a surgical technique and instruments tailored to the narrowness of the nasal cavity.     

Are there auditory processing and perception disorders in children with dyslexia?

BACKGROUND: In this paper the dichotic tests and the CERA (Cortical Evoked Response Audiometry) of children with dyslexia had been examined, in order to find out if there are auditory processing and perception disorders. PATIENTS AND METHODS: 33 children with dyslexia had been compared with 28 children without problems of writing and reading. The mean age of the children was 9 years. All of the children had been examined by the following audiometric measurements: tympanometry, pure-tone-audiometry, speech-audiometry, dichotic Tests by Uttenweiler and Feldmann and the Cortical Evoked Response Audiometry (CERA) rated according to Esser. RESULTS: The intelligence quotients were in the group of dyslexic children significantly lower. The Uttenweiler and Feldmann tests were in dyslexic children significantly lower in the control group as well. The late cortical responses ware normal or near normal in both groups. CONCLUSION: Dichotic speech tests indicate central auditory processing and perception deficits in dyslexia. These tests are confounded, however, by attention and memory deficits. The CERA rated according to Esser does not point out to these auditory disorders in dyslexia.     

Is POSSUM predictive of morbidity and mortality in laryngectomy patients?

Objectives

To test the validity of the comparative audit tool of POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) against a cohort of 92 consecutive laryngectomies at a major tertiary referral centre for head and neck cancer. The major outcome measurements were 30-day mortality rates, formation of a pharyngo-cutaneous fistula, and length of hospital stay.

Methods

By means of a prospective and retrospective case note analysis.

Results

No significant difference between the mean POSSUM morbidity scores of those patients who did, or did not develop a fistula, was found (p = 0.535, 95% C.I. −4.36 to 8.33). No significant correlation was observed between POSSUM predicted morbidity and bed occupancy [r = 0.137 (95% C.I. −0.070 to 0.334)]. The Portsmouth POSSUM equation for mortality however did accurately predict the mortality rate (observed to expected ratio of 1.05).

Conclusion

The authors propose that whilst there are many similar factors linked to mortality between cohorts of general surgical and head and neck patients, there are several highly specific risk factors in open surgery of the upper aero-digestive tract in the head and neck which are linked with wound breakdown and morbidity which are omitted from the POSSUM scoring system. The authors warn against the use of this comparative audit tool in its current state for such surgical procedures and recommend the creation of a specific POSSUM for head and neck cancer surgery.     

Are hearing and middle ear statuses at risk in Chinese patients undergoing orthognathic surgery?

Orthognathic surgery, which is performed to correct dentofacial abnormalities, has been associated with postoperative reduction in hearing sensitivity and middle ear dysfunction. In this study, the pre- and postoperative hearing status and middle ear function of 37 Chinese subjects who underwent orthognathic surgery, as well as subjective reports of aural symptoms, particularly hearing loss, tinnitus, fullness and otalgia, were investigated. There was a significant increase in the number of subjects with measured loss, perceived loss and aural fullness from pre-surgery to 1 week post surgery. However, the percentage of increase was small compared with previous findings. This difference in findings was attributed to the type of surgical techniques used, and to the fact that the Chinese population appears to be less susceptible to middle ear effusion. Subjective complaints of aural symptoms may not be accompanied by measured loss.     

A "wait and learn" strategy of postural control learning in children?

This study compares the children and adult response to a novel postural challenge. One group of children (n=13, age 7-9) and one adult reference group (n=12 age 15-32) were subjected to vibration induced body sway and posturography with both open and closed eyes for 5 consecutive days. There was a gradual decrease of induced body sway over time in both groups (p< 0.001) between the subsequent trials, but only in the adult group was there a reduction of induced body sway over time within each trial (p< 0.05). The children had on a considerably less level of induced body sway when they started the second trial than they finished the first (p< 0.01). There appears to be a different approach of adaptation to a new postural challenge between children and adults.     

Are Somatostatin Analogs Therapeutic Alternatives in the Management of Head and Neck Paragangliomas?

BACKGROUND: Although mostly benign, head and neck paragangliomas require active management because of injury to adjacent neurovascular structures. Surgery, usually preceded by embolization, allows for complete tumor removal. However, surgery carries a significant risk of iatrogenic injury, related to tumor volume. Because paragangliomas express somatostatin receptors with high density, we investigated the effect of a long-acting somatostatin analogue (OCT-LAR) on the size of such tumors to reduce iatrogenic injury and related the percentage of tumor shrinkage to a tracer uptake index calculated on somatostatin receptor scintigraphy (SRS). METHODS: In eight of the first nine patients, 30 mg of OCT-LAR was given intramuscularly every 28 days for 3 doses; one patient withdrew after the first dose because of side effects. Conventional imaging with computed tomography (CT) scan or magnetic resonance imaging plus SRS revealed 18 paraganglioma sites. For each lesion, a tracer uptake index was calculated on pretreatment SRS. All 18 tumors were measured by CT scan before treatment and 1 month after the third injection. RESULTS: The average percent tumor shrinkage was 4.0 +/- 10.0%, and the average tumor reduction was 1.0 +/- 3.8 cm (P = .27, NS). Only 2 of the 18 paragangliomas shrank by more than 20%; these two tumors belonged to the only one secreting patient. There was no significant relation between tracer uptake index and tumor response. CONCLUSION: These results suggest 1) that SRS results do not predict OCT-LAR efficacy on paraganglioma size, and 2) OCT-LAR is not useful in the preoperative management of paragangliomas.     

Does intervention improve the natural course of glomus tumors? A series of 108 patients seen in a 32-year period.

To acquire more insight into the results of treatment versus the "natural" course of glomus tumors, we studied the clinical data of 108 patients, in 58 of whom the disease was hereditary. During a period of 32 years (1956 to 1988), 175 tumors were diagnosed: 52 glomus jugulotympanic tumors, 32 vagal body tumors, and 91 carotid body tumors. The results of radical surgical treatment were disappointing for tumors located at the skull base, ie, nonradical in 59% (n = 23) of the cases, but very good for the carotid body tumors, for which 96% (n = 68) radical excision was achieved. Moreover, surgery at the level of the skull base dramatically increased morbidity, since it frequently induced cranial nerve palsy. During the follow-up period (maximal observation time 32 years, mean 13.5 years) none of the patients died of residual or recurrent tumor or developed distant metastases, irrespective of the mode and outcome of treatment. When these results are combined with the results of pedigree analysis, a realistic approximation of the "natural" course of the disease for both hereditary and nonfamilial tumors can be made. The results raise the question of whether this natural behavior is really improved by intervention. We conclude that removal of carotid body tumors and solitary vagal body tumors should be considered in order to prevent future morbidity. However, for skull base and bilateral glomus tumors a more conservative monitored "wait and see" policy can be sensible and should be considered in any proposal for treatment of head and neck paragangliomas.(ABSTRACT TRUNCATED AT 250 WORDS)     

Are corticosteroids useful in all degrees of severity and rapid recovery of Bell’s palsy?

Conclusions The results provide preliminary evidence that corticosteroids were not effective in all grades of dysfunction and for achieving a rapid remission in the early phase of BP, highlighting the need to define standard and rigorous criteria to prescribe corticosteroids in these patients. Objectives The main aim of this study was to investigate whether the use of corticosteroids better associated than paralleled with neuromuscular training (C?+?FNT) is more effective than facial neuromuscular training (FNT) applied alone, in terms of recovery degree and facial symmetry during the early phase of Bell’s palsy (BP). Patients and methods A prospective single-blinded study involved 73 patients: the C?+?FNT group (n?=?42; median age = 37.5 years) and FNT group (n?=?31; median age = 49.0 years). Patients were assessed before and 6 weeks after treatment by House-Brackmann (HB-FGS) and Sunnybrook Facial Grading System (SB-FGS). Results Recovery degree and facial symmetry improved significantly in both groups (p?p?>?0.05). However, the C?+?FNT group displayed better outcomes for cheek (p?=?0.004) and mouth (p?=?0.022) resting symmetry at SB-FGS, instead of compared to the FNT group. The corticosteroids had no significant effect on all recovery degrees (p?=?0.992) and rapid remission (p?=?0.952). Multiple linear regression analysis showed that the type of intervention was not a significant predictor for recovery degree (p?=?0.917).     

Foreign bodies of the nose and ears in children. Should these be managed in the accident and emergency setting?

OBJECTIVE: This study reviews the management of children with foreign bodies in the nose or ear in an attempt to see whether these children can be successfully managed in the Accident and Emergency (A & E) Department or whether they should be directly referred to the Otolaryngology service. METHODS: The records of all children with a foreign body in either the nose or ear who presented to the Accident and Emergency Department at The National Children's Hospital over a 2-year period were reviewed. RESULTS: 82 children presented with a foreign body in the nose and 53 (65%) were successfully managed in the A & E Department. In contrast, of the 58 children with a foreign body in the ear only 4 (7%) were successfully removed in the A & E Department. CONCLUSION: Most foreign bodies in the nose can be successfully removed in the Accident and Emergency Department. In contrast there is a high failure rate in removal of foreign bodies from the ear in the A & E Department and these should be referred directly to the ENT service.     

Cost and morbidity of MRSA in head and neck cancer patients: what are the consequences?

Methicillin resistant Staphylococcus aureus (MRSA) has become a prevalent nosocomial pathogen worldwide. The objectives of this study were to assess the morbidity and cost associated with the treatment of head and neck cancer patients who become colonized or infected with MRSA following major surgical procedures. We present a retrospective review of patients who underwent major surgery for head and neck cancer over a one year period and who then became MRSA positive in the post-operative period. MRSA affected 25/55 (45 per cent) patients who underwent major head and neck procedures during the period studied. The mean time of diagnosis was 13 days post-surgery. Morbidity included cellulitis, osteomyelitis and MRSA pneumonia. Thirteen of the patients who became MRSA positive (52 per cent of the MRSA group) required further surgery including plate removal, new flap formation and wound debridement as a result of the infection. Average in-hospital stay was almost three times more prolonged for patients who became MRSA positive compared to those who did not have MRSA. The costs of the first hospital stay were over three times more in the MRSA-positive group of patients. Antibiotic costs were increased by pound 2470 per patient because of MRSA. The extra stay in hospital, together with extra days in intensive care, extra medical and nursing care and additional costly antibiotic treatment, led to major cost implications and loss of health service resources in the unit. MRSA infection is a serious cause of morbidity in any surgical group of patients and this study focuses on the consequences for treatment of head and neck cancer patients in particular.