Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Objectives

The aim of this study was to assess the pharyngeal airway space (PAS) in nasal and mouth-breathing children using cone beam computed tomography (CBCT).

Methods

Volume, area, minimum axial area and linear measurements (PAS-NL, PAS-UP, PAS-OccL, PAS-UT, PAS-Bgo, PAS-ML, PAS-TP) of the pharyngeal airway of 50 children (mean age 9.16 years) were obtained from the CBCT images. The means and standard deviations were compared according to sexes (28 male and 22 female) and breathers patterns (25 nasal breathers and 25 mouth breathers).

Results

There were no statistically significant differences (p > 0.05) between all variables when compared by sexes. Comparisons between nasal and mouth breathers showed significant differences only in two linear measurements: PAS-OccL (p < 0.001) and PAS-UP (P < 0.05). Airway volume (p < 0.001), area (p < 0.001) and minimum axial area (p < 0.01) had significant differences between the groups.

Conclusions

The CBCT evaluation showed that pharyngeal airway dimensions were significantly greater in nasal-breathers than in mouth-breathers.     

Does auditory tube angle really affect childhood otitis media and size of the mastoid?

Objective

To assess the cross-sectional area of mastoid air cells and auditory tube angles (ATA), which were defined as the angles between the longitudinal line bisecting the transverse length of the external auditory canal and the longitudinal axis of the auditory tube (AT), both in healthy ears and diseased ears in patients with unilateral chronic otitis media (COM).

Methods

25 patients who had unilateral COM were included in the study. Assessment was performed using a quantitative digital image processing computer tomography (CT) program.

Study design

Prospective study with institutional review board approval including adult patients who had otological symptoms since their childhood period.

Results

Mastoid areas were greater on the healthy side than on the diseased side (p < 0.05). ATA were not significantly different among groups (p > 0.05). When we compared ATA with mastoid area in each group; there were no significant correlations in both healthy group and COM group (p > 0.05). Mastoid size in COM group was smaller than in the healthy group.

Conclusion

We suggest that middle ear inflammations in childhood may affect mastoid size but, the anatomic relationships of the auditory tube, mastoid and middle ear that form a functional unit may not be significantly important in chronic ear disease.     

Middle ear volume as an adjunct measure in congenital aural atresia

Objective

To examine middle ear volume in patients with aural atresia and investigate the role of middle ear volume as an adjunct measure in determining surgical candidacy.

Methods

We performed a retrospective review of children with aural atresia in a tertiary academic pediatric otolaryngology practice. High resolution multiplanar CT scans of the temporal bones were analyzed for middle ear volume and staged according to existing clinical grading scales. Atretic ears were compared to the nonatretic ears of the same patient as well as to ears of a control population.

Results

The average age of patients at the time CT was performed was 4.7 years (range <0.1-13.8 years). The average middle ear volume of the atretic ears was 0.34 cc compared to an average of 0.51 cc for the nonatretic ears. The mean ratio of the atretic to nonatretic volume was 0.67. In patients who underwent serial scans, no statistically significant difference in rates of growth existed between atretic and nonatretic ears. Finally, measures of middle ear volume correlated well with clinical grading scales.

Conclusions

Both middle ear volume and the ratio of the atretic volume to nonatretic volume serve as useful adjunct measurements in determining surgical candidacy. The practitioner may be better able to assess surgical candidacy by supplementing classic atresia classification systems with middle ear volume measurements.     

Is Carhart notch an accurate predictor of otitis media with effusion?

Background

In the era of pediatric otolaryngology, a number of different methods have been used for the diagnosis of otitis media with effusion (OME). Although there are divers articles within the filed of assessment of the accuracy of diagnostic methods of OME, surprisingly there are very few data published and a small number of researches explaining the accuracy of Carhart notch (CN) for diagnosis of OME cases and comparing the CN with abnormal tympanic membrane findings in binocular microtympanoscopy.

Methods

Audiometric parameters studied in 89 children (178 ears) suffering from chronic otitis media with effusion. Significant CN was defined as a minimum depression of 10 dB in comparison of the rest of thresholds, at any frequency from 500 to 4000 Hz. Intra-operative microscopic otoscopic findings and the type of middle ear fluid were documented in a specially formatted questionnaire.

Results

The incidence of CN was 44.94% (80 ears) and that of significant CN was 25.28% (45 ears). The correlation between abnormal tympanic membrane findings and significant CN was significant and the association between CN and middle ear effusion (MEE) was not statistically significant.

Conclusions

Significant CN is a sensitive diagnostic tool for detection of MEE but not specific. The diagnosis of OME in children requires a combinational diagnostic methods including tympanometry and audiometric variables especially CN.     

Incidence of long-term ipsilateral and contralateral ototoxicity following radiotherapy for nasopharyngeal carcinoma

Objective

To characterize the long-term adverse effects of radiotherapy on the ears in patients with nasopharyngeal carcinoma (NPC), we investigated ipsilateral and contralateral ototoxicities in the external, middle, and inner ear.

Methods

The records of 48 ears in 24 radiotherapy-treated NPC patients were retrospectively analyzed. Radiotherapy doses varied between 60 and 70 Gy in 2-Gy fractions at 5 fractions/week. Ototoxicities were identified by otoscope and pure-tone audiograms conducted at 2-3 month intervals for ≥12 months. The relationship between radiation dosage and sensorineural threshold deterioration was statistically compared using the Mann-Whitney U-test.

Results

Post-radiotherapy, 50% of all ears (3 of 6) that developed severe otitis externa were on the contralateral side. There was a post-radiotherapy increase in contralateral otitis media with effusion (OME) (1-7 ears), but a decrease in ipsilateral cases (16-12 ears), with 2 ears on either side subsequently developing chronic otitis media (COM). All ears that showed sensorineural hearing loss (SNHL) before radiotherapy exhibited a further threshold deterioration of more than 15 dB. No statistically significant difference (p = 0.086) in average radiation dose was seen between ears with sensorineural threshold deterioration (50.0 Gy) and those without (48.2 Gy).

Conclusion

Long-term ototoxicity following radiotherapy for NPC can occur in either the ipsilateral or contralateral ears. Pathophysiology varies between and within each side. The post-therapy increase in OME on the contralateral side was thought to be due to radiotherapy-induced Eustachian tube damage, and the sensorineural threshold deterioration in at least 4 ears was thought to be due to chronic cochlea damage secondary to COM.     

Retropharyngeal infections in children. Treatment strategies and outcomes

Objective

To optimize the treatment of retropharyngeal infections in children.

Methods

Retrospective chart review of 101 consecutive pediatric cases of retropharyngeal infections referred to our center from January 2006 to July 2009.

Results

Two-thirds of patients were males. Their mean age was 52 months (range: 6-163). Upper airway obstruction was observed in three patients. In another child, the infection evolved towards a diffuse cervical cellulitis. Medical treatment was initially planned in 44% of patients. Failures requiring surgical drainage occurred in 18% of them. In 56% of cases, surgical treatment was immediately instigated. It failed in 16% of patients, requiring a second surgical drainage. There was no difference in the duration of fever and of hospital stay between patients initially treated medically or surgically. Both medical and surgical treatment failures were associated with longer durations of fever (p = 0.002, and p < 0.0001, respectively) and of hospital stay (p = 0.0006, and p = 0.0005, respectively). Some characteristics of CT-scan anomalies were correlated with treatment failure. A hypodense core surrounded by rim enhancement, with a largest long axis ≥20 mm, was more frequent in case of medical failure (p = 0.02). Surgical failure was associated with the same feature, but with a largest long axis ≥30 mm (p = 0.05).

Conclusions

The present study suggests that severe complications are rare in pediatric retropharyngeal adenitis, and that CT-scan is a useful tool to choose between medical and surgical treatment.     

A comparative study on efficiency of middle ear pressure equalization techniques in healthy volunteers

Objective

To compare success rates of middle ear inflation device (Ear Popper ^©), Valsalva maneuver and Toynbee maneuver in middle ear pressure equalization in healthy adults.

Materials and methods

Adult volunteers with otoscopically healthy ears were enrolled to the study. In a prospective setting, 60 ears of 35 volunteers were divided into two groups according to eustachian tube (ET) functions tested using the nine step inflation deflation test. Group A: good eustachian tube function at nine step inflation deflation test (30 ears), Group B: possible dysfunction of the ET at nine step inflation deflation test (30 ears). All the volunteers performed Valsalva maneuver, Toynbee maneuver and Ear Popper^© application, respectively. The efficiencies of all the three techniques were statistically compared first overall, then paired-wise between the two groups.

Results

There was no statistical difference in success rates of middle ear pressure equalization techniques in 60 ears, regardless of ET function results (Valsalva and Toynbee maneuvers 51.7% effective, Ear Popper^© 43.3% effective). There was also no statistical difference among the middle ear pressure shifts obtained by these three techniques. In almost half of the subjects in whom at least one technique was unsuccessful, the other two was effective. When the groups were separately compared; there was no significant difference between Valsalva and Toynbee maneuvers, whereas Ear Popper^© was found more effective in Group A (56.7% vs. 30%, p = 0.037).

Conclusion

No statistical difference in equalization of the middle ear pressure was found among Valsalva maneuvers, Toynbee maneuvers and Ear Popper^© in healthy adults under physiological conditions. Using alternative techniques may improve the success individually when a technique fails.     

Microdebrider vs. electrocautery for tonsillectomy: a meta-analysis

Objective

Tonsillectomy remains to be an ordinary operative process in otorhinolaryngology. Although there are a plenty of surgical means adopting in otorhinolaryngology, the advantage of one method over another has not been systematically demonstrated. The aim of designing this systematic review is to evaluate the efficiency of electrocautery tonsillectomy (ECT) compared with the microdebrider intracapsular tonsillotomy (MIT).

Methods

We retrieved randomized controlled trials (RCTs) from PubMed, EMBASE, Cochrane Library, CBM. Two reviewers extracted the information of included trials independently. The quality of included trials was assessed according to the criteria provided by Cochrane Handbook 5.0.1.

Results

Four researches were meeting the inclusive criteria which contained 501 participants, 253 in microdebrider tonsillotomy group and 248 in electrocautery tonsillectomy group. Systematic review illustrated that MT group had the recovery to normal activity and diet faster than ECT group [χ² = 1.02, P < 0.00001, 95% CI (−1.74, −1.30)] and [χ² = 0.01, P < 0.0001, 95% CI (−2.56, −0.92)]. There was a statistically significant in blood loss between microdebrider tonsillotomy and electrocautery tonsillectomy, the mean difference of 5.0 ml [P = 0.01, 95% CI (3.4, 26.6)]. There was no statistical significance in surgical time.

Conclusions

Compared with the electrocautery tonsillectomy, microdebrider tonsillotomy could significantly speed up the time to return to normal activity and normal diet. Two groups were similar in terms of surgical time of tonsillectomy. This conclusion is needed to be further supported by large-scale, high-quality, placebo-controlled, double-blind trials between microdebrider tonsillotomy and other techniques in the surgery time and blood loss of operation.     

Does adenoid hypertrophy really have effect on tympanometry?

Objective

The goal of this study is to determine the correlation between the radiographic measurements of adenoid size and tympanometric findings.

Study design

Prospective study.

Setting

Haydarpasa Numune Research and Education Hospital, Istanbul, Turkey.

Subjects and methods

Nine five consecutive children complaining of one or more of the symptoms of upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were included in the study. Symptom severity was assessed by a standardized questionnaire. All patients underwent digital lateral soft tissue radiographs. Assessment of nasopharyngeal obstruction in radiographs was done according to four different methods. Tympanometry was used to evaluate the middle ear.

Results

Of 190 ears, 79 were type A, 49 were type B and 62 were type C tympanograms. The symptom severity of 14 patients was graded as mild, 56 patients as moderate and 25 patients as severe. There was no statistically significant difference between UAO symptom severity groups and tympanogram types (p > 0,05). Each one of the four methods of radiologic measurements of the adenoid enlargement showed no statistically significant difference between the tympanogram types (p > 0,05).

Conclusion

The adenoid hypertrophy in both means of radiologic measurements and symptom severity does not correlate with the changes in tympanograms. These findings do not support the hypothesis that adenoidal size plays a major role in the etiopathogenesis of middle ear effusion (MEE).     

Colchicine prolongs patency of myringotomy in an animal model

Objective

Chronic otitis media with effusion (COME) is a frequently observed condition in childhood. The most common and effective surgical therapy for COME is myringotomy with insertion of a ventilation tube (VT). Our aims were to investigate the combined effect of myringotomy and the topical application of Colchicine solution to the external ear canal for the prolongation of patency in the treatment of patients with COME and to evaluate the ototoxicity of Colchicine applied directly to the middle ear.

Methods

A prospective study on 47 ears in 26 fat sand rats was fashioned. In the first phase, solutions of different concentrations of Colchicine were applied to the middle ear cavity in order to determine the drug's ototoxicity, assessing inner ear function with ABR. In the second phase myringotomy was performed and a non ototoxic concentration of Colchicine applied to 12 external ear canals, while saline was applied to nine.

Results

In the first phase, Colchicine concentration of 0.1% and higher applied to the middle ear cavity caused an ABR threshold elevation. In the second phase, the mean closure time after 0.01% Colchicine application was prolonged to >2.14 weeks (P < 0.05).

Conclusion

Colchicine has a proven potential for prolongation of myringotomy patency when applied as a solution to the external ear as a 0.01% solution. Further investigations are required to validate these results in humans and to study the potential effect of repetitive Colchicine application on the duration of myringotomy patency for the treatment of COME.     

Wideband energy reflectance findings in presence of normal tympanogram in children with Down's syndrome

Objectives

The prevalence of middle ear disorders in children with Down syndrome is higher than normal children due to the associated craniofacial abnormalities. The goal of this study is to evaluate middle ear function using wideband energy reflectance at ambient pressure in 14 young children with Down syndrome and matched control group (2½-5 years old; N = 19 ears per group) who each have a normal 226 Hz tympanogram.

Methods

All children underwent otoscopic examination, hearing screening using play audiometry (500-4000 Hz), and middle ear testing using 226 Hz tympanometry and wideband energy reflectance. The chirp signals for the wideband energy reflectance were presented to the child's ear at 65 dB SPL stimulus level and the recording was done over 220-8000 Hz range. The measured energy reflectance represents the ratio of the sound energy reflected from the tympanic membrane to the incident sound energy transmitted to the middle ear at a specific frequency. Paired Samples t-test was computed for the mean, 95th, 75th, 25th, and 5th percentile data of each frequency of the two groups.

Results

Despite the presence of normal tympanometric findings in both groups, results revealed abnormal wideband energy reflectance findings in 63% of the children with Down syndrome compared to the normal wideband energy reflectance findings in the control group. The mean energy reflectance ratio of the Down syndrome group was abnormally lower than that of the control at 5700-8000 Hz (p < 0.0005). The 5th and 95th percentile ratios of the Down syndrome group fell outside the 5th and 95th percentile of the control group (p < 0.0005).

Conclusions

Abnormally low energy reflectance ratios above 4000 Hz in the presence of normal tympanograms in the Down syndrome group may suggest associated congenital middle ear anomalies in children with DS. The present findings suggest that wideband energy reflectance has the potential to be of more practical value in children with DS than tympanometry. Further research with a larger number of Down syndrome children will illuminate the potential of wideband energy reflectance in diagnosing middle ear disorders in children with Down syndrome.     

Increased expression of VEGF, iNOS, IL-1β, and IL-17 in a rabbit model of gastric content-induced middle ear inflammation

Objective

To investigate the histopathological changes and the expression of vascular endothelial growth factor (VEGF), inducible NO-synthase (iNOS), endothelial NO-synthase (eNOS), interleukin (IL)-1β, and IL-17 in the rabbit middle ear mucosa after direct gastric content exposure.

Methods

Exploratory controlled study in which histological and immunochemical features were studied after gastric content-induced inflammation was established in rabbits. Sixteen healthy rabbits were divided into two equal groups. Gastric contents of an animal were injected into the middle ear of the same animal for 20 days. Saline was injected into the middle ear of the animals in the control group. The rabbits were humanely killed on day 27. Inflammation was assayed by light microscopy. Immunochemical staining was performed for VEGF, iNOS, eNOS, IL-1β, and IL-17 expression. Experimental and control animals were examined using the same protocol.

Results

The expression levels of VEGF, iNOS, IL-1β, and IL-17 differed significantly between the experimental and control groups (p = 0.018, p = 0.010, p = 0.002, and p = 0.002, respectively). The expression level of eNOS was not significantly different between the two groups (p = 0.132).

Conclusion

This study demonstrates that gastroesophagial reflux induced middle ear inflammation is associated with increased expression of VEGF, IL-1β, IL-17, and iNOS.     

Frequency distribution of synchronized spontaneous otoacoustic emissions showing sex-dependent differences and asymmetry between ears in 2- to 4-day-old neonates

Objective

The mature pattern of frequency distribution of synchronized spontaneous otoacoustic emissions (SSOAEs) has been reported to be bimodal in adults and children between 5 and 11 years of age; however, little is known about the distribution in neonates between 2 and 4 days after birth. Furthermore, overall differences in frequency distribution resulting from difference in sex and asymmetry between ears have not been carefully examined. The aim of this study is to determine the frequency distribution of SSOAEs in neonates at 2 to 4 days of age, evaluate the maturity of the pattern of distribution in this age group, and to evaluate the effects of differences in sex and asymmetry between left and right ears on the frequency distribution.

Methods

We evaluated 224 ears in 112 newborns (59 girls, 53 boys) whose ages ranged from 2 to 4 days. The SSOAEs were measured using ILO96.

Results

Most of the SSOAEs (86.5%) appeared at frequencies between 1.01 and 4.50 kHz. The overall frequency distribution of the SSOAEs showed a ‘peak-valley-peak’ pattern when plotted. Two peaks with maxima at 1.41-1.60 and 3.01-3.20 kHz were separated by a valley with a minimum at 2.41-2.60 kHz. Both girls and boys had approximate monomodal patterns in the distribution of SSOAEs. Significant sex-dependent differences were noted with more SSOAEs at the lower frequencies (≤2 kHz) in boys (46.1%) than in girls (32.0%) (P < 0.05) and more SSOAEs at the higher frequencies (2.51- 4.50 kHz) in girls (50.9%) than in boys (37.5%) (P < 0.05). Both the right and left ears showed the ‘peak-valley-peak’ pattern that was similar to the overall distribution pattern. But, compared with the peaks measured in the left ears at 1.01-1.50 and 3.01-3.50 kHz, the peaks of the right ears at 1.51-2.00 and 2.51-3.00 kHz were much closer to the valley.

Conclusions

The overall distribution of frequency of SSOAEs in 2- to 4-day-old neonates had the similar mature ‘peak-valley-peak’ distribution pattern seen in adults. Significant sex-dependent differences of the SSOAEs frequency distributions have been found. However, only slight ear asymmetries of the SSOAEs frequency distributions can observed in this age group.     

The clinical status of the eardrum: An inclusion criterion for the treatment of chronic secretory otitis media in children

Objective

To investigate if the clinical status of the eardrum could be an inclusion criterion for the therapy of chronic secretory otitis media (CSOM). To compare the results of treating CSOM by adenoidectomy and by adenoidectomy in combination with tympanostomy tubes in two groups of patients chosen according to that criterion.

Methods

161 ears in 87 children were treated for CSOM. An otomicroscopic examination showed there were no pathological changes on the tympanic membrane (signs of adhesive process, malleus rotation, and dangerous attic retractions). The patients were randomly divided into two groups: the first group of 59 ears was treated by myringotomy and tympanostomy tubes and adenoidectomy, while the other group of 102 ears was treated only by adenoidectomy. At least 6 months after the treatment, otomicroscopy and audiological assessments were performed in order to show the resolution of the middle ear effusion (MEE), audiological results and incidence of clinical sequelae of the eardrum.

Results

The resolution of MEE by adenoidectomy alone was not significantly different from the results of treatment by adenoidectomy and tympanostomy tubes (z = 1.565; p = 0.0587).There were no differences in pure tone audiometry between the two methods of treatment. Only at the frequency of 2000 Hz (t = 2.173; p = 0.031) in treatment with adenoidectomy and tympanostomy tubes the values of air-bone gap (ABG) were lower.Sequelae: scars of the eardrum (chi-square = 28.107; ss = 1; p < 0.001) and attic retractions (chi-square = 4.592; ss = 1; p = 0.032) were more often in treatment with tubes. The incidence of clinical sequelae on the eardrum after treatment by tubes was commented on.

Conclusion

A criterion that could influence the approach to the therapy of CSOM in children.     

Acoustic rhinometry, spirometry and nitric oxide in relation to airway allergy and smoking habits in an adolescent cohort

Objective

This study aimed to analyze upper and lower airway function and the impact of smoking habits in a cohort of allergic and healthy adolescents. The influence of smoking habits on the outcomes of rhinitis and asthma is well documented, but only few reports are available showing smoke related upper airway impairment by rhinometric measurements, and none with focus on early changes in adolescents.

Methods

A cohort followed from infancy was re-examined at the age of 18 years concerning allergy development. Acoustic rhinometry (VOL2), spirometry (FEV₁) and measurements of nitric oxide levels from the upper (nNO) and lower airways (eNO) were performed before and after physical exercise, and smoking habits were registered.

Results

Active smoking habits were reported by 4/21 subjects suffering from allergic rhinitis, by 1/4 from probable allergic rhinitis, by 0/3 subjects with atopic dermatitis and by 2/10 healthy controls. Smoking habits were reported as daily by 2 and occasional by 5 of the 7 active smokers. VOL2 did not increase in smokers after exercise as in non-smokers, resulting in a post-exercise group difference (7.3 ± 1.1 cm³ vs. 8.8 ± 1.5 cm³; p = 0.02), and FEV₁ values were lower in smokers compared to non-smokers (89 ± 7% vs. 98 ± 8%; p = 0.02). The nNO and eNO levels were, however, only slightly reduced in smokers. Airway allergy was discerned only in subjects with current allergen exposure by increased eNO levels compared to healthy controls (41 ± 44 ppb vs. 13 ± 5 ppb). The levels of VOL2, nNO and FEV₁ did not differentiate allergic subjects from healthy controls.

Conclusions

Low levels of tobacco smoke exposure resulted in reduced airway functions in this adolescent cohort. Acoustic rhinometry and spirometry were found to be more sensitive methods compared to nitric oxide measurements in early detection of airway impairment related to smoke exposure. A possible difference in airway vulnerability between allergic and healthy subjects due to smoke exposure remains to be evaluated in larger study groups.     

Impedance audiometry in infants with a cleft palate: The standard 226-Hz probe tone has no predictive value for the middle ear condition

Objective

Infants with a cleft palate and microscopical evidence for middle ear effusion attracted our attention because of normal tympanometry results and negative otoacoustic emissions. These contradictory findings initiated us to study to what extent high frequency tampynometry is able to supply us with more reliable results.

Methods

Eighty-three ears of 46 cleft palate babies aged between 2 and 7 months were examined within the pedaudiological screening procedure via tympanometry before their surgical cleft closure. We applied probe tone frequencies of 226 Hz and 678 Hz. A control cohort of 69 ears of 36 babies without cleft palate was established. Results were later compared to the intraoperative findings.

Results

By tympanometry with a 226-Hz probe tone, the examiners predicted the intraoperative findings correctly in only 29 cases of 83 examined ears (34.9%). However, their interpretation of tympanometry results by means of a 678-Hz probe tone correlated to the intraoperative findings in 96.3% cases.

Conclusions

In cleft palate babies tympanometry with a 678-Hz probe tone yields clear evidence of middle ear effusion and should therefore serve as an essential instrument before the first surgical step of palate closure. In case of applying the 226-Hz probe tone, we were often confronted with normal function of the Eustachian tube despite of proved existence of middle ear effusion.     

The accuracy of otomicroscopy for the diagnosis of paediatric middle ear effusions

Objective

To determine the diagnostic accuracy of otomicroscopy performed by otolaryngology specialists for the diagnosis of paediatric middle ear effusions.

Methods

Prospective study of consecutive children receiving tympanostomy tubes between December 2004 and February 2005 within the Department of Otolaryngology—Head & Neck Surgery, Manukau Surgery Centre, Middlemore Hospital, New Zealand. Eighty-six children were included in the study. Intraoperative otomicroscopic examination of the ears was performed under general anaesthesia by two otolaryngology specialists. The presence or absence of middle ear effusion was predicted prior to myringotomy. Intraoperative myringotomy findings were used as the diagnostic reference standard.

Results

The prevalence of middle ear effusions was 52.6% (71/135 ears). Otomicroscopy had a sensitivity 94.4% (95% CI: 85.5-98.2), and specificity 93.8% (95% CI: 84.0-98.0). The positive predictive and negative predictive values of otomicroscopy for the identification of middle ear effusions were 94.4% (95% CI: 85.5-98.2), and 93.8% (95% CI: 84.0-98.0) respectively. The overall accuracy of otomicroscopy was 94.1%. There was an excellent level of agreement between otomicroscopy and myringotomy findings (kappa = 0.88, 95% CI: 0.80-0.96).

Conclusions

Otomicroscopy performed by the specialist otolaryngologist is an accurate tool for the diagnosis of middle ear effusions. Otomicroscopy performed on the anaesthetised child achieves greater diagnostic accuracy than tympanometry and pneumatic otoscopy.     

TLR-9, NOD-1, NOD-2, RIG-I and immunoglobulins in recurrent otitis media with effusion

Objectives

Pattern recognition receptors (PRRs) induce appropriate immune responses after recognizing certain molecular characteristics of pathogens. It is not known, however, whether PRRs are expressed in middle ear infections and whether the expression of PRRs and immunoglobulins is correlated in recurrent otitis media with effusion (OME). We therefore investigated the expression of PRRs and immunoglobulins in children with OME.

Materials and methods

The study population consisted of 66 children with OME, of whom 27 had more than 4 episodes in 12 months or more than 3 episodes in 6 months (otitis-prone group), and 39 had fewer than 4 episodes in 12 months or 3 episodes in 6 months (non-otitis-prone group). The expression in middle ear effusion of Toll-like receptor (TLR)-9, nucleotide-binding oligomerization domain (NOD)-1, NOD-2, and retinoic acid-inducible gene (RIG)-I mRNA, as determined by real-time PCR, and the concentrations of IgG, IgA, and IgM, as determined by ELISA, were compared between the two groups.

Results

The levels of TLR-9, NOD-1 and RIG I mRNAs were significantly lower in the otitis-prone than in the non-otitis-prone group (p < 0.05 each). The concentrations of IgG, IgA and IgM in effusion fluid did not differ significantly between the two groups (p > 0.05), and there were no correlations between immunoglobulin concentration and the expression of PRPs (p > 0.05).

Conclusions

Decreased expression of PRRs may be associated with increased susceptibility to OME.     

The role of audiological diagnostics in children with cleft lip & palate (CLP)

Objective

To assess the otologic and audiologic status of patients with cleft lip and palate (CLP) operated in the Department of Pediatric Surgery attached to the Advanced Pediatric Centre, Post Graduate Institute of Medical Education & Research (PGIMER), India. The main idea of carrying out this study was to know the incidence of middle ear pathologies in a group where no complaints have been noticed.

Setting

Research study was carried in Post Graduate Institute of Medical Education & Research (PGIMER) which is one of the tertiary care institutions in India.

Participants

55 children (Mch: 28; Fch: 27) in the age range of 4-13 years constituted the study group. These children were operated upon by the same surgeon (JKM) during the period 1996-1998 and were attending the speech clinics at PGIMER. None of these children/parents had complained of any ear problem and were taken up for the study to find out the middle ear pathology. The ontological and audiological evaluation was done for all the children.

Results

53 of 110 ears had normal hearing status. None of the ears had severe or profound hearing loss. The air conduction thresholds ranged from 20.2 to 29.63 dB across the frequencies whereas the bone conduction thresholds varied from 7.13 to 12.41 dB. Only 42% of the right (R) ears and 47% of the left (L) ears had a normal tympanic membrane.

Conclusion

On the basis of this finding, investigation of the benefits of early and routine follow-up for otologic and audiologic status is warranted. Patients with cleft lip and palate should have an intense and detailed otologic and audiologic follow-up to identify any ME pathology/hearing loss so that timely intervention can be taken.     

Iatrogenic perinatal pharyngoesophageal injury: A disease of prematurity

Objective

Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage. Our objective was to estimate the incidence of iatrogenic perinatal pharyngoesophageal injury (IPPI) in preterm versus term infants in a children's hospital neonatal intensive care unit (NICU). A secondary goal was to explore the clinical characteristics and outcomes associated with these complications.

Methods

All NICU discharge summaries from 2004 to 2008 were searched for IPPI-related keywords. Highlighted records were reviewed and the incidence of complications calculated by gestational age and weight.

Results

Of 5910 total NICU discharges, 6 cases of IPPI were identified, for an overall incidence of 0.10%. All injuries occurred in infants less than 33 weeks gestational age and 1500 g, with a trend towards higher incidence with increasing prematurity. The incidence of IPPI rose to 4/1321 (0.30%) at 27-32 weeks and 2/521 (0.38%) at less than 27 weeks gestation. Similarly, IPPI occurred in 3/675 (0.44%) babies born at 1000-1500 g and 3/642 (0.47%) babies below 1000 g. All affected infants survived with conservative management.

Conclusions

IPPI is a rare but serious complication of perinatal airway instrumentation and is primarily a disease of prematurity. In this sizeable cohort, no complications occurred in term infants, and the incidence of injury increased with decreasing gestational age and weight. This increased propensity towards injury should prompt special care when performing even routine airway procedures on premature neonates.