Massive retropharyngeal lymphadenopathy in an infant: an unusual presentation of infectious mononucleosis

Infectious mononucleosis causing upper airway obstruction due to tonsillar disease and associated lymphadenopathy in adolescents is well recognized. However, infection with Epstein-Barr virus (EBV) in a young child of six months is rare. The authors present such a case, with massive swelling of the retropharyngeal lymph nodes, that has not been published previously. The patient presented to this department with a short history of an upper respiratory tract infection and mild upper airway obstruction. On examination there was a massive enlargement of the retropharyngeal space with a compromised airway. This was confirmed on X-ray. She made an uneventful recovery following incision and drainage and a short period of endotracheal intubation. Because of the presence of retropharyngeal lymphoid tissue in infancy an alternative site of upper airway obstruction may occur here in this age group.     

Low dose radiotherapy for adenotonsillar lymphoid hyperplasia in HIV-positive patients

Lymphoid hyperplasia is common in HIV positive patients. The aim of this study was to determine the response to radiotherapy. Thirty-three adult patients with recurrent tonsillitis or upper airway obstruction due to tonsillar hyperplasia and conformed histology of follicular hyperplasia were included. Thirteen underwent a 24 Gy course of radiotherapy and were followed up for a minimum of 16 weeks post-radiotherapy. There was a statistically significant decrease in the median tonsillar size (95% confidence interval [-3;-2]) and in the median CD(4) count (95% CI [3;152]) after 16 weeks. None of the patients had acute tonsillitis or airway obstruction after radiotherapy. Low dose radiotherapy is effective in the management of adenotonsillar hyperplasia in HIV positive patients.     

Airway obstruction in an immunosuppressed child

Recipients of organ transplants who require continuous immunosuppression appear to have an increased incidence of lymphoproliferative disorders. A case of severe upper airway obstruction resulted from adenotonsillar hypertrophy in a 2-year-old girl following liver transplantation. Tonsillectomy and adenoidectomy dramatically reversed the airway problem and confirmed a transplant-associated lymphoproliferative disorder. A generalized lymphadenopathy also regressed with reduction of cyclosporine immunosuppression. We urge vigilance in monitoring transplant recipients, particularly children, for problems of upper airway obstruction and advocate prompt biopsy of persistently enlarged lymphoid tissue in all immunosuppressed individuals who fail to respond to conventional medical therapy.     

Radiofrequency volume tissue reduction of the tonsils: case report and histopathologic findings

Innovative new techniques to resect tonsillar tissue have been described in the recent literature. We report the case of a patient who underwent volume reduction of tonsillar tissue by radiofrequency energy under local anesthesia in an office setting. Treatment resulted in a reduction of tonsillar size with minimal pain, which can be attributed to the avoidance of mucosal interruption. The patient subsequently underwent standard tonsillectomy, which allowed us to examine the histopathology of the tissue that was treated with radiofrequency. In doing so, we noted an absence of fibrosis and preservation of normal histologic architecture. We conclude that performing volume reduction of tonsillar tissue by applying radiofrequency energy to the stroma of the tonsils without temperature control results in objective improvement in airway size with minimal effects on the histopathology of the tonsillar stroma. Mucosa-sparing tonsillar reduction may be a preferable alternative to other techniques of tonsillar reduction, especially for young children, who would experience a nearly pain-free procedure.     

Endoscopic examination of obstructive sleep apnea syndrome patients during drug-induced sleep

Sixty patients diagnosed with obstructive sleep apnea syndrome (OSAS) underwent uvulopalatopharyngoplasty (UPPP). The effects of surgery were studied based on endoscopic findings during drug-induced sleep and determination of the apnea-hypopnea index (AHI) before and after the operation. Changes in the form of the airway during sleep in the recumbent position were observed, and the role of upper airway endoscopy in the diagnosis and surgical treatment of OSAS was determined. The site of airway obstruction during sleep induced by i.v. injection of 10 mg of diazepam was classified into five types, and changes in AHI and the site of airway obstruction were compared before and after surgery. Changes in airway morphology during sleep in the supine and recumbent positions were also compared before surgery. The postoperative improvement rate was 74.4% for the soft palatal type of obstruction, 76.2% for the tonsillar type, 53.3% for the circumferential palatal type and 34.0% for the mixed type. Treatment produced excellent or good effects for the soft palatal and tonsillar types of obstruction. However, many patients with the circumferential palatal and mixed types of obstruction showed only some improvement or no change. Good airway morphology was maintained in the recumbent position by patients with the soft palatal type of obstruction. With the circumferential palatal and mixed types of obstruction, improvement can be expected from operations which include surgical treatment of the posterior pharyngeal wall or lateral funiculus, or with midline laser glossectomy. A good operative outcome can be predicted in patients showing improvement of apnea in the recumbent position preoperatively.     

Candida infection after tonsillectomy in a 12-year-old girl

Tonsillectomy has been associated with complications such as bleeding, pain, dehydration, edema, airway obstruction, atlantoaxial subluxation and infection. However, fungal infection is a very rare complication of tonsillectomy. We describe the case of a 12-year-old girl who developed oral Candida infection as a complication of tonsillectomy. She had pain and difficulty in swallowing on the third postoperative day, and a local examination revealed an easily grazing, white plate on the tonsillar fossa. A culture of the lesion tissue identified Candida albicans. Local nystatin therapy was administered, and the lesion healed completely by postoperative day 12. We conclude that fungal infection, though rare, can occur as a complication of tonsillectomy.     

Painless tonsillectomy

PURPOSE OF REVIEW: Even though pediatric tonsillectomy is a well accepted treatment for upper airway obstruction or recurrent tonsillar infection, the painful recovery of this operation is unwelcome. As more studies are published on the beneficial effects of tonsillectomy, the number of tonsillectomies performed is likely to increase. It would behoove any surgeon performing this operation to be aware of the available options for post/perioperative pain control. RECENT FINDINGS: New techniques used to perform tonsillectomy, innovative adjuvant medical therapy and other tools are reviewed. SUMMARY: The search for 'the painless tonsillectomy' continues. Finding a technique that works best for each surgeon is paramount to successful tonsillectomy. Patient comfort, surgical time, complications such as bleeding and regrowth of tonsillar tissue, or recurrence of symptoms that lead to the initial operation should all be considered in the surgeon's choice of a particular tonsillectomy technique. Medical therapies such as corticosteroids in the perioperative period are well accepted as a pain adjuvant. Newer adjuvants include the use of pretonsillectomy injection of mixtures that include local anesthetics with opioids and clonidine. The use of nonsteroidal antiinflammatory drugs appears to be helpful for pain, but controversial regarding bleeding. Another successful strategy used to decrease pain perception is distraction.     

Influence of upper airway narrowing on the effective continuous positive airway pressure level

BACKGROUND AND OBJECTIVES: The aim of this study was to determine the relationship between the continuous positive airway pressure (CPAP) titration level and upper airway variables in obstructive sleep apnea syndrome (OSAS). SUBJECTS AND METHODS: Forty-seven patients suffering from OSAS were enrolled in this study. They were asked to answer a questionnaire about nasal stuffiness and mouth breathing, and the degree of tonsillar hypertrophy and shape of the oropharyngeal inlet were evaluated. The minimal cross-sectional area (MCA) of the nasal cavity was measured with acoustic rhinometry, followed by optimal CPAP level titration. We compared optimal CPAP levels with body mass index (BMI), perceived nasal stuffiness, and anatomic upper airway narrowing. RESULTS: The mean CPAP level was 6.32 +/- 2.17 cm H2O. We found a significant correlation between CPAP levels and BMI (P = .01), apnea-hypopnea index (P = .015), and the degree of tonsillar hypertrophy (P = .011). Furthermore, the CPAP level increased significantly with the MCA on the narrow side of the nasal cavity (P = .038) in patients with a BMI less than 25. Other variables, such as subjective symptoms and anatomic nasal airway occlusion in obese patients (BMI > or = 25), revealed no correlation with the CPAP level. CONCLUSIONS: Upper airway occlusion including nasal obstruction or tonsillar hypertrophy might increase the effective CPAP level.     

Management of upper airway obstruction.

The tongue is the most common cause of upper airway obstruction, a situation seen most often in patients who are comatose or who have suffered cardiopulmonary arrest. Other common causes of upper airway obstruction include edema of the oropharynx and larynx, trauma, foreign body, and infection. The management of the patient with upper airway obstruction depends upon the cause of the obstruction, the training and skills of the rescuer, and the availability of adjuncts necessary to perform advanced airway techniques. In most cases, merely positioning the patient or performing one of the three maneuvers designed to elevate the tongue will open the airway of the comatose patient or the victim of cardiac arrest. In patients with suspected foreign body obstruction, abdominal or chest compression should be performed immediately, with digital extraction of the foreign body reserved for those in whom these maneuvers are unsuccessful. Most patients with obstruction secondary to edema, trauma, or infection can be managed initially with orotracheal or nasotracheal intubation. Intubation should be attempted prior to surgical management of the airway in most cases of upper airway obstruction. Occasionally, however, cricothyroidotomy or tracheostomy is necessary to establish an airway. The choice of technique depends primarily on the experience and skills of the rescuing physician or paramedic. In most cases, cricothyroidotomy is technically more simple and more easily performed than tracheotomy, especially for the physician who has not been trained in surgery or otolaryngology and for the nonphysician rescuer. No matter what the method employed in establishing an airway in a patient with upper airway obstruction, it must be performed quickly and a source of ventilation provided for the patient once the airway has been secured.     

Complications of the 'treatment' of tonsillar infection by traditional healers in Nigeria

Traditional healers in Nigeria attempt to treat tonsillar infections either by performing uvulectomy with a sickle knife or by digital rupture of the tonsil. These procedures result in various complications, including haemorrhage, septicaemia, cellulitis of the neck, peritonsillar and parapharyngeal abscess, upper airway obstruction, and pharyngo-laryngocele with pneumothorax. These complications are illustrated with case reports. The danger of encouraging traditional healers to practise unsupervised and unscientific medicine is stressed.     

Immunology of tonsils and adenoids: everything the ENT surgeon needs to know

The lymphoid tissue of Waldeyer's ring, and particularly the nasopharyngeal tonsil (adenoids), appears to be functionally comparable to nasal-associated lymphoid tissue in rodents. Antigen-stimulated lymphoid follicles give rise to: (a) clonal B-cell expansion; (b) B-cell receptor affinity maturation; (c) positive selection of B cells according to receptor affinity for antigen; (d) differentiation to B memory cells and plasma cells; and (e) variable induction of the joining (J)-chain gene. B-cell differentiation is also important to promote downstream isotype switching of the immunoglobulin (Ig) heavy chain constant genes. For tonsillar B cells, this process gives mainly rise to IgG and IgA plasma cells, partially associated with J-chain expression. Because the J chain is a key peptide in the polymer structure of secretory IgA, tonsils and adenoids may provide B cells for mucosal effector sites. Thus, several observations suggest that these lymphoid organs generate polymeric IgA (pIgA)-expressing B cells that migrate to the upper airway mucosa, lacrimal glands and salivary glands. Accordingly, the nasal route of vaccination induces secretory IgA-dependent regional mucosal immunity and will also enhance systemic immunity. Although the pIgA-producing capacity of tonsillar B cells is considerably decreased in children with recurrent tonsillitis, a conservative attitude towards adenotonsillectomy appears immunologically desirable, particularly in the young age group.     

Evaluation of upper airway obstruction in snoring patients using digital video stroboscopy

Stroboscopy is routinely used in voice disorder clinics but its use in studying the mechanisms of upper airway obstruction in patients who snore has not yet been described. This study combines the use of stroboscopy during sleep nasendoscopy to evaluate the oscillations and vibrations observed during snoring in slow motion. In addition, we utilised the multi-dimensional voice programme simultaneously to study some of the acoustic parameters of snoring whilst visualising the dynamics of the upper airway. Forty-five patients with primary snoring or mild obstructive sleep apnoea were recruited at two different centres and underwent sleep nasendoscopy. The simultaneous use of acoustic analysis was included to ascertain whether sound analysis alone could replace the need for using the sedation endoscopy in these patients. The use of a stroboscopic light source indeed enhanced the visualisation during the procedure and some subtle aspects of the mechanisms of upper airway obstruction, such as vibrations of the posterior pharyngeal wall and mucosal waves were identified. Most of the patients in this study exhibited multilevel obstruction and thus acoustic analysis alone would not be sufficient in accurately locating the site of upper airway obstruction in snorers.     

Synovial sarcoma of the parapharyngeal space

Synovial sarcoma is a rare soft tissue sarcoma in the head and neck region and parapharyngeal space. A 21-year-old girl presented with a 6-month history of progressive right arm pain, neck mass and upper aerodigestive tract obstruction. On physical examination there was a large painless mass arising from the right-sided parapharyngeal space causing airway obstruction and with no cervical lymphadenopathy. Initial magnetic resonance imaging (MRI) revealed a large tumor in the right-sided parapharyngeal space. She underwent near total resection of the tumor. Pathologic report disclosed the diagnosis of synovial sarcoma. She then received postoperative adjuvant external radiotherapy to the primary site and a dose of 60 Gy was delivered. Less than 8 months after the completion of the treatment she developed widespread lung metastases. Herein we describe the clinical, radiological and pathological finding of the case.     

Bilateral recurrent laryngeal nerve palsy following blunt neck trauma

Blunt trauma neck to larynx is an uncommon injury that results in a wide spectrum of damage to endolaryngeal soft tissues as well as underlying cartilaginous skeleton leading to upper airway obstruction requiring emergency tracheostomy. A case report of blunt trauma neck anterior is presented who developed upper airway obstruction necessitating tracheostomy. Indirect Laryngoscopy and fibre optic examination identified vocal cord paralysis as primary cause of upper airway obstruction although X ray soft tissue neck and CT neck revealed fracture hyoid as well as hematoma surrounding the laryngeal frame work. Emergency tracheostomy was done and patient recovered uneventfully.     

Cryptococcosis of the larynx.

An unusual case of cryptococcosis of the larynx initially developed as an acute upper airway obstruction that necessitated tracheostomy. Concomitant findings were tracheobronchial ulcerations and edema with severe mainstem bronchial constriction on the left side. Budding "yeast-like organisms" that were consistent with Cryptococcus neoformans appeared in tissue specimens. Epithelial changes that were consistent with pseudoepitheliomatous hyperplasia occurred in areas in the immediate vicinity of the organisms. Sputum and bronchial washing cultures grew nonmycelial, mucinous, encapsulated forms that were positive to staining with mucicarmine and Alcian blue. Treatment with amphotericin B resulted in resolution of the laryngeal obstruction, permitting decannulation. Follow-up direct laryngoscopy and biopsy three months after completion of therapy revealed only mild edema of the false vocal folds. No organisms were found in the tissue, and the pseudoepitheliomatous hyperplastic mucosal changes had resolved.     

Body growth in relation to tonsillar enlargement and tonsillectomy.

Severe airway obstruction caused by tonsillar enlargement can result in disturbances in body growth. The effect of this interference and of tonsillectomy in the child with only moderate symptoms have been less satisfactoril evaluated. In this study, 122 children with symptoms and signs of tonsillar obstruction were investigated concerning the height and weight before and after tonsillectomy. None of the individuals demonstrated cardiopulmonary complications of tonsillar obstruction. Altogether 10% of the children exhibited abnormalities in body weight and/or length prior to surgery. Especially during the first postoperative year, the weight and height gain exceeded the expected in 75% of the patients. The accelerated weight gain increased with tonsil size, but there was no relation to the extent of difficulties in swallowing or sleeping disruptions. The results support the hypothesis that tonsillar hypertrophy frequently is associated with disturbances in body growth and that this is seldom demonstrable prior to tonsillectomy.     

Tracheostomy in human immuno-deficiency virus infected children at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa

Tracheostomy in adults with HIV/AIDS has been reported to be associated with both high and early mortality of 47-100%. There is minimal data regarding the role of tracheostomy in HIV infected children. We did a retrospective analysis of HIV positive children that underwent tracheostomy at our institution over a 5-year period, 2002-2006. A total of 70 tracheostomies were done during the period and 15 (21.4%) of these children were confirmed as HIV infected. The average age at presentation for HIV infected children with upper airway obstruction resulting eventually in tracheostomy was 9.4 months and 60% were under 1 year of age. Only three (20%) were on Anti-Retroviral Therapy (ART) prior to presentation. The cause of upper airway obstruction was croup in 14 (93%) of these 15 children. Following tracheostomy all were treated with ART. To date six children have been successfully decannulated (40%) and there have been three deaths (20%) which were unrelated to tracheostomy. CONCLUSION: Tracheostomy in HIV positive children is not associated with the high mortality that has been reported in adults provided such children are started on treatment with antiretroviral therapy.     

Infectious mononucleosis complicated by lingual tonsillitis

Although upper airway obstruction and superimposed infection are well-known complications of infectious mononucleosis, lingual tonsillitis in this context has not been mentioned in the literature. We describe a case of acute bacterial lingual tonsillitis with airway obstruction complicating infectious mononucleosis. The role of the base of tongue region in the pathophysiology of infectious mononucleosis is discussed.     

Treatment of laryngeal sarcoidosis with intralesional steroid injection

Laryngeal sarcoidosis presents with hoarseness, cough, and dysphagia. Shortness of breath due to upper airway obstruction may occur. Indirect laryngoscopy reveals mucosal edema and erythema, granulomas, and nodules. The supraglottic larynx is the most frequently affected area. Systemic corticosteroids can be used initially; however, with persistent symptoms and/or severe airway problems, intralesional steroid injections may be more effective, as in the six patients presented.