The presence of Streptococcus pneumoniae in chronic otitis media was determined with a new antigen detection kit, the NOW test. The NOW test was originally designed as a urinary antigen test but was adapted to middle-ear effusions for the present study. Middle-ear effusions from 52 children were studied. Streptococcus pneumoniae was cultured from 10 per cent of the effusions. The NOW test was positive in 23 per cent of the effusions, 80 per cent of culture positive and 17 per cent of culture negative effusions. The NOW test proved to be rapid, simple, reliable and relatively inexpensive for the detection of pneumococcal antigen in the middle-ear effusions. This test may prove valuable for the management of children with acute otitis media who undergo tympanocentesis.

Objective: to determine if there is a correlation between common otolaryngologic symptoms and presence of gastroesophageal reflux disease (GERD) in children. Methods: charts of 295 children presenting with suspicion of GERD were reviewed for presenting symptoms including: (1) airway symptoms: stertor, stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, blue spells, hoarseness, throat clearing; (2) feeding symptoms: wet burps, globus sensation, frequent emesis, dysphagia, choking/gagging, sore throat, halitosis, food refusal, stomach aches, arching, drooling, chest pain, irritability, and failure to thrive. At least one positive test of barium esophagram, gastric scintiscan, pH probe or esophageal biopsy resulted in inclusion in the GERD positive group. Results: 214 children had GERD diagnosed while 81 had no positive tests for GERD. Between the GERD positive and GERD negative groups, the significantly different symptoms were stertor (P=0.040), cyanotic spells (P=0.043), frequent emesis (P=0.007), failure to thrive (P=0.006), and choking/gagging (P=0.044). Three pooled variables were created: airway flow (stertor, stridor, cyanotic spells), airway irritation (frequent cough, recurrent croup, throat clearing), and feeding (dysphagia, failure to thrive, frequent emesis). GERD patients who were 2 years or less were compared to those older than 2 years and all three of these pooled variables were significantly different between these groups (P<0.001). Conclusion: children who present with a certain constellation of airway or feeding symptoms are more likely to have a positive GERD test. Children 2 years old or less are more likely to present with airway symptoms or feeding difficulties while children older than 2 years are more likely to present with airway irritation.

OBJECTIVE:To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD). STUDY DESIGN:Retrospective chart review METHODS:Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy). RESULTS:A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality. CONCLUSION:Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis.

We present the development of ASGS in two of three premature male triplets; the affected infants were monozygotic, while the unaffected triplet was dizygotic. All three shared remarkably similar risk factor profiles. There is suggested the existence of a genetic factor or factors which may predispose certain infants to the development of ASGS. The expression of such genetic influence may be expressed through the a priori presence of CSGS or other genetically based mechanisms including abnormal cartilage growth or development, specific patterns of chondral or mucosal injury, the action of specific growth factors, or the effects of autoimmune or inflammatory mediators. We propose that genetic predisposition be considered a possible risk factor in the development of subglottic stenosis.

Duplication anomalies of the nose include polyhinia (double nose) and supernumerary nostril (assessory nostril). These are rare congenital nasal deformities resulting from aberrant embryological development. Differential diagnoses include glioma, encephalocele, nasal dermoid, nasolacrimal duct duplication, mid facial cleft and proboscis lateralis (K. Nakamura, T. Onizuka. Plast. Reconstr. Surg. 80 (3) (1987) 436–441). Our review of the English language literature revealed eight reported cases of duplication anomalies of the nose. Four of these were cases of polyrhinia (double nose). Of the cases remaining, one patient had a supernumerary nostril in association with a cleft lip, leaving only three reported cases of an isolated supernumerary nostril. We present a newborn infant with an isolated right supernumerary nostril. MRI, CT and photographic documentation are provided. Pertinent embryology, anatomy and a thorough review of the literature are included.

Background: Chronic sinusitis in children is a complex clinical problem. Some patients do not improve with medical therapy and some fail surgery as well.Objective: A therapeutic trial of intravenous immune serum globulin (IVIG) was given to children whose sinus disease was recalcitrant to the usual therapeutic modalities. The objective of IVIG administration was to modulate the inflammatory process contributing to the chronicity of the sinusitis.Methods: Six patients were given a 12-month trial of monthly (400 mg/kg) IVIG infusions. Entry criteria included persistence of sinusitis after 3 months of full course antibiotics, or two episodes of sinusitis within a 3-month period while on prophylactic antibiotics. All patients had abnormal sinus CT (computerized tomography) scans at entry. Three of the six patients remained symptomatic despite prior sinus surgery. Patients with primary immune deficiencies were excluded. Each patient served as his own control based on their previous 12-month history and clinical course. Four of the 6 patients were atopic as demonstrated by prick skin testing; however, all patients had nasal eosinophilia.Results: Full course antibiotic use decreased in five of the six patients (183 to 84 days); correspondingly, the episodes of sinusitis decreased (average 9 to 4 per year). In addition, sinus CT scans showed significant improvement.Conclusion: This preliminary open-trial of IVIG suggests its usefulness as adjunct therapy to medical management in selected patients with chronic sinus disease. The mechanism(s) by which IVIG may be helpful is probably not based on the concept of replacement therapy, but more likely as an immune or inflammatory modulating agent.

Congenital stridor is a common problem that has many very different etiologies. A complete history and physical examination will allow the astute clinician to direct the laboratory evaluation efficiently. Establishing a relationship with a specialist will be useful for consultation when considering a referral in questionable situa.

Craniofacial dysostosis (Crouzon syndrome) is a syndrome characterized by premature closing of calvarial and cranial base sutures as well as those of the orbit and maxillary complex. Orofacial manifestations of this disease include maxillary hypoplasia, external nasal deformity, and prognathism. Airway distress is a well described feature of this syndrome, and both upper and lower airway obstruction may be present in the Crouzon syndrome. Obstructions in the upper airway have been reported secondary to septal deviation, midnasal and choanal abnormalities, and nasopharyngeal narrowing. This study presents a child with the Crouzon syndrome who required tracheotomy during the first 2 years of life for airway obstruction caused in the newborn period (first 6 months) by midnasal stenosis and later (6 months to 2 years) compounded by soft palate obstruction at the level of the oro/hypopharynx. A review of the English language literature revealed one similar patient presentation but no comprehehsive review of this subject. Previously reported airway anomalies are reviewed and airway management is discussed in patients with Crouzon syndrome.

As home care tracheotomy has become a viable option for children with long-term canulation, medical personnel are challenged to provide as safe an environment as possible out of the hospital for these children. The tools used in the training of the families and other caregivers have received little attention in the literature. This study describes the development of a home-care tracheotomy manual for parents. The use of appropriate content presented in an organized, informative and pleasing fashion at the appropriate reading level is stressed. The evaluation of the manual by parents with children who have a child with a tracheotomy is also described.

Needle aspiration for the treatment of peritonsillar abscess was assessed in 43 consecutive children aged 7 to 18 years (mean age, 13.9 +/- 2.5 years) during the 3-year period from 1988 through 1991. A positive aspirate was obtained in 31 (76%) of the 41 patients who cooperated for needle aspiration; a mean of 2.9 +/- 1.9 mL of pus was withdrawn. Of the 31 children with a positive aspirate, in 27 (87%) the abscess resolved, two (6%) required a second aspiration for resolution, and two (6%) underwent immediate tonsillectomy for persistent abscess. Of the 10 children (24%) with negative aspirations, in six (60%) the abscess resolved with antibiotic treatment alone, three (30%) underwent immediate (quinsy) tonsillectomy, and in one (10%) the abscess spontaneously drained. No bleeding, airway obstruction, or anesthetic complications occurred. Needle aspiration of peritonsillar abscess in children, with tonsillectomy reserved for nonresponders, appears to be an efficacious and safe method of treatment.

The effect of postoperative diet and activity instructions on the recovery rate after tonsillectomy and adenoidectomy (T & A) was assessed in 92 children ages 3 to 14 years. Two types of postoperative instruction were randomly assigned: 'Restricted', which advised limited, stay at home activities and a soft food liquid diet for 7-10 days, and 'nonrestricted', which advised return to activity and diet as tolerated by the child. Parental evaluation of the levels of pain, activity, and diet using an equal intervals scale was obtained. The number of doses of pain medication, the types of food eaten and postoperative complications were also recorded. No significant differences were found between the two groups in pain level, activity tolerance, return to normal diet, and numbers of doses of pain medication at day 3 and day 7 after surgery. More 'junk' food and spicy foods were eaten in the 'nonrestricted' group. Postoperative hemorrhage requiring intervention occurred in one child in each group. Implications for the children and their families undergoing T & A are discussed with attention to a review of the literature.

Adenoid physiology as reflected in the qualitative and quantitative bacteriology and immune cell distribution was correlated with clinical presentation in 69 children (16 to 130 months of age) undergoing adenoidectomy for obstructive adenoid hyperplasia (n = 38) or chronic adenoid infection (n = 31) and in 16 adenoid core biopsy specimens from 16 nondiseased controls. In the control adenoids, few potentially pathogenic bacteria were found as the dominant bacteria in the adenoid core (25%), and significantly greater concentrations of nonpathogens (commensals) were isolated (P < .01). Potential pathogens as the dominant bacteria were found twice as often in obstructive adenoid hyperplasia (62%) and in chronic adenoid infection (55%) (P < .05). Haemophilus influenzae was most common in the diseased adenoids, 53% in obstructive adenoid hyperplasia and 48% in chronic adenoid infection, compared with only 19% in the controls (P < .05). No significant differences in lymphocyte density, B and T cells, as well as T-helper subsets, were found between clinical classifications. However, T-suppressor cells, monocytes-macrophages, and natural killer cells were significantly increased in chronic adenoid infection only (P < .05). The findings in this study support roles for both alterations in bacterial homeostasis and an altered immune profile in the etiology of chronic adenoid disease in children.

In order to better understand the pathogenesis and sequelae of obstructive adenoid hyperplasia in children, the anatomic relationships of the adenoids to the hard and soft palates, oropharynx, and nasopharynx were studied in vivo in 94 children. Direct, intraoperative palatal, nasopharyngeal, and oropharyngeal measurements were performed in 19 children with normal, nondiseased adenoids (controls [C]) and compared to 75 children undergoing adenoidectomy for obstructive adenoid hyperplasia (OAH) (n = 44) or chronic adenoid infection (CAI) (n = 31).As expected, the weight and volume of the adenoids removed were significantly greater in the OAH vs. CAI group (P<.001). Before adenoidectomy, the volume of the nasopharynx was significantly smaller in the OAH group; however, nasopharyngeal volumes after adenoidectomy were quite similar in all three groups and ranged from 5.4 to 6.2 cc. Only the change in the volume of the nasopharynx after adenoidectomy for obstruction was significant (2.5 +/- 1.2 cc, P<.01). Differences in oropharyngeal and palatal dimensions were not associated with longstanding obstruction from adenoid hyperplasia.These data indicate that the nasal obstruction from adenoid hyperplasia is due to an absolute increase in adenoid size rather than a relatively smaller nasopharynx. Differences in palatal and oropharyngeal dimensions usually described and attributed to longstanding nasal obstruction could not be demonstrated in this study.

The effect of prior antibiotic treatment on the course of otitis media was assessed in a group of 62 children who experienced 83 episodes of ear infection during 3 years of observation. Bacterial quantitation in middle ear fluids demonstrated a significantly higher colony count in symptomatic children (3.9 x 10(4) +/- 12 bacteria per milliliter) compared to asymptomatic children (6.3 x 10(3) +/- 10 bacteria per milliliter; p = .05). Bacterial counts similarly tended to be higher in children with Streptococcus pneumoniae (4.0 x 10(6) +/- 16 bacteria per milliliter) and Hemophilus influenzae (2.0 x 10(6) +/- 16 bacteria per milliliter), who were more often symptomatic (73% and 55%, respectively, versus 38%) than children with Moraxella catarrhalis (7.9 x 10(3) +/- 2). Antibiotic therapy between 3 and 30 days prior to bacterial diagnosis was associated with a reduction in symptoms from 70% to 38% (p less than .025). However, prior treatment did not statistically reduce bacterial colony counts, although S pneumoniae decreased 90% in the previously treated group. Resistance to ampicillin occurred in 0% of S pneumoniae, 39% of nontypeable H influenzae, and 80% of M catarrhalis subjects without prior treatment and in 0%, 46%, and 100%, respectively, of subjects previously treated (p less than .025). These data suggest that prior treatment has a significant impact on the subsequent course of otitis media in children.

Needle aspiration of neck abscesses with CT-scan guidance was studied in 17 children with 18 abscesses from 1986 to 1991. Clinical and radiologic findings were analyzed according to treatment outcome. A majority of abscesses (55.6%) resolved after treatment with one to two attempts at needle aspiration and parenteral antibiotics. Unilocular abscesses were more likely than multilocular abscesses to resolve with needle aspiration. In general, abscesses in younger children who presented with smaller neck masses on physical examination and smaller abscess cavities on CT scan resolved with needle aspiration. The data support the use of needle aspiration as an effective initial treatment for pediatric neck abscesses. CT scan was found beneficial in documenting the abscesses and in guiding treatment. A treatment protocol is suggested for the use of needle aspiration in the management of neck abscesses in children.

Nasopharyngeal carriage of the three major middle ear pathogens ( Streptococcus pneumoniae, nontypeable Hemophilus influenzae, and Moraxella catarrhalis) was evaluated prospectively in a group of 110 children followed up for the first 3 years of life. The findings suggested that nasopharyngeal carriage of middle ear pathogens increases significantly during respiratory illness among the general population of young children; however, otitis-prone children demonstrated a tendency to carry nontypeable H influenzae at an unusually high rate even during health. This propensity to carry nontypeable H influenzae might explain why nontypeable H influenzae is a major cause of recurrent or chronic otitis media.

Groups of C.B-17 SCID mice were reconstituted intraperitoneally with human tonsillar mononuclear cells (hu-TMC) from children seropositive for antibody to respiratory syncytial virus (RSV) and subsequently challenged intraperitoneally with inactivated RSV or sham-immunized. The synthesis and the distribution characteristics of human antibody to RSV in various murine tissues were studied using an enzyme-linked immunospot assay (ELISPOT). No specific antibody was observed in sham-immunized animals. In contrast, mice engrafted with hu-TMC exhibited the appearance of specific human antibody secreting cells (hu-ASC) after i.p. immunization with inactivated RSV. RSV-specific hu-ASC were detected only in animals engrafted with cells from donors seropositive for antibodies to Epstein-Barr virus. Hu-TMC engrafted mice showed RSV-specific IgM and, in lower numbers, IgG hu-ASC in several tissues including the lungs. Numbers of RSV-specific IgA hu-ASC were low, however, and detected only in the lung. No RSV-specific hu-ASC were detected in the intestine. These data demonstrate for the first time that hu-TMC-SCID chimeras respond to immunization with viral antigen. Furthermore, the results suggest that hu-TMC engraft in lungs but not in the intestinal tissue.

Fifty-five tonsils removed for chronic tonsillar disease (chronic tonsillitis and obstructive tonsillar hyperplasia) underwent surface swab and quantitative core cultures in order to identify the relationship between core bacterial concentration and the presence of aerobic bacteria on the tonsil surface. The accuracy of a single core culture was further established by quantitative cultures of 9 sections per tonsil in an additional 19 tonsils. The results indicate that many (61.5%) but not all aerobic bacteria which were found in the tonsil core were cultured from the surface of the tonsil. Conversely, the tonsil core bacteria with the highest bacterial concentrations are more likely to be present on the tonsillar surface and the greater the bacterial concentration, the more likely the bacteria are to be found in most if not all areas of the tonsil core. Therefore, the core bacterial concentration appears to be related to the presence of aerobic bacteria on the tonsillar surface. Surface bacteria may not, however, be truly representative of the core bacterial environment. Implications for the management of chronic tonsillar disease will be discussed.

Middle ear effusions (MEEs) from 78 children (98 ears) with otitis media were examined for products of arachidonic acid (AA) metabolism, including leukotrienes B4, C4, D4, and E4 and prostaglandins D2 and E2, by high-performance liquid chromatography. Leukotrienes B4 and D4 were recovered most frequently: 59% and 54%, respectively. Leukotriene B4 was found in highest concentration, 1.29 ± 3.46 ng/0.1 mL. The concentrations of leukotrienes B4 (p < .03), C4 (p < .01), and E4 (p< .02) were significantly higher in culture-positive than in culture-negative MEEs. Neither the concentration nor the type of AA metabolite correlated with bacterial species isolated, chronicity of effusion, age of subject, or consistency of MEE. These data suggest that the AA metabolites are synthesized relatively frequently during otitis media of childhood. Leukotriene B4 is the most frequently detected AA metabolite in MEEs and is highly associated with the presence of viable bacteria.