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S250 – Otogenic Lateral Sinus Thrombosis: A Review of 7 Cases
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2-4 days prior to surgery. Interval CT scans revealed progression to retropharyngeal abscess with mediastinal extension. One patient’s retropharyngeal abscess was drained trans-orally, one externally, and one required a combined approach. 2 of the 3 patients required video-assisted thoracoscopic debridement of the mediastinitis. 2 cultures grew out methicillin-resistant staphylococcus aureus, while one grew out methicillin-sensitive staphylococcus aureus (all were clindamycin sensitive). The patients’ peak white blood cell counts were 18.4, 30.2, and 44.9 thousand. All 3 patients survived and were discharged on long-term antibiotics. CONCLUSIONS: Despite appropriate initial empiric antibiotic therapy, all 3 patients developed retropharyngeal abscess with mediastinal extension. The otolaryngologist should maintain vigilance when treating infants with intravenous antibiotics for a deep neck space infection, liberal use of imaging studies should be performed to monitor progression of the infection, a significantly elevated white blood cell count should be interpreted with caution, and initial empiric therapy should include clindamycin. Despite the adult literature that quotes a 50% mortality rate from mediastinitis, infant mediastinitis may be a different disease process, as all 3 of our patients survived. S248 – Supraglottoplasty for Laryngomalacia with Sleep Apnea Mark E Zafereo, Jr, MD (presenter); Rodney J Taylor, MD, MSPH; Kevin D Pereira, MD, MS(ORL) OBJECTIVES: To determine if supraglottoplasty is effective in reversing abnormal respiratory parameters in children with laryngomalacia and obstructive sleep apnea. METHODS: 10 patients with laryngomalacia and obstructive sleep apnea as documented by polysomnography underwent supraglottoplasty at a tertiary referral children’s hospital between 2005 and 2007. Retrospective data collection included age, findings on flexible and rigid endoscopy, type of procedure performed, and postoperative course. The postoperative polysomnographies were reviewed to identify changes in obstructive apnea index (OAI), obstructive apnea/hypopnea index (OAHI), respiratory disturbance index (RDI), and low arterial oxygen saturation (O2 nadir) after supraglottoplasty. Pre- and postoperative mean data were calculated, and comparisons were made with a Student’s T-test. RESULTS: All 10 patients were successfully extubated following supraglottoplasty. There were no perioperative or postoperative complications, and no patient required a subsequent airway procedure. Each patient had a postoperative nocturnal polysomnography performed following supraglottoplasty at 11 weeks (range 2-29 weeks). Caregivers reported mild improvement (10%), significant improvement (70%), and complete resolution (20%) of stridor and nocturnal snoring at a follow-up visit 4 weeks after hospital discharge. Marked im-
provements were observed in OAI, OAHI, RDI and O2 nadir, all of which were statistically significant (p⬍0.05). CONCLUSIONS: Polysomnography should be included in the initial evaluation of infants with laryngomalacia to rule out obstructive sleep apnea. Supraglottoplasty is an effective treatment for infants with laryngomalacia and obstructive sleep apnea. The significant benefits of the procedure outweigh the low morbidity. Improvement after surgery can be reliably confirmed by polysomnography. S249 – Grisel’s Syndrome in Otolaryngology: A Systematic Review Nagaraj Sivaji, MBBS, DLO, FRCS (presenter); Peter Karkos, MD; Samuel Leong OBJECTIVES: To assess etiology, treatment, and outcome of Grisel’s syndrome. METHODS: A Medline search was performed using the terms Grisel’s syndrome, spontaneous atlantoaxial subluxation, head, neck, ear, nose and throat. A systematic review of the literature was performed. Case series of both adult and pediatric cases were included. Only papers focusing on true non-traumatic atlantoaxial subluxation were included. RESULTS: 71 papers have been published from 1950 to 2006. 48 of these fulfilled our inclusion criteria, totaling 103 patients for review. The main causes of Grisel’s syndrome were infection (48%) and post-adenotonsillectomy (31%). Less common causes included other postoperative cases such as pharyngoplasty and ear operations. Neurosurgical consultation was paramount in all cases. In the majority of cases, conservative management in the form of bed rest, antibiotics, muscle relaxants, traction, and collar was effective; in a few cases, only surgery in the form of arthrodesis was deemed necessary. Morbidity was significant in those cases where diagnosis was delayed, with the most devastating consequence a permanent neurological deficit in one case. CONCLUSIONS: Grisel’s syndrome is a rare but dangerous complication that can go unnoticed in its early phase and can be a major cause of morbidity and mortality following infection or head and neck procedures/interventions. Early recognition of any cervical complication following routine otolaryngological operations, together with early neurosurgical consultation, is mandatory to prevent devastating consequences. S250 – Otogenic Lateral Sinus Thrombosis: A Review of 7 Cases Jesse T. Ryan, MD (presenter); Diego A Preciado, MD, PhD; Maria T Pena, MD; George H Zalzal, MD OBJECTIVES: Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic
Scientific Posters
S251 – Facial Symptoms Related to Allergic Rhinitis in U.S. Children M Jennifer Derebery, MD (presenter); Eli O Meltzer, MD; John Boyle, PhD OBJECTIVES: In addition to general symptoms related to nasal congestion, common secondary symptoms of allergic rhinitis (AR) include headache, facial pain/pressure, and ear pain/pressure. The prevalence of secondary AR symptoms in U.S. children is described herein. METHODS: The prevalence of headache, facial pain/pressure, and ear pain/pressure in children with and without AR was studied in Pediatric Allergies in America, a national survey of parents of 500 children with current symptoms of nasal allergies and 504 children without nasal allergies (aged 4 to 17 years) among 35,757 U.S. households. Children aged 10 to 17 years were also interviewed, in addition to their parents. RESULTS: Parents report that the occurrence of headaches (55% vs 18%), facial pain/pressure (29% vs 3%), and ear pain/pressure (24% vs 5%) is more frequent in children with AR, compared with those without, respectively. These figures represent an approximately 3-fold increase in headaches, nearly a 10-fold increase in facial pain/pressure, and an approximately 5-fold increase in ear pain/pressure in children suffering from presumed AR, compared with children without
AR. Furthermore, headache (59%; 63%), facial pain/pressure (53%; 54%), and ear pain/pressure (56%; 44%) were rated moderately or extremely bothersome by more than half of parents and older children (aged 10 to 17 years) who reported experiencing these symptoms, respectively. CONCLUSIONS: The Pediatric Allergies in America survey suggests that children with presumed AR may suffer significant headache, facial pain/pressure, and ear pain/pressure from nasal allergy symptoms that are not shared by children without nasal allergies. S252 – The Efficacy of Tympanostomy Tubes In Down Syndrome Patients Brett M Cordes, MD (presenter); Nurupama Madduri, MD; Ellen M Friedman, MD OBJECTIVES: The purpose of this report is to relate a single institution’s experience with middle ear disease and the incidence and efficacy of tympanostomy tube (PET) insertion in children with Down syndrome. METHODS: Retrospective chart review of 130 consecutive pediatric Down syndrome patients seen at a single tertiary care children’s hospital between the years 2001-2007. Middle ear function, and speech and language development, is reported and those patients who underwent tympanostomy tube insertion for middle ear disease are analyzed. RESULTS: The mean age of the patient population was 4.5 years, ranging from 8 months to 10 years. 41/130 patients (31.5%) were treated with tympanostomy tube insertion for middle ear disease. Of this group, 11/41 patients (26.8%) and 2/11 patients (18.1%) required second and third tube insertions, respectively, for persistent pathology and failed tube function. The mean age at first tube insertion was 3.3 years, while the mean age at second and third tube insertion was 6.9 and 6.0 years. Outcome measures included a documented conductive hearing loss on audiological assessment and/or persistent middle ear effusion on physical exam. Speech and language skills were also assessed. CONCLUSIONS: Children with Down syndrome have an increased incidence and persistence of middle ear disease. Additionally, affected children may require multiple surgical interventions for persistent disease and failed tube function. The multiple medical problems often associated with Down syndrome result in an increased anesthetic risk for these patients. Therefore, we propose the utility of a durable tympanostomy tube for more efficient treatment and the avoidance of multiple interventions. S253 – Management of Pediatric Skull Base Abscesses Tyler G Kimbrough, MD, PhD (presenter); Abby C Meyer, MD; Marsha Finkelstein, MS; James D Sidman, MD
SCI. POSTERS
otitis media (OM). Mortality rates for LST are quoted as 8-25% in most recent larger case series. Controversy exists regarding the surgical and medical management of LST. We sought to clarify this by reviewing our experience in patients who presented with otogenic LST in the past 5 years. METHODS: A retrospective chart review was conducted. 7 patients were identified and charts were examined for presentation, co-existing intracranial complications, treatment, cultured organisms, and outcome. RESULTS: Patients most commonly presented with fever (5/7), otalgia (5/7), and mastoid tenderness (4/7). Co-existing intracranial complications were present in 4/7 patients, including meningitis (1/7), epidural abscess (2/7), otitic hydrocephalus (2/7), and cavernous sinus thrombosis (1/7). All patients received IV antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus, and tympanostomy tube placement. Thrombectomy was not performed on any patient. Anticoagulation was used on 5/7 patients without complication. Streptococcus sp. was the most common organism isolated (2/7). All patients recovered well without major sequelae. One patient with cavernous sinus thrombosis and otitic hydrocephalus had a persistent right visual field deficit. CONCLUSIONS: In this limited series, we demonstrate good outcomes by emergently treating LST from an otitic source with mastoidectomy and unroofing of the sigmoid sinus, IV antibiotics, and selective anticoagulation. We did not find thrombectomy to be necessary.
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2-4 days prior to surgery. Interval CT scans revealed progression to retropharyngeal abscess with mediastinal extension. One patient’s retropharyngeal abscess was drained trans-orally, one externally, and one required a combined approach. 2 of the 3 patients required video-assisted thoracoscopic debridement of the mediastinitis. 2 cultures grew out methicillin-resistant staphylococcus aureus, while one grew out methicillin-sensitive staphylococcus aureus (all were clindamycin sensitive). The patients’ peak white blood cell counts were 18.4, 30.2, and 44.9 thousand. All 3 patients survived and were discharged on long-term antibiotics. CONCLUSIONS: Despite appropriate initial empiric antibiotic therapy, all 3 patients developed retropharyngeal abscess with mediastinal extension. The otolaryngologist should maintain vigilance when treating infants with intravenous antibiotics for a deep neck space infection, liberal use of imaging studies should be performed to monitor progression of the infection, a significantly elevated white blood cell count should be interpreted with caution, and initial empiric therapy should include clindamycin. Despite the adult literature that quotes a 50% mortality rate from mediastinitis, infant mediastinitis may be a different disease process, as all 3 of our patients survived. S248 – Supraglottoplasty for Laryngomalacia with Sleep Apnea Mark E Zafereo, Jr, MD (presenter); Rodney J Taylor, MD, MSPH; Kevin D Pereira, MD, MS(ORL) OBJECTIVES: To determine if supraglottoplasty is effective in reversing abnormal respiratory parameters in children with laryngomalacia and obstructive sleep apnea. METHODS: 10 patients with laryngomalacia and obstructive sleep apnea as documented by polysomnography underwent supraglottoplasty at a tertiary referral children’s hospital between 2005 and 2007. Retrospective data collection included age, findings on flexible and rigid endoscopy, type of procedure performed, and postoperative course. The postoperative polysomnographies were reviewed to identify changes in obstructive apnea index (OAI), obstructive apnea/hypopnea index (OAHI), respiratory disturbance index (RDI), and low arterial oxygen saturation (O2 nadir) after supraglottoplasty. Pre- and postoperative mean data were calculated, and comparisons were made with a Student’s T-test. RESULTS: All 10 patients were successfully extubated following supraglottoplasty. There were no perioperative or postoperative complications, and no patient required a subsequent airway procedure. Each patient had a postoperative nocturnal polysomnography performed following supraglottoplasty at 11 weeks (range 2-29 weeks). Caregivers reported mild improvement (10%), significant improvement (70%), and complete resolution (20%) of stridor and nocturnal snoring at a follow-up visit 4 weeks after hospital discharge. Marked im-
provements were observed in OAI, OAHI, RDI and O2 nadir, all of which were statistically significant (p⬍0.05). CONCLUSIONS: Polysomnography should be included in the initial evaluation of infants with laryngomalacia to rule out obstructive sleep apnea. Supraglottoplasty is an effective treatment for infants with laryngomalacia and obstructive sleep apnea. The significant benefits of the procedure outweigh the low morbidity. Improvement after surgery can be reliably confirmed by polysomnography. S249 – Grisel’s Syndrome in Otolaryngology: A Systematic Review Nagaraj Sivaji, MBBS, DLO, FRCS (presenter); Peter Karkos, MD; Samuel Leong OBJECTIVES: To assess etiology, treatment, and outcome of Grisel’s syndrome. METHODS: A Medline search was performed using the terms Grisel’s syndrome, spontaneous atlantoaxial subluxation, head, neck, ear, nose and throat. A systematic review of the literature was performed. Case series of both adult and pediatric cases were included. Only papers focusing on true non-traumatic atlantoaxial subluxation were included. RESULTS: 71 papers have been published from 1950 to 2006. 48 of these fulfilled our inclusion criteria, totaling 103 patients for review. The main causes of Grisel’s syndrome were infection (48%) and post-adenotonsillectomy (31%). Less common causes included other postoperative cases such as pharyngoplasty and ear operations. Neurosurgical consultation was paramount in all cases. In the majority of cases, conservative management in the form of bed rest, antibiotics, muscle relaxants, traction, and collar was effective; in a few cases, only surgery in the form of arthrodesis was deemed necessary. Morbidity was significant in those cases where diagnosis was delayed, with the most devastating consequence a permanent neurological deficit in one case. CONCLUSIONS: Grisel’s syndrome is a rare but dangerous complication that can go unnoticed in its early phase and can be a major cause of morbidity and mortality following infection or head and neck procedures/interventions. Early recognition of any cervical complication following routine otolaryngological operations, together with early neurosurgical consultation, is mandatory to prevent devastating consequences. S250 – Otogenic Lateral Sinus Thrombosis: A Review of 7 Cases Jesse T. Ryan, MD (presenter); Diego A Preciado, MD, PhD; Maria T Pena, MD; George H Zalzal, MD OBJECTIVES: Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic
Scientific Posters
S251 – Facial Symptoms Related to Allergic Rhinitis in U.S. Children M Jennifer Derebery, MD (presenter); Eli O Meltzer, MD; John Boyle, PhD OBJECTIVES: In addition to general symptoms related to nasal congestion, common secondary symptoms of allergic rhinitis (AR) include headache, facial pain/pressure, and ear pain/pressure. The prevalence of secondary AR symptoms in U.S. children is described herein. METHODS: The prevalence of headache, facial pain/pressure, and ear pain/pressure in children with and without AR was studied in Pediatric Allergies in America, a national survey of parents of 500 children with current symptoms of nasal allergies and 504 children without nasal allergies (aged 4 to 17 years) among 35,757 U.S. households. Children aged 10 to 17 years were also interviewed, in addition to their parents. RESULTS: Parents report that the occurrence of headaches (55% vs 18%), facial pain/pressure (29% vs 3%), and ear pain/pressure (24% vs 5%) is more frequent in children with AR, compared with those without, respectively. These figures represent an approximately 3-fold increase in headaches, nearly a 10-fold increase in facial pain/pressure, and an approximately 5-fold increase in ear pain/pressure in children suffering from presumed AR, compared with children without
AR. Furthermore, headache (59%; 63%), facial pain/pressure (53%; 54%), and ear pain/pressure (56%; 44%) were rated moderately or extremely bothersome by more than half of parents and older children (aged 10 to 17 years) who reported experiencing these symptoms, respectively. CONCLUSIONS: The Pediatric Allergies in America survey suggests that children with presumed AR may suffer significant headache, facial pain/pressure, and ear pain/pressure from nasal allergy symptoms that are not shared by children without nasal allergies. S252 – The Efficacy of Tympanostomy Tubes In Down Syndrome Patients Brett M Cordes, MD (presenter); Nurupama Madduri, MD; Ellen M Friedman, MD OBJECTIVES: The purpose of this report is to relate a single institution’s experience with middle ear disease and the incidence and efficacy of tympanostomy tube (PET) insertion in children with Down syndrome. METHODS: Retrospective chart review of 130 consecutive pediatric Down syndrome patients seen at a single tertiary care children’s hospital between the years 2001-2007. Middle ear function, and speech and language development, is reported and those patients who underwent tympanostomy tube insertion for middle ear disease are analyzed. RESULTS: The mean age of the patient population was 4.5 years, ranging from 8 months to 10 years. 41/130 patients (31.5%) were treated with tympanostomy tube insertion for middle ear disease. Of this group, 11/41 patients (26.8%) and 2/11 patients (18.1%) required second and third tube insertions, respectively, for persistent pathology and failed tube function. The mean age at first tube insertion was 3.3 years, while the mean age at second and third tube insertion was 6.9 and 6.0 years. Outcome measures included a documented conductive hearing loss on audiological assessment and/or persistent middle ear effusion on physical exam. Speech and language skills were also assessed. CONCLUSIONS: Children with Down syndrome have an increased incidence and persistence of middle ear disease. Additionally, affected children may require multiple surgical interventions for persistent disease and failed tube function. The multiple medical problems often associated with Down syndrome result in an increased anesthetic risk for these patients. Therefore, we propose the utility of a durable tympanostomy tube for more efficient treatment and the avoidance of multiple interventions. S253 – Management of Pediatric Skull Base Abscesses Tyler G Kimbrough, MD, PhD (presenter); Abby C Meyer, MD; Marsha Finkelstein, MS; James D Sidman, MD
SCI. POSTERS
otitis media (OM). Mortality rates for LST are quoted as 8-25% in most recent larger case series. Controversy exists regarding the surgical and medical management of LST. We sought to clarify this by reviewing our experience in patients who presented with otogenic LST in the past 5 years. METHODS: A retrospective chart review was conducted. 7 patients were identified and charts were examined for presentation, co-existing intracranial complications, treatment, cultured organisms, and outcome. RESULTS: Patients most commonly presented with fever (5/7), otalgia (5/7), and mastoid tenderness (4/7). Co-existing intracranial complications were present in 4/7 patients, including meningitis (1/7), epidural abscess (2/7), otitic hydrocephalus (2/7), and cavernous sinus thrombosis (1/7). All patients received IV antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus, and tympanostomy tube placement. Thrombectomy was not performed on any patient. Anticoagulation was used on 5/7 patients without complication. Streptococcus sp. was the most common organism isolated (2/7). All patients recovered well without major sequelae. One patient with cavernous sinus thrombosis and otitic hydrocephalus had a persistent right visual field deficit. CONCLUSIONS: In this limited series, we demonstrate good outcomes by emergently treating LST from an otitic source with mastoidectomy and unroofing of the sigmoid sinus, IV antibiotics, and selective anticoagulation. We did not find thrombectomy to be necessary.
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