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Aural live foreign bodies in children
102
Letters to the Editor
deaminase overproduction, idiopathic thrombocytopenic purpura, and rheumatoid arthritis (7). Ishihara et al. reported that the foamy cells associated with red cell adenosine deaminase overproduction were essentially similar to Gaucher-like cells described in patients with thalassemia, and it was suggested that the accelerated destruction of red cells was one of the factors responsible for the development of foamy cells (7). They also noted that foamy cells in idiopathic thrombocytopenic purpura and rheumatoid arthritis are closely associated with an increased destruction of platelets in the spleen. In the pathogenesis of foamy cells associated with blood cell dyscrasia, the accelerated destruction of blood cells or acquired disorders in catabolic pathways within the macrophages are suggested to be the underlying mechanism of an intralysosomal accumulation of incompletely degraded cellular debris (7). In a newborn infant, hemolytic anemia may be caused by Rh, A, and B incompatibility, blood subtype incompatibility, thalassemia, erythrocyte glucose-6-phosphate dehydrogenase deficiency, sickle cell anemia, or hereditary spherocytosis, etc. In our patient, we were not able to diagnose the primary underlying disorder leading to hemolytic anemia because he died just after admission to hospital. Although we diagnosed foamy cells in the liver but not in the spleen, we think that the foamy cells primarily occurred due to hemolytic anemia as mentioned by Ishihara et al (7). Our patient demonstrates that foamy cells may be seen in severe hemolytic anemia. Hu¨seyin C¸aksen, MD Department of Pediatrics Yu¨zu¨ncu¨ Yıl University Faculty of Medicine Van, Turkey Selim Kurtog˘lu, MD Department of Pediatrics Erciyes University Faculty of Medicine Kayseri, Turkey doi:10.1016/S0736-4679(03)00124-0
REFERENCES 1. Turpin JC, Masson M, Baumann N. Clinical aspects of NiemannPick type C disease in the adult. Dev Neurosci 1991;13:304 – 6. 2. Dawson PJ, Dawson G. Adult Niemann-Pick disease with sea-blue histiocytes in the spleen. Hum Pathol 1982;13:1115–20. ¨ zsoylu S¸, Koc¸ak N, Berkel AI˙. Sea-blue histiocyte syndrome. Acta 3. O Paediatr Scan 1974;63:147–50. 4. Go¨g˘u¨s¸ S, Go¨c¸men A, Koc¸ak N, et al. Lipidosis with sea-blue histiocytes. Report of two siblings with lung involvement. Turk J Pediatr 1994;36:139 – 44. 5. Abenoza P, Sibley RK. Farber’s disease: a fine structural study. Ultrastruct Pathol 1987;11:397– 403.
6. Beck M, Bender SW, Reiter HL, et al. Neuraminidase deficiency presenting as non-immune hydrops fetalis. Eur J Pediatr 1984;143: 135–9. 7. Ishihara T, Yamashita Y, Okuzono Y, et al. Three kinds of foamy cells in the spleen: comparative histochemical and ultrastructural studies. Ultrastruct Pathol 1985;8:13–23.
e AURAL LIVE FOREIGN BODIES IN CHILDREN e To The Editor: Foreign bodies (FBs) of the ears and nose are a common and challenging problem in children (1). Most FBs are self-inflicted and seen in children under 5 years of age, within 24 h of impaction (2). Both live and non-vegetative, inanimate FBs are encountered in external auditory canals in children (1– 4). Herein, we report the findings in 14 children with aural live FBs and discuss their treatment approach. The study includes 14 children (8 girls, 6 boys) who were admitted with the complaint of aural FBs or discharge from external auditory canal, and diagnosed with an aural live FB. Their ages ranged from 1 year to 12 years and the parents of all children were farmers. Otoscopic and rhinological examination was performed in all children. The diagnosed aural live FBs were as follows; Acarus (Rh. Sanguineus) in 7 cases, fly in 4 cases, and myasis (maggots) in 3 cases (Figures 1 and 2). All of the children with myasis had perforated tympanic membrane and chronic otitis media with purulent discharge. Myasis was diagnosed bilaterally in two of three children with myasis. Additionally, dead flies were extracted in a child with myasis. Topical anesthesia was used in all children. None of the patients required surgical removal of the aural FB under general anesthesia. A combination of suctioning and alligator forceps was used to remove FB objects. Additionally, antibiotics were given to children with purulent discharge. Foreign bodies of the ear, either vegetative or nonvegetative, are a common finding in children (2). Ansley and Cunningham reviewed the findings of 191 patients (ages ranged from 10 months to 17 years) with aural FBs and reported that 27 different objects were encountered, with pebbles, beads, insects, and plastic toys being the most common (5). Baker et al. reported that the items most commonly removed from children’s external auditory canals were roaches, paper wads, toy parts, earring parts, hair beads, eraser tips, and food (1). In another series that included 168
The Journal of Emergency Medicine
103
Figure 1. Live Acarus (Rh. Sanguineus) on the tympanic membrane is shown.
pediatric cases with aural FBs, it was noted that 86.30% of FBs were seen to impact in the external auditory canal and their nature revealed a predominance of non-vegetative inanimate FBs (43.45%) (2). In our study, we reviewed only the children with aural live FBs, and found that acarus was the most common agent. In the treatment, approximately 90% of all FBs were able to be removed, without significant complications, by Emergency Department personnel with simple equipment (1). If the FB is a living insect, it
Figure 2. Aural live myasis (maggots) are shown.
should be drowned before being manipulated. Syringing is the method of choice for a non-impacted relatively small FB, even if it is vegetative (2). In the treatment, instilling the canal with alcohol or lidocaine is effective in killing this particularly annoying FB (6). An impacted aural FB requires endaural incision and canal widening for removal (2,7). The presence of otorrhea in cases of penetrating FB or aural myasis should be treated as with otitis media after removing the FB (2). In our patients, we used only a combina-
104
Letters to the Editor
tion of suctioning and alligator forceps, and antibiotics were given in children with purulent discharge. Ko¨ksal Yuca, MD Department of Otorhinolaryngology Yu¨zu¨ncu¨ Yıl University Faculty of Medicine Van, Turkey Sevil Arı Yuca, MD Hu¨seyin C¸aksen, MD Department of Pediatrics Yu¨zu¨ncu¨ Yıl University Faculty of Medicine Van, Turkey doi:10.1016/S0736-4679(03)00123-9
REFERENCES 1. Baker MD. Foreign bodies of the ears and nose in childhood. Pediatr Emerg Care 1987;3:67–70. 2. Mishra A, Shukla GK, Bhatia N. Aural foreign bodies. Indian J Pediatr 2000;67:267–9. 3. Cho JH, Kim HB, Cho CS, Huh S, Ree HI. An aural myiasis case in a 54-year-old male farmer in Korea. Korean J Parasitol 1999;37: 51–3. 4. Pride H, Schwab R. A new technique for removing foreign bodies of the external auditory canal. Pediatr Emerg Care 1989;5:135– 6. 5. Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics 1998;101:638 – 41. 6. Couch EM. History and physical examination. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE, eds. Otolaryngology: Head and Neck Surgery, 2nd edn. Baltimore, MD: Mosby Inc.; 1999. 7. Engelsma RJ, Lee WC. Impacted aural foreign body requiring endaural incision and canal widening for removal. Int J Pediatr Otorhinolaryngol 1998;44:169 –71.
e A CASE OF LIMB-BODY WALL COMPLEX DIAGNOSED IN UTERO e To The Editor: The term “Limb-body wall (LBW) complex” (limb-body wall defect or body-stalk syndrome) refers to a variable group of congenital defects having in common abdomino- or thoraco-schisis and limb deficiency (1–3). The developmental pathogenesis as well as the etiology of LBW complex is controversial (1). Three general pathogenic mechanisms have been proposed for this disorder: amnion rupture, vascular disruption, and embryonic malformation (2). In this letter we report a case of LBW complex that was diagnosed in utero. Our purpose is to emphasize the importance of prenatal diagnosis of limb-body wall complex. A 23-year-old healthy pregnant woman was admitted to our hospital. The physical examination was normal. On ultrasonographic examination, the fetus was alive and
Figure 1. Anterior-posterior view of the fetus.
the gestational age was compatible with 23 weeks, however, the placenta was placed abnormally and the umbilical cord could not be seen. It was explained to the parents that the fetus had a malformation, and with the consent of the parents, delivery was undertaken. The fetus was delivered by induction. On inspection, about one-half of the placenta was attached to the uterus and the other half was attached to the baby’s thoracic wall. The length of the umbilical cord was short, 15 cm. The baby died a few minutes after birth. She was the fourth baby of the mother. The first and third babies were healthy, but the second pregnancy resulted in spontaneous abortion. No maternal use of medication or antepartum illnesses were reported. On postmortem physical examination, the weight was 570 g, the height was 33 cm, and the head circumference was 21 cm. A thoracic wall defect, 5 ⫻ 4 cm in diameter, was noted on the back region, where the placenta had attached. There was an appearance of rhizomelic shortening of the upper limbs with some brachydactyly. In addition, the face was unusual with mid-face hypoplasia and micrognathia (Figures 1 and 2). The LBW complex is frequently associated with exencephaly/encephalocele, and facial clefts. The vast majority of cases are spontaneously aborted; the remainder
Letters to the Editor
deaminase overproduction, idiopathic thrombocytopenic purpura, and rheumatoid arthritis (7). Ishihara et al. reported that the foamy cells associated with red cell adenosine deaminase overproduction were essentially similar to Gaucher-like cells described in patients with thalassemia, and it was suggested that the accelerated destruction of red cells was one of the factors responsible for the development of foamy cells (7). They also noted that foamy cells in idiopathic thrombocytopenic purpura and rheumatoid arthritis are closely associated with an increased destruction of platelets in the spleen. In the pathogenesis of foamy cells associated with blood cell dyscrasia, the accelerated destruction of blood cells or acquired disorders in catabolic pathways within the macrophages are suggested to be the underlying mechanism of an intralysosomal accumulation of incompletely degraded cellular debris (7). In a newborn infant, hemolytic anemia may be caused by Rh, A, and B incompatibility, blood subtype incompatibility, thalassemia, erythrocyte glucose-6-phosphate dehydrogenase deficiency, sickle cell anemia, or hereditary spherocytosis, etc. In our patient, we were not able to diagnose the primary underlying disorder leading to hemolytic anemia because he died just after admission to hospital. Although we diagnosed foamy cells in the liver but not in the spleen, we think that the foamy cells primarily occurred due to hemolytic anemia as mentioned by Ishihara et al (7). Our patient demonstrates that foamy cells may be seen in severe hemolytic anemia. Hu¨seyin C¸aksen, MD Department of Pediatrics Yu¨zu¨ncu¨ Yıl University Faculty of Medicine Van, Turkey Selim Kurtog˘lu, MD Department of Pediatrics Erciyes University Faculty of Medicine Kayseri, Turkey doi:10.1016/S0736-4679(03)00124-0
REFERENCES 1. Turpin JC, Masson M, Baumann N. Clinical aspects of NiemannPick type C disease in the adult. Dev Neurosci 1991;13:304 – 6. 2. Dawson PJ, Dawson G. Adult Niemann-Pick disease with sea-blue histiocytes in the spleen. Hum Pathol 1982;13:1115–20. ¨ zsoylu S¸, Koc¸ak N, Berkel AI˙. Sea-blue histiocyte syndrome. Acta 3. O Paediatr Scan 1974;63:147–50. 4. Go¨g˘u¨s¸ S, Go¨c¸men A, Koc¸ak N, et al. Lipidosis with sea-blue histiocytes. Report of two siblings with lung involvement. Turk J Pediatr 1994;36:139 – 44. 5. Abenoza P, Sibley RK. Farber’s disease: a fine structural study. Ultrastruct Pathol 1987;11:397– 403.
6. Beck M, Bender SW, Reiter HL, et al. Neuraminidase deficiency presenting as non-immune hydrops fetalis. Eur J Pediatr 1984;143: 135–9. 7. Ishihara T, Yamashita Y, Okuzono Y, et al. Three kinds of foamy cells in the spleen: comparative histochemical and ultrastructural studies. Ultrastruct Pathol 1985;8:13–23.
e AURAL LIVE FOREIGN BODIES IN CHILDREN e To The Editor: Foreign bodies (FBs) of the ears and nose are a common and challenging problem in children (1). Most FBs are self-inflicted and seen in children under 5 years of age, within 24 h of impaction (2). Both live and non-vegetative, inanimate FBs are encountered in external auditory canals in children (1– 4). Herein, we report the findings in 14 children with aural live FBs and discuss their treatment approach. The study includes 14 children (8 girls, 6 boys) who were admitted with the complaint of aural FBs or discharge from external auditory canal, and diagnosed with an aural live FB. Their ages ranged from 1 year to 12 years and the parents of all children were farmers. Otoscopic and rhinological examination was performed in all children. The diagnosed aural live FBs were as follows; Acarus (Rh. Sanguineus) in 7 cases, fly in 4 cases, and myasis (maggots) in 3 cases (Figures 1 and 2). All of the children with myasis had perforated tympanic membrane and chronic otitis media with purulent discharge. Myasis was diagnosed bilaterally in two of three children with myasis. Additionally, dead flies were extracted in a child with myasis. Topical anesthesia was used in all children. None of the patients required surgical removal of the aural FB under general anesthesia. A combination of suctioning and alligator forceps was used to remove FB objects. Additionally, antibiotics were given to children with purulent discharge. Foreign bodies of the ear, either vegetative or nonvegetative, are a common finding in children (2). Ansley and Cunningham reviewed the findings of 191 patients (ages ranged from 10 months to 17 years) with aural FBs and reported that 27 different objects were encountered, with pebbles, beads, insects, and plastic toys being the most common (5). Baker et al. reported that the items most commonly removed from children’s external auditory canals were roaches, paper wads, toy parts, earring parts, hair beads, eraser tips, and food (1). In another series that included 168
The Journal of Emergency Medicine
103
Figure 1. Live Acarus (Rh. Sanguineus) on the tympanic membrane is shown.
pediatric cases with aural FBs, it was noted that 86.30% of FBs were seen to impact in the external auditory canal and their nature revealed a predominance of non-vegetative inanimate FBs (43.45%) (2). In our study, we reviewed only the children with aural live FBs, and found that acarus was the most common agent. In the treatment, approximately 90% of all FBs were able to be removed, without significant complications, by Emergency Department personnel with simple equipment (1). If the FB is a living insect, it
Figure 2. Aural live myasis (maggots) are shown.
should be drowned before being manipulated. Syringing is the method of choice for a non-impacted relatively small FB, even if it is vegetative (2). In the treatment, instilling the canal with alcohol or lidocaine is effective in killing this particularly annoying FB (6). An impacted aural FB requires endaural incision and canal widening for removal (2,7). The presence of otorrhea in cases of penetrating FB or aural myasis should be treated as with otitis media after removing the FB (2). In our patients, we used only a combina-
104
Letters to the Editor
tion of suctioning and alligator forceps, and antibiotics were given in children with purulent discharge. Ko¨ksal Yuca, MD Department of Otorhinolaryngology Yu¨zu¨ncu¨ Yıl University Faculty of Medicine Van, Turkey Sevil Arı Yuca, MD Hu¨seyin C¸aksen, MD Department of Pediatrics Yu¨zu¨ncu¨ Yıl University Faculty of Medicine Van, Turkey doi:10.1016/S0736-4679(03)00123-9
REFERENCES 1. Baker MD. Foreign bodies of the ears and nose in childhood. Pediatr Emerg Care 1987;3:67–70. 2. Mishra A, Shukla GK, Bhatia N. Aural foreign bodies. Indian J Pediatr 2000;67:267–9. 3. Cho JH, Kim HB, Cho CS, Huh S, Ree HI. An aural myiasis case in a 54-year-old male farmer in Korea. Korean J Parasitol 1999;37: 51–3. 4. Pride H, Schwab R. A new technique for removing foreign bodies of the external auditory canal. Pediatr Emerg Care 1989;5:135– 6. 5. Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics 1998;101:638 – 41. 6. Couch EM. History and physical examination. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE, eds. Otolaryngology: Head and Neck Surgery, 2nd edn. Baltimore, MD: Mosby Inc.; 1999. 7. Engelsma RJ, Lee WC. Impacted aural foreign body requiring endaural incision and canal widening for removal. Int J Pediatr Otorhinolaryngol 1998;44:169 –71.
e A CASE OF LIMB-BODY WALL COMPLEX DIAGNOSED IN UTERO e To The Editor: The term “Limb-body wall (LBW) complex” (limb-body wall defect or body-stalk syndrome) refers to a variable group of congenital defects having in common abdomino- or thoraco-schisis and limb deficiency (1–3). The developmental pathogenesis as well as the etiology of LBW complex is controversial (1). Three general pathogenic mechanisms have been proposed for this disorder: amnion rupture, vascular disruption, and embryonic malformation (2). In this letter we report a case of LBW complex that was diagnosed in utero. Our purpose is to emphasize the importance of prenatal diagnosis of limb-body wall complex. A 23-year-old healthy pregnant woman was admitted to our hospital. The physical examination was normal. On ultrasonographic examination, the fetus was alive and
Figure 1. Anterior-posterior view of the fetus.
the gestational age was compatible with 23 weeks, however, the placenta was placed abnormally and the umbilical cord could not be seen. It was explained to the parents that the fetus had a malformation, and with the consent of the parents, delivery was undertaken. The fetus was delivered by induction. On inspection, about one-half of the placenta was attached to the uterus and the other half was attached to the baby’s thoracic wall. The length of the umbilical cord was short, 15 cm. The baby died a few minutes after birth. She was the fourth baby of the mother. The first and third babies were healthy, but the second pregnancy resulted in spontaneous abortion. No maternal use of medication or antepartum illnesses were reported. On postmortem physical examination, the weight was 570 g, the height was 33 cm, and the head circumference was 21 cm. A thoracic wall defect, 5 ⫻ 4 cm in diameter, was noted on the back region, where the placenta had attached. There was an appearance of rhizomelic shortening of the upper limbs with some brachydactyly. In addition, the face was unusual with mid-face hypoplasia and micrognathia (Figures 1 and 2). The LBW complex is frequently associated with exencephaly/encephalocele, and facial clefts. The vast majority of cases are spontaneously aborted; the remainder