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Sialadenitis in childhood
768
ABSTRACTS
hyperalimentation and subsequently submitted to portacaval shunt. Serum lipids, glucose levels, and acid-basic status were restored to normal before the operation. This small experience reinforces similar reports indicating the benefit of this therapy.--Alberto Peha. A Life-Threatening Complication of the infusion Pump. Arnran Ayalon, Yacov Berlatzky, Haim Anner, and Medad Schiller. Lancet 1:853-854 (April), 1978
The authors report 2 patients in whom serious disturbances of respiration and venous return resulted from extravasation of fluid into the mediastinum during intravenous parenteral nutrition via a central vein. The authors relate this complication to the use of a peristaltic infusion pump and stress that pressures of up to 850 mm Hg can be generated by the pump, which will continue to operate despite extravasation and will cause a rise in pressure in closed compartments. They suggest that the infusion pump be abandoned in neonatal practice.--J. G. Harvey Zinc
and Copper Changes
After Neonatal
Parenteral
Alimentation. K. N. Sivasubramanian,
G. Hox, and Mary Kate Davitt. Lancet 1:508 (March), 1978 The authors report a child with necrotizing enterocolitis who underwent parenteral alimentation with Freamine II and Intralipid for 5 wk. Serum zinc fell from 64 #g/dl to 18 #g/dl; serum copper fell from 62 /Lg/dl to 39 #g/dl. The child developed weeping erythematous skin lesions and showed increasing irritability. Treatment was instituted with zinc sulfate, 100 ug/kg/day, with improvement after 48 hr and disappearance of the dermatologic and neurologic symptoms and signs within 4 days. The authors stress the necessity of measuring the serum zinc and serum copper and of using supplements of these two metals over long periods of parenteral alimentation.--J. G. Harvey HEAD AND
NECK
The Role of Psychiatry in a Craniofacial Team. A. Lefebvre,
and 1. Munro. Plast and Reconstr Surg 61:564-569 (April), 1978 Because surgical and medical advances have not permitted reconstruction of severe congenital facial deformities until recently, psychological changes produced by this correction are not completely known. This study attempts to answer psychological questions involving the importance of the patient's age at surgery, the postoperative results, and contraindications. Seventy patients and their parents were seen for separate 1-hr preoperative interviews. During these interviews, tests were used to reveal body image, impressions of deformities, coping mechanisms used by the child and parents, and other background information. Postoperatively, the parents and child were again seen separately for an interview, with similar parameters being retested. The intellectual capacities of these children appeared to be normal. Appreciation of the deformity ranged in degree from grotesque to minimally deformed, apparently related to the self-assurance and confidence enjoyed by the patient. The improvement of the deformity as seen by the child and
parents postoperatively appeared to be related to the degree of expectation and self-assurance of the child. Coping mechanisms used by both child and parents were reviewed, with explanations given. It was recommended that the surgical intervention be performed at the earliest possible date. No absolute eontraindications to surgery were seen even in the most "maladjusted child." However, it was suggested that children demonstrating psychotic behavior are poor candidates for plastic surgery. The article is recommended to all physicians and paramedical personnel concerned with the surgical treatment and medical support given to the child with craniofacial anomalies.--A. B. Sokol Advancement of the Orbits and the Midface In One Piece, Combined With Frontal Repositioning, for the Correction of Crouzon's Deformities. F. Ortiz-Monasterio,
A. Fuente de/ Campo, and A. Carrillo. Plast and Reconstr Surg 61:507-516 (April), 1978
From a total of 176 orbital and facial mobilizations done in 5 yr, the authors report on 7 patients with Crouzon's deformity. These patients had advancement of the complete orbits, frontal bone, and maxilla, in one piece to achieve correction. All patients had maxillary retrusion, type III malocclusion, and exorbitism. Two patients were adults (35 and 24 yr old) and the other 5 were between the ages of 4 and 6 yr. The authors believe that the best time for this operation is 5 yr of age. Preoperative studies include the use of cephalograms, dental molds, facial photographs, and exophthalmometry. Preoperative planning includes exact reconstruction and repositioning required so that concurrent bicortical iliac bone grafts and split rib grafts can be taken during the procedure. The operation is performed under general nasotracheal anesthesia. No tracheostomy nor mannitol has been required. The operation consists of two incisions, one coronal and one intraoral. Through these incisions the entire frontal bone and midface are separated from the skull to allow advancement and correction of the deformity. The advancement is secured by bicortical iliac and split rib grafts. No interdental fixation is required. An excellent review is given of the evolution of craniofaeial surgery. In addition, the article is accompanied by excellent preoperative and postoperative clinical photographs demonstrating the remarkable results obtained with this procedure. Finally, there is clear operative discussion, and there are diagrams to facilitate an understanding of this operation.--A. B. Sokol L. B. Kaben, J. B. Mulliken, and J. E. Murray. Am J. Surg 135:570-576 (April), 1978 Sialadenitis in Childhood.
A 30-yr retrospective review of 49 patients up to 16 yr of age treated at the Children's Hospital Medical Center, Boston, Mass., suggests four types of sialadenitis differing in etiology, clinical manifestations, treatment required, and prognosis. Acute suppurative parotitis (18 patients) was the most common form of pediatric sialadenitis, and it commonly occurred in neonates and in children, with fevel", dehydration, or immunosuppression accompanying an
ABSTRACTS
769
underlying systemic illness. Diagnosis by physical examination (tender preauricular induration; edematous, red Stenson's papilla) and treatment with antistaphylococcal antibiotics usually permitted recovery from a single attack without development of the chronic form of the disease. Recurrent acute parotitis (14 patients), in contrast, was characterized by multiple attacks of pain, swelling, and fever without local or underlying systemic causes. Duct manipulation and/or sialography to provide curative drainage along with antibiotics were used during the acute episodes. Alpha Streptococcus was most frequently cultured, making penicillin the drug of choice. The attacks of sialadenitis ceased spontaneously around the time of puberty. Chronic parotitis (9 patients) occurred in Patients with underlying autoimmune disease and presented clinically as bilateral low-grade persistent or intermittent swelling and pain without an acute inflammatory response. Treatment with heat, massage, and sialogogues in 6 patients, total parotidectomy in 2 patients, and radiotherapy (not recommended) in 1 patient made all permanently symptom-free. Acute submaxillary sialadenitis (8 patients) was caused by mechanical obstruction of Wharton's duct in all instances (7 stone, 1 stenosis). Diagnosis of duct abnormality by physical examination, soft-tissue radiography, or sialography and excision of the submaxillary gland resulted in cure in all
instances.--Carey P. Page
A Protocol for Management of Acute Epiglottitis: Successful Experiences With 27 Consecutive Instances Treated by Naaotracheal IntubaUon. J. K. Lewis, J. C. Gartner, and A. G.
Galvis. Clin Pediatr 17:494~,96 (June), 1978. Twenty-three of 27 children, ages 15 mo to 16 yr, with documented epiglottitis were treated successfully by nasotracheal intubation. Extubation occurred after a mean of 47 hr, and all did well, with no complications of subglottic stenosis or need for reintubation. Twenty-four patients had positive blood cultures for Haemophilus influenza type b; 18 also had epiglottis cultures positive for H. inftuenzae. All patients were treated with ampicillin. The management advantages of nasotracheal intubation over elective tracheostomy, plus the equally satisfactory results seen with either procedure, suggest that nasotracheal intubation is the treatment of choice in epiglottitis.--Daniel 14I. Thomas
Critical Evaluation of Adenoidectomy. J.
Hibbert and P. M.
Stell. Lancet 1:489-490 (March), 1978 The authors report a series of two matched groups of 32 children; one group underwent tonsillectomy alone, and the other underwent tonsillectomy and adenoidectomy. Symptoms attributable to adenoidal hypertrophy were equally present in both groups before operation and improved with equal frequency postoperatively. The authors surmise that the operation of tonsillectomy alone is unlikely to cure adenoidal symptoms but that any improvement after added adenoidectomy i s purely subjective, the operation having a placebo effect on the mother.--J. G. Harvey
ALIMENTARY
TRACT
Injection of Scleroaing Agents in Children With Bleeding Esophageal Varlces.
K.-J. Paquet and K. D. Lindecken. Z
Kinderchir 23:267-279 (March), 1978 Treatment of portal hypertension in childhood is still problematic. Although first or even second hemorrhages have a very low mortality in childhood, conservative treatment by means of volume replacement, hemostyptic agents, or insertion of a Sengstaken-Blakemore tube is often not successful. Injection of sclerosing agents has been a safe and successful procedure carrying a low risk. A rigid esophagoscope 6 mm in diameter and 30 cm long is used with a Hopkins optical system additionally equipped with a nozzle for rinsing and suction and a balloon allowing air to be inflated to stretch the esophageal wall. The sclerosing agent is injected near the varices into the subepithelial region through a long needle. A maximum of 30 cc are injected during each session. Usually two to four sessions at 4- to 7-day intervals are necessary. Bleeding ceases immediately because of the mucosal edema compressing bleeding varices. Later, scars covering the varices prevent recurrent rupture but leave the collaterals patent. Sixteen children between 2 and 19 yr have been treated since 1973. Esophageal bleeding, which could not be stopped by conservative treatment before, ceased in every patient. One child 2 yr of age suffering from prehcpatic block and cirrhosis died because of hemorrhage from gastric varices 2 mo after five endoscopic sessions. In 1 patient superficial necrosis of the esophageal wall without mediastinitis was seen, and in a second patient a stricture developed that was treated successfully by one dilatation. Up to now, 7 children are alive without recurrent hemorrhage for more than 3 yr. Nine patients had intervals without hemorrhage of between 3 mo and 3 yr.--Karl-Ludwig
Waag Oesophageal Troubles After Repair in Infancy. Editorial.
Lancet 1:700 (April), 1978 The author praises the long-term results after repair of tracheoesophageal fistula and esophageal atrcsia in infancy. He finds that narrowing of the anastomosis, which requires dilatation, occurs in 30%-50% of cases; recurrent fistula occurs in 5.5%, with a second fistula occurring in 1%-8% of cases. Other causes of dysphagia include tracheomalacia, aberrant subclavian artery, and rare abnormalities of the larynx, such as laryngeal clefts or subglottic stenosis. Abnormalities of peristalsis occur postoperatively and in the long term, including incoordination between the upper and lower parts of the esophagus and spasm or inertia of the distal esophagus. Abnormalities of the cardioesophageal sphincter occur, varying from spasm to gross laxity, reflux, and subsequent esophagitis and stricture formation. The author draws attention to two recent papers that have assessed esophageal motility by means of manometric estimations 10-27 yr after repair of esophageal atresia. They found functional abnormalities despite normal endoscopic a p p e a r a n c e s ; these also o c c u r r e d in eases of tracheoesophageal fistula without atresia and therefore suggest an element of neuromuscular incoordination, possibly associated with.division of the vagal fibers locally.
ABSTRACTS
hyperalimentation and subsequently submitted to portacaval shunt. Serum lipids, glucose levels, and acid-basic status were restored to normal before the operation. This small experience reinforces similar reports indicating the benefit of this therapy.--Alberto Peha. A Life-Threatening Complication of the infusion Pump. Arnran Ayalon, Yacov Berlatzky, Haim Anner, and Medad Schiller. Lancet 1:853-854 (April), 1978
The authors report 2 patients in whom serious disturbances of respiration and venous return resulted from extravasation of fluid into the mediastinum during intravenous parenteral nutrition via a central vein. The authors relate this complication to the use of a peristaltic infusion pump and stress that pressures of up to 850 mm Hg can be generated by the pump, which will continue to operate despite extravasation and will cause a rise in pressure in closed compartments. They suggest that the infusion pump be abandoned in neonatal practice.--J. G. Harvey Zinc
and Copper Changes
After Neonatal
Parenteral
Alimentation. K. N. Sivasubramanian,
G. Hox, and Mary Kate Davitt. Lancet 1:508 (March), 1978 The authors report a child with necrotizing enterocolitis who underwent parenteral alimentation with Freamine II and Intralipid for 5 wk. Serum zinc fell from 64 #g/dl to 18 #g/dl; serum copper fell from 62 /Lg/dl to 39 #g/dl. The child developed weeping erythematous skin lesions and showed increasing irritability. Treatment was instituted with zinc sulfate, 100 ug/kg/day, with improvement after 48 hr and disappearance of the dermatologic and neurologic symptoms and signs within 4 days. The authors stress the necessity of measuring the serum zinc and serum copper and of using supplements of these two metals over long periods of parenteral alimentation.--J. G. Harvey HEAD AND
NECK
The Role of Psychiatry in a Craniofacial Team. A. Lefebvre,
and 1. Munro. Plast and Reconstr Surg 61:564-569 (April), 1978 Because surgical and medical advances have not permitted reconstruction of severe congenital facial deformities until recently, psychological changes produced by this correction are not completely known. This study attempts to answer psychological questions involving the importance of the patient's age at surgery, the postoperative results, and contraindications. Seventy patients and their parents were seen for separate 1-hr preoperative interviews. During these interviews, tests were used to reveal body image, impressions of deformities, coping mechanisms used by the child and parents, and other background information. Postoperatively, the parents and child were again seen separately for an interview, with similar parameters being retested. The intellectual capacities of these children appeared to be normal. Appreciation of the deformity ranged in degree from grotesque to minimally deformed, apparently related to the self-assurance and confidence enjoyed by the patient. The improvement of the deformity as seen by the child and
parents postoperatively appeared to be related to the degree of expectation and self-assurance of the child. Coping mechanisms used by both child and parents were reviewed, with explanations given. It was recommended that the surgical intervention be performed at the earliest possible date. No absolute eontraindications to surgery were seen even in the most "maladjusted child." However, it was suggested that children demonstrating psychotic behavior are poor candidates for plastic surgery. The article is recommended to all physicians and paramedical personnel concerned with the surgical treatment and medical support given to the child with craniofacial anomalies.--A. B. Sokol Advancement of the Orbits and the Midface In One Piece, Combined With Frontal Repositioning, for the Correction of Crouzon's Deformities. F. Ortiz-Monasterio,
A. Fuente de/ Campo, and A. Carrillo. Plast and Reconstr Surg 61:507-516 (April), 1978
From a total of 176 orbital and facial mobilizations done in 5 yr, the authors report on 7 patients with Crouzon's deformity. These patients had advancement of the complete orbits, frontal bone, and maxilla, in one piece to achieve correction. All patients had maxillary retrusion, type III malocclusion, and exorbitism. Two patients were adults (35 and 24 yr old) and the other 5 were between the ages of 4 and 6 yr. The authors believe that the best time for this operation is 5 yr of age. Preoperative studies include the use of cephalograms, dental molds, facial photographs, and exophthalmometry. Preoperative planning includes exact reconstruction and repositioning required so that concurrent bicortical iliac bone grafts and split rib grafts can be taken during the procedure. The operation is performed under general nasotracheal anesthesia. No tracheostomy nor mannitol has been required. The operation consists of two incisions, one coronal and one intraoral. Through these incisions the entire frontal bone and midface are separated from the skull to allow advancement and correction of the deformity. The advancement is secured by bicortical iliac and split rib grafts. No interdental fixation is required. An excellent review is given of the evolution of craniofaeial surgery. In addition, the article is accompanied by excellent preoperative and postoperative clinical photographs demonstrating the remarkable results obtained with this procedure. Finally, there is clear operative discussion, and there are diagrams to facilitate an understanding of this operation.--A. B. Sokol L. B. Kaben, J. B. Mulliken, and J. E. Murray. Am J. Surg 135:570-576 (April), 1978 Sialadenitis in Childhood.
A 30-yr retrospective review of 49 patients up to 16 yr of age treated at the Children's Hospital Medical Center, Boston, Mass., suggests four types of sialadenitis differing in etiology, clinical manifestations, treatment required, and prognosis. Acute suppurative parotitis (18 patients) was the most common form of pediatric sialadenitis, and it commonly occurred in neonates and in children, with fevel", dehydration, or immunosuppression accompanying an
ABSTRACTS
769
underlying systemic illness. Diagnosis by physical examination (tender preauricular induration; edematous, red Stenson's papilla) and treatment with antistaphylococcal antibiotics usually permitted recovery from a single attack without development of the chronic form of the disease. Recurrent acute parotitis (14 patients), in contrast, was characterized by multiple attacks of pain, swelling, and fever without local or underlying systemic causes. Duct manipulation and/or sialography to provide curative drainage along with antibiotics were used during the acute episodes. Alpha Streptococcus was most frequently cultured, making penicillin the drug of choice. The attacks of sialadenitis ceased spontaneously around the time of puberty. Chronic parotitis (9 patients) occurred in Patients with underlying autoimmune disease and presented clinically as bilateral low-grade persistent or intermittent swelling and pain without an acute inflammatory response. Treatment with heat, massage, and sialogogues in 6 patients, total parotidectomy in 2 patients, and radiotherapy (not recommended) in 1 patient made all permanently symptom-free. Acute submaxillary sialadenitis (8 patients) was caused by mechanical obstruction of Wharton's duct in all instances (7 stone, 1 stenosis). Diagnosis of duct abnormality by physical examination, soft-tissue radiography, or sialography and excision of the submaxillary gland resulted in cure in all
instances.--Carey P. Page
A Protocol for Management of Acute Epiglottitis: Successful Experiences With 27 Consecutive Instances Treated by Naaotracheal IntubaUon. J. K. Lewis, J. C. Gartner, and A. G.
Galvis. Clin Pediatr 17:494~,96 (June), 1978. Twenty-three of 27 children, ages 15 mo to 16 yr, with documented epiglottitis were treated successfully by nasotracheal intubation. Extubation occurred after a mean of 47 hr, and all did well, with no complications of subglottic stenosis or need for reintubation. Twenty-four patients had positive blood cultures for Haemophilus influenza type b; 18 also had epiglottis cultures positive for H. inftuenzae. All patients were treated with ampicillin. The management advantages of nasotracheal intubation over elective tracheostomy, plus the equally satisfactory results seen with either procedure, suggest that nasotracheal intubation is the treatment of choice in epiglottitis.--Daniel 14I. Thomas
Critical Evaluation of Adenoidectomy. J.
Hibbert and P. M.
Stell. Lancet 1:489-490 (March), 1978 The authors report a series of two matched groups of 32 children; one group underwent tonsillectomy alone, and the other underwent tonsillectomy and adenoidectomy. Symptoms attributable to adenoidal hypertrophy were equally present in both groups before operation and improved with equal frequency postoperatively. The authors surmise that the operation of tonsillectomy alone is unlikely to cure adenoidal symptoms but that any improvement after added adenoidectomy i s purely subjective, the operation having a placebo effect on the mother.--J. G. Harvey
ALIMENTARY
TRACT
Injection of Scleroaing Agents in Children With Bleeding Esophageal Varlces.
K.-J. Paquet and K. D. Lindecken. Z
Kinderchir 23:267-279 (March), 1978 Treatment of portal hypertension in childhood is still problematic. Although first or even second hemorrhages have a very low mortality in childhood, conservative treatment by means of volume replacement, hemostyptic agents, or insertion of a Sengstaken-Blakemore tube is often not successful. Injection of sclerosing agents has been a safe and successful procedure carrying a low risk. A rigid esophagoscope 6 mm in diameter and 30 cm long is used with a Hopkins optical system additionally equipped with a nozzle for rinsing and suction and a balloon allowing air to be inflated to stretch the esophageal wall. The sclerosing agent is injected near the varices into the subepithelial region through a long needle. A maximum of 30 cc are injected during each session. Usually two to four sessions at 4- to 7-day intervals are necessary. Bleeding ceases immediately because of the mucosal edema compressing bleeding varices. Later, scars covering the varices prevent recurrent rupture but leave the collaterals patent. Sixteen children between 2 and 19 yr have been treated since 1973. Esophageal bleeding, which could not be stopped by conservative treatment before, ceased in every patient. One child 2 yr of age suffering from prehcpatic block and cirrhosis died because of hemorrhage from gastric varices 2 mo after five endoscopic sessions. In 1 patient superficial necrosis of the esophageal wall without mediastinitis was seen, and in a second patient a stricture developed that was treated successfully by one dilatation. Up to now, 7 children are alive without recurrent hemorrhage for more than 3 yr. Nine patients had intervals without hemorrhage of between 3 mo and 3 yr.--Karl-Ludwig
Waag Oesophageal Troubles After Repair in Infancy. Editorial.
Lancet 1:700 (April), 1978 The author praises the long-term results after repair of tracheoesophageal fistula and esophageal atrcsia in infancy. He finds that narrowing of the anastomosis, which requires dilatation, occurs in 30%-50% of cases; recurrent fistula occurs in 5.5%, with a second fistula occurring in 1%-8% of cases. Other causes of dysphagia include tracheomalacia, aberrant subclavian artery, and rare abnormalities of the larynx, such as laryngeal clefts or subglottic stenosis. Abnormalities of peristalsis occur postoperatively and in the long term, including incoordination between the upper and lower parts of the esophagus and spasm or inertia of the distal esophagus. Abnormalities of the cardioesophageal sphincter occur, varying from spasm to gross laxity, reflux, and subsequent esophagitis and stricture formation. The author draws attention to two recent papers that have assessed esophageal motility by means of manometric estimations 10-27 yr after repair of esophageal atresia. They found functional abnormalities despite normal endoscopic a p p e a r a n c e s ; these also o c c u r r e d in eases of tracheoesophageal fistula without atresia and therefore suggest an element of neuromuscular incoordination, possibly associated with.division of the vagal fibers locally.