Biomedical subjects
Publications and source records attributed to P Contencin.
Ultrasound of the larynx appears as a new way of imaging the larynx in infants and children. The normal sonographic anatomy is briefly described. The pathological findings of this method, its advantages and its drawbacks are discussed. It appears to be a very interesting method for functional disorders and space-occupying lesions.
This paper reports three cases of 'occult' submucous posterior laryngeal cleft in which MR examination has visualized the deficiency of the posterior cricoid lamina. Laryngeal cleft is an uncommon anomaly, and its clinical and endoscopic diagnosis is always difficult. To our knowledge, the role of MR in this diagnosis has not yet been emphasized.
Several studies published over the last few years have pointed out the importance of gastroesophageal reflux (GER) in the pathogenesis of certain cases of chronic or recurrent pharyngo-laryngitis. While the presence of an acid reflux at the level of the pharyngo-larynx has recently been demonstrated in certain cases, the real incidence and pathogenic impact of this reflux is not precisely known. A new technique of continuous 24 hour bi-level monitoring of endoluminal pH in the esophagus and the oro/hypopharynx has made it possible to observe the variations in acid-base balance in contact with the pathological mucosa. 21 patients, 2 months to 7.5 years old, presenting recurrent episodes of pharyngitis or laryngitis, underwent continuous pH monitoring during a 24 hour hospitalization. 6 control subjects, 1 month to 13 years old, presenting no chronic or recurrent ear, head or neck pathology and no sign or symptom of GER were subjected to the same monitoring regimen. A statistically significant difference between the 2 groups is evident for most of the parameters analysed. The most discriminative parameter is the fraction of the total recording time where the pharyngeal readings remain under ph6 (p < 0.0005). These results demonstrate that, in this clinical condition, acid of gastroesophageal origin is in contact with the pharyngeal mucosa. This suggests that the acid has a causal role in the pathological changes observed in the pharyngolaryngeal mucosa.
In view of the well-known relationship between gastro-oesophageal reflux (GOR) and inflammatory diseases of the bronchi, trachea and larynx, the possibility of a pathogenic acid reflux reaching the pharynx has sometimes been suspected but never demonstrated. Paediatric E.N.T. specialists are often confronted with chronic inflammatory rhinopharyngitis of no obvious origin. In order to test the hypothesis of rhinopharyngeal contamination by gastric acid, the nycthemeral local pH was recorded in children presenting with chronic rhinopharyngitis and gastro-oesophageal reflux, and in two groups of controls without rhinopharyngitis and with or without GOR. Falls in rhinopharyngeal pH were found to be more frequent and to last longer in the 18 patients than in controls. The most significant criterion was the time during which the pH was lower than 6 compared with the total time of recording in these cases where pharyngeal pH measurements were recorded over 15 to 26 hours. It seemed most probable that this acidity resulted from the gastro-oesophageal reflux. Such variations in acid-base balance at the surface of a respiratory mucosa might be instrumental in the genesis or maintenance of the nasopharyngeal inflammatory reaction. However, these two hypotheses must be confirmed or infirmed by further studies.
The etiology and mechanisms involved in determining and/or maintaining the inflammatory process along the airway mucosa remain partially obscure. The role of gastroesophageal reflux (GER) has been demonstrated in some cases of bronchitis and laryngitis especially in children. In adults, GER-related laryngitis has also been mentioned. In children, repeated rhinopharyngitis and otitis media due to GER remain a putative question. In this study, 31 infants and children underwent a day and night nasopharyngeal pH monitoring. Thirteen patients with known GER suffered from chronic or repeated rhinitis or rhinopharyngitis. Eighteen control subjects with or without GER were free of upper airway inflammatory process. In some pathological cases the pH dropped dramatically. The pH drops were more important in most of the GER/rhinitis cases than in controls. Of the reviewed criteria, the percentage of time spent below pH 6 (or pharyngeal acidity index) is the most statistically significant (P less than 0.00005). Thus, the influence of a gastro-esophago-nasopharyngeal acid reflux is strongly suggested in this common pediatric pathology, among other causes. However, the technique used does not allow us to assess the true origin of these pH changes. Further investigation with two-site pH monitoring and larger series of patients are required in order to fully assess the influence of GER on pediatric nasopharyngeal inflammation.
The frequency of obstructive sleep apnea syndromes in children is not negligible. The diagnosis is based on the parents' answers and on sleep recordings. Radiographs sometimes help defining the site of obstruction. However, except when there is a considerable, clinically obvious tonsillar hypertrophy (which is fortunately the most frequent case), the exact location of the obstruction may be difficult to assess. In fact, it is far less obvious and more often multiple than in adults, especially in cases of craniofacial malformation. A pharyngolaryngeal exploration technique with a flexible endoscope under general anesthesia (GA) has been developed in our department. With natural ventilation, when a GA is induced with halothane through a mask, muscular relaxation similar to that of natural sleep is obtained. A thin flexible endoscope is then inserted through the mask to observe the obstructive structures at the nasal, rhino/oropharyngeal or pharyngolaryngeal levels. During the past two years, 17 children were examined with this technique, which allows an extremely accurate diagnosis of the site of the obstruction. Four children had a craniofacial malformation. The examination evidenced 9 cases of adenotonsillar hypertrophy, 4 cases of dynamic laryngeal obstruction, 3 cases of basilingual obstruction and one case of circular collapse of the oropharynx. The evolution under treatment confirm the merits of this endoscopic examination technique for the etiological diagnosis of respiratory obstruction.
We report our experience with laryngotracheal stenosis (LTS) in children during the last 12 years. Documentation and follow-up were available for 115 patients who underwent surgery for acquired or congenital LTS. Most were severe cases according to Cotton's classification. Forty-six weighed less than 10 kg at the time of surgery; 45 had pure congenital subglottic stenosis; 70 had acquired subglottic stenosis, mainly due to endotracheal intubation. The surgical techniques used have been various. The three main types of procedure were castellated laryngotracheoplasty, anterior cartilage rib grafting, and anterior and posterior cricoid cuts with or without grafting. All cases but 1 (44/45) of congenital subglottic stenosis have been successfully decannulated, 7 requiring a second procedure. The decannulation rate for acquired SGS was 89% (62/70), but 14 patients required multiple procedures. Current trends in subglottic stenosis management in our institution are presented.
Normal sonographic anatomy of the larynx in children was established by studying 40 healthy children and 3 fetuses. The normal anatomy is described on transverse sonograms passing at level of the ventricular bands, the true vocal cords and the subglottis and the interpretation of the sonographic aspect of the larynx is given. Ultrasound of the larynx seems to provide a good analysis of cartilaginous and endolaryngeal structures and can also show the dynamic aspect of the larynx. A pathological case is described as an illustration of the potentialities of this new way of imaging the larynx.
Clinical and endoscopic data of 219 cases of laryngeal paralysis in newborns, infants, and children are briefly reported. The management of severe cases of persistent dyspnea then is discussed, according to the literature. Of 219 cases, 22 young patients underwent a surgical procedure because of lack of spontaneous recovery and poor tolerance of their disease after 6 to 9 months of follow-up. Arytenoidectomy technique has been used three times and arytenoidopexy 19 times, with fair to excellent results. Other possible treatments for infants are discussed. On the basis of this important series of surgical pediatric cases, the arytenoidopexy technique is advocated, besides arytenoidectomy, to avoid the risks of a long-term tracheostomy in young patients with vocal cord paralysis and severe dyspnea.
Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.
Among the causes of inflammatory swelling of the neck in children, the "cysts" and ducts joining in the hypopharynx deserve being individualized. This unrecognized pathology is indeed responsible for suppurative pseudothyroiditis or cervical abscesses relapsing in spite of adequate antibiotic treatment and incision-drainage. X-ray films may help as they often show the fistula. Diagnosis relies on hypopharyngoscopy. This investigation only may assess the origin of this "internal fistula" by showing the mucous opening of the bottom of the pyriform sinus, from which sometimes springs some pus when pressing the neck. The clear left predominance of this canal and its junction between the superior and inferior laryngeal nerves suggest that its origin could be the 4th branchial pouch. Its treatment consists of complete surgical excision, which avoids relapses.
Laryngotracheal stenosis in children is difficult to manage, especially in cases of acquired lesions. Of 317 cases reviewed, 75 surgical cases are reported here: 28 were congenital and 47 acquired, mostly due to endotracheal intubation. A large variety of laryngotracheoplasty techniques have been used in reconstruction, depending on the age and status of the patient, the size of the laryngeal lumen, the exact site of the stenosis and any associated anomalies. The three main techniques used have been described by Evans, Cotton, and Rethi. Stenting relied on Silastic rolls, Montgomery T-tubes and Aboulker Teflon prostheses. The results in 65 patients showed a decannulation rate of 92% in cases of congenital stenosis and 80% in acquired ones. Improvements in therapy still seem necessary in order to reduce the cannulation time following treatment and the sequelae producing dysphonia.
The technique of laryngotracheoplasty, with an anterior approach, with or without a posterior cut, and with or without anterior or posterior cartilage grafts, has been described previously. On occasion, a severely stenotic subglottis or aberrant shape to the cricoid cartilage makes division of the lateral aspects of the cricoid cartilage desirable. In attempting to delineate the relationship of the recurrent laryngeal nerve to proposed lateral cricoid cuts, an anatomic study was conducted. Dissections of neonatal, infant, child and adult larynges and trachea were carried out, with the relative distance of a cut through the lateral cricoid cartilage to the recurrent laryngeal nerve measured and outlined. The distance was very close in the fetal larynx (measuring 1.5 mm in the 23rd week of gestational age), with an increase in dimension in the infant and child, increasing to a distance of over 1 cm in the mature adult. The clinical significance of this relationship to proposed cuts of the lateral cricoid in different age groups is discussed.
355 children, 3 months to 15 years old, presenting with acute otitis media, underwent a bacteriological study of otitis exsudate. From November 1985 to September 1987, 162 myringotomy and 149 acute otitis media spontaneously discharging were studied in Paris. From October 1981 to September 1987, 62 myringotomy and 46 spontaneously discharging acute otitis were studied in Valognes. There was none pathogenic bacterium in respectively 20 and 14% of the samples. Two or more pathogenic bacterium were isolated in 24 and 7% of the samples. In Paris as in Valognes, 3 pathogens were predominants: Haemophilus (17% were beta-lactamase producers), S. pneumoniae and Staphylococcus. There was only 5 and 3% Streptococcus pyogenes, 2% Branhamella catarrhalis in Paris, none in Valognes. Pseudomonas was present only in case of spontaneous otorrhea, even if recent. For the moment, the combination of amoxicillin with clavulanic acid is not our first treatment in case of acute otitis media in children. Actually we prescribe amoxicillin alone, 50 to 100 mg/kg/day. If the child is allergic to beta lactamin, we give him the combination of trimethoprime and sulfamethoxazole.
We report twenty case of perilymphatic fistulae in children. A fistula was discovered in every case where the cochlear aqueduct is larger than normal on high resolution CT scan of the temporal bone. The surgical treatment of these fistulae allowed only a significant improvement of hearing in the cases were an asymmetry or a dilatation of the cochlear aqueducts and a fluctuating deafness coexisted. Unfortunately these improvements do not look permanent.
The authors report the cases of ten children treated for sub-glottic laryngeal stenosis, in the Department of Pr. Narcy in Hospital Robert-Debre. Medical treatment of the laryngeal stenosis had failed in these cases. Treatment, most often surgical, of the gastro-oesophageal reflux present in these ten cases enabled these children to be cured. A review of the literature stresses the role and responsibility of gastro-oesophageal reflux in laryngeal pathology. Based on their experience, the authors suggest: systematic investigation for gastro-oesophageal reflux during management of laryngeal stenosis, especially when laryngeal inflammation is encountered; the adoption of an interventionist attitude vis-a-vis gastro-oesophageal reflux which would seem to have an important pathogenic role in certain laryngeal stenoses.
For a long time pediatric tracheotomy has had a poor reputation. Its indications are incontestably restricted in view of improvements in anesthesia and pediatric intensive care. We analysed 144 cases for the period 1976-1986. While very few peri-operative complications were noted, thanks to a rigorous technique, a review of which may be worthwhile, secondary complications such as tube obstruction, accidental displacement and superinfection of the lower airways were often fatal. These could be prevented by better training of both the families and also hospital staff. On average, these children had a tracheostomy for one year. There were few difficulties associated with removal of the tracheostomy tube.
Twenty-nine children presenting with chronically recurring serous otitis media, or with serous otitis media complicated by retracted eardrum, underwent either unilateral or bilateral mastoidectomy. For 23 of the children (26 surgical cases) whose follow-up extended over a sufficiently long period of time, results were assessed by otoscopic eardrum inspection, audiometry, and tympanometry. Long-standing recovery of serous otitis media, accompanied by a return to normal of the tympanic membrane, the tympanometric and audiometric parameters, was achieved in 2/3 of cases. These data compare well with results obtained by other authors, and they are telling as regards the efficacy of mastoidectomy for stabilizing the inflammatory process and restoring normal tubal function, in some cases of chronic serous otitis media.