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PubMed1992

Current therapy for otitis media and criteria for evaluation of new antimicrobial agents.

Otitis media is the most commonly diagnosed disease in infants and children in the United States. For routine empirical treatment of uncomplicated acute otitis media, amoxicillin is the drug of choice. Persistence of signs and symptoms of infection during antimicrobial therapy calls for a change to an antibiotic effective against beta-lactamase-producing bacteria (e.g., trimethoprim-sulfamethoxazole, amoxicillin/clavulanate, or one of the newer oral cephalosporins) or performance of tympanocentesis/myringotomy or both. The most common nonsurgical and surgical methods currently employed for prevention of frequent recurrences are antimicrobial prophylaxis, myringotomy with insertion of a tympanostomy tube, and adenoidectomy. For patients who have otitis media with effusion for which treatment is indicated, antimicrobial agents have been shown to be effective; amoxicillin is preferred as initial therapy. Guidelines for evaluating new antimicrobial agents in the treatment of otitis media are presented in this report.

Acute Disease↗
PubMed2000

Adenoids provide a microenvironment for the generation of CD4(+), CD45RO(+), L-selectin(-), CXCR4(+), CCR5(+) T lymphocytes, a lymphocyte phenotype found in the middle ear effusion.

Adenoidectomy in children with otitis media with effusion reduces inflammation in the middle ear by an unknown mechanism. Potentially, the adenoids of these children may serve as a site for the differentiation of lymphocytes, which after entering blood circulation eventually extravasate in the middle ear mucosa and thereby contribute to excessive inflammation. During lymphocyte extravasation various adhesion molecules and chemokines play a crucial role. To evaluate possible connections between the adenoids and middle ear inflammation, the expression of the chemokine receptors CXCR4 and CCR5 and the lymphocyte homing receptor L-selectin were analyzed in adenoidal and middle ear lymphocytes. It was found that most CD4(+) T lymphocytes in the middle ear effusion express the memory phenotype marker CD45RO and the chemokine receptors CXCR4 and CCR5, but are negative for the lymphocyte homing receptor L-selectin. This cell phenotype was rare in peripheral blood but was found much more frequently in the adenoids. The results suggest that the adenoids provide a microenvironment for the generation for CD4(+), CD45RO(+), L-selectin(-), CXCR4(+) and CCR5(+) T lymphocytes. Further, these cells may include cells that have the capacity to home to the middle ear mucosa. As the adenoidal CD4(+) memory phenotype CD45RO(+) T cells expressed the activation antigen CD69 and included cells expressing the HIV co-receptors CXCR4 and CCR5 at a high level, they may be permissive for HIV infection.

Adenoids↗
PubMed1996

Concentrations of cefpodoxime in plasma, adenoid, and tonsillar tissue after repeated administrations of cefpodoxime proxetil in children.

Cefpodoxime proxetil was administered to 36 children undergoing tonsillectomy, adenoidectomy or both. It was very well tolerated. The detectable tissue concentrations of cefpodoxime were moderate but remained constant (approximately 0.05 mg/kg) 3, 6, and 12 h after the last dose of the drug, while the respective plasma concentrations were declining. This suggests the possibility of twice-daily administration. However, 30% of children did not have quantifiable concentrations in the tonsil and more than half the adenoids did not have quantifiable levels. Whether a higher dosage would lead to higher and more satisfactory tissue concentrations is a matter for further investigation.

Adenoids↗
PubMed2001

Effect of amoxycillin with or without clavulanate on adenoid bacterial flora.

The effect of antimicrobial therapy with amoxycillin (AMX) or co-amoxiclav (AMC) on the adenoid bacterial flora of 45 children with recurrent otitis media (ROM), scheduled for elective adenoidectomy, was studied. Patients were randomized before surgery into three groups of 15, having had either no antibiotic therapy (control), or 10 days of therapy with AMX or AMC. Core adenoid tissues were quantitatively cultured for aerobic and anaerobic bacteria. Polymicrobial aerobic-anaerobic flora was present in all instances. The predominant aerobes in all groups were alpha-haemolytic and non-haemolytic streptococci, Haemophilus influenzae, Staphylococcus aureus, group A beta-haemolytic streptococci and Moraxella catarrhalis. The prominent anaerobes were Peptostreptococcus spp., Prevotella spp. and Fusobacterium spp. The number of isolates was significantly reduced in those treated with AMX (110; P < 0.05) or AMC (54; P < 0.001) compared with control (148). The number of bacteria per gram of tissue was lower in those treated with both antibiotics. The number of potential pathogens was lower in those treated with AMC compared with the other two groups (P < 0.001 ). The number of beta-lactamase- producing bacteria (BLPB) was lower in those treated with AMC compared with those treated with AMX (P < 0.025) or no antibiotic (P < 0.001). These data illustrate the ability of AMX and AMC to reduce the bacterial load as well as potential pathogens and BLPB from the adenoids of children with ROM.

Adenoids↗
PubMed2003

Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children.

STUDY OBJECTIVES: To assess the prevalence of sleep-disordered breathing in a nonselected group of children with Down syndrome and to determine significant predisposing factors for this condition. DESIGN: Prospective study. SETTING: Tertiary care university hospital in Madrid, Spain. PATIENTS: The study population included 108 consecutive children with Down syndrome (mean [SD] age, 7.9 [4.5] years; range, 1-18 years) independently of whether or not suggestive clinical features of sleep-disordered breathing were present. INTERVENTIONS: In addition to history, physical examination, and lateral radiographs of the nasopharynx, all participants underwent an overnight cardiorespiratory polygraphy at the hospital using a portable ambulatory device (Apnoescreen II plus). An apnea-hypopnea index of at least 3 was required for defining the presence of sleep-disordered breathing. RESULTS: The prevalence of sleep-disordered breathing was 54.6%, with a significantly higher prevalence in boys (64.7%) than in girls (38.5%) (P < .05). The group with sleep-disordered breathing was significantly younger (6.4 [3.9] years) than those with normal polysomnographic recordings (9.6 [4.6] years) (P < .001). In the multivariate analysis, age (less than 8 years old) (odds ratio [OR], 3.36; 95% confidence interval [CI], 1.40, 8.06); male sex (OR, 3.32; 95% CI, 1.32, 8.12); and tonsillar hyperplasia (OR, 5.24; 95% CI, 1.52, 19.03) were significantly associated with sleep-disordered breathing. Body mass index, adenoid hyperplasia, previous tonsillectomy or adenoidectomy, congenital heart disease, malocclusion, and macroglossia did not affect the prevalence of sleep-disordered breathing. CONCLUSIONS: The prevalence of sleep-disordered breathing in children with Down syndrome is very high, particularly in boys. Tonsillar hyperplasia may play a role in the pathophysiology of sleep-disordered breathing in these patients. Adenoid hyperplasia, obesity, and congenital heart disease were not important risk factors for sleep-disordered breathing.

Adolescent↗
PubMed1995

A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding.

The study was designed to compare intravenous ketorolac to rectal acetaminophen for analgesia and bleeding in pediatric patients undergoing tonsillectomy. We studied 50 patients, aged 2-15 yr undergoing tonsillectomy with or without adenoidectomy. In a randomized, prospective double-blind fashion, patients were assigned to receive either ketorolac (1 mg/kg) or rectal acetaminophen (35 mg/kg). Bleeding was evaluated by measuring intraoperative blood loss and noting extra measures required to obtain hemostasis. Bleeding times were also measured before and during surgery. Pain was evaluated using a standard objective pain score for the first 3 h. Persistent pain was treated with morphine, acetaminophen, and codeine and recorded for 24 h. Blood for determination of acetaminophen levels was drawn at 20 and 40 min after the administration of study drugs. Pain scores were not significantly different between the ketorolac and acetaminophen groups. The majority of patients in both groups required additional opioid in the postoperative period. Acetaminophen levels were all less than the therapeutic range. Intraoperative bleeding times were normal in all patients, but blood loss was significantly higher in the ketorolac group (2.67 mL/kg) compared to the acetaminophen group (1.44 mL/kg), P = 0.025. Significantly more measures to achieve hemostasis were required in the ketorolac group (P = 0.012). We conclude that ketorolac is no more effective than high-dose rectal acetaminophen for analgesia in the patient undergoing tonsillectomy. Hemostasis during tonsillectomy was significantly more difficult to achieve in patients receiving ketorolac.

Acetaminophen↗
PubMed2002

The effect of fentanyl on the emergence characteristics after desflurane or sevoflurane anesthesia in children.

UNLABELLED: Desflurane and sevoflurane anesthesia are associated with emergence agitation in children. In this study, we examined the effect of a single intraoperative dose of fentanyl on emergence characteristics in children undergoing adenoidectomy. One hundred children, 2-7 yr old, were randomly assigned to receive desflurane or sevoflurane for maintenance of general anesthesia after an inhaled induction with sevoflurane and a 2.5 microg/kg dose of fentanyl. An observer blind-ed to the anesthetic technique assessed the times to achieve emergence, extubation and recovery criteria, as well as emergence behaviors. The results showed a similar incidence of severe emergence agitation after general anesthesia with desflurane (24%) and sevoflurane (18%). Times to achieve extubation and postanesthesia care unit discharge criteria were shorter with desflurane than with sevoflurane. With this technique, desflurane allows for a more rapid emergence and recovery than sevoflurane. In children receiving desflurane or sevoflurane, the concurrent use of fentanyl in a dose of 2.5 microg/kg results in a small incidence of emergence agitation. IMPLICATIONS: The concurrent use of fentanyl in a dose of 2.5 microg/kg in children receiving desflurane or sevoflurane results in a low incidence of emergence agitation. Desflurane allows for a more rapid emergence and recovery than sevoflurane.

Analgesics, Opioid↗
PubMed1978

Regional differences in surgical care based upon uniform physician and hospital discharge abstract data.

Population based surgical rates for various common surgical procedures were analyzed on a regional basis by examining select uniform hospital discharge abstract data from Wisconsin hospitals. The surgical asbracts of nearly 64,000 procedures were compared to the supply of physicians and showed a significant variation in the rates of common procedures even within rather large planning districts. In general, the volume of surgery correlated with the supply of surgeons. Exceptions were noted; for example, primary appendectomy, tonsillectomy and adenoidectomy (T & A), and inguinal herniorrhaphy did not correlate with the supply of surgeons, but did correlate with the supply of general practitioners. Further, T & A had a strong negative correlation to the supply of ear, nose and throat specialists. Information of this type has significance both for Professional Standard Review Organizations (PSROs) and Health Planning Agencies (HPAs). Further work will be necessary to define optimal surgical rates.

Delivery of Health Care↗
PubMed1996

Obstructive sleep apnea in infants and young children.

The obstructive sleep apnea syndrome (OSAS), is a common cause of morbidity during childhood. Childhood OSAS usually stems from adenotonsillar hypertrophy. OSAS in infants is usually related to craniofacial anomalies. Other risk factors include obesity and neuromuscular disease. Symptoms include snoring and difficult breathing during sleep. Infants may have problems with feedings and experience failure to thrive. Definitive diagnosis is made by polysomnography. Normative polysomnographic parameters vary with age; thus age-appropriate norms must be used. In contrast to adults, children often manifest a pattern of persistent partial airway obstruction during sleep, rather than cyclical, discrete obstructive apneas. Most children are cured by tonsillectomy and adenoidectomy. However, some children require further therapy, such as continuous positive airway pressure.

Adult↗
PubMed1998

Airway management in children with major craniofacial anomalies.

OBJECTIVES: Delineation of clinical characteristics affecting the airway in a cohort of craniofacially deformed children. What factors differ between patients requiring and those not requiring surgical airway intervention? What factors predispose to the need for tracheotomy? When can decannulation be expected if tracheotomy is required? What interventions aid decannulation? STUDY DESIGN: Five-year retrospective chart review at tertiary center. METHODS: Two hundred fifty-one patients met the following entry criteria: enrollment in the New York University Institute of Reconstructive and Plastic Surgery's Craniofacial Clinic and admission to Tisch Hospital in Manhattan for surgery from 1990 to 1994. Hospital, clinic, and departmental office records were reviewed. All patients had major craniofacial bony anomalies and underwent administration of general anesthesia at least once. RESULTS: Nearly 20% of all children required tracheotomy (47/251). Craniofacial synostosis patients (Crouzon, Pfeiffer, or Apert syndrome) had the highest rate of tracheotomy (48% [28/59]). Mandibulofacial dysostoses patients (Treacher Collins or Nager syndrome) had the next highest rate (41% [28/59]). Patients with oculo-auriculo-vertebral sequence were less likely to undergo tracheotomy (22% [9/41]). Children with craniosynostosis rarely required a surgical airway, unless there was marked associated facial dysmorphism (1% [1/72]). The duration of cannulation was related to the age at tracheotomy in a bimodal distribution. Generally, tracheotomies required before age 4 years remained for several years, whereas those placed after age 4 were removed after several weeks. The presence of a cleft palate correlated with reduced risk for tracheotomy, but the presence of a ventriculoperitoneal shunt correlated with an increased risk for tracheotomy. Procedures selectively used to improve the airway included midface advancement, mandibular expansion, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, anterior tongue reduction, and endoscopic tracheal granuloma excision. CONCLUSIONS: The likelihood for surgical airway management is related to specific craniofacial diagnosis. The length of tracheal cannulation is greatest for infants and young children who manifest severe airway compromise, often because of nasal obstruction in combination with other anatomic factors. Early tracheotomy is advocated for these patients to promote optimal growth and development. Choanal atresia is often misdiagnosed in these infants; nasal obstruction is actually secondary to midface retrusion. Staged surgical interventions can allow eventual successful decannulation in nearly all cases of craniofacial syndromes.

Adolescent↗
PubMed2000

Otolaryngological manifestations of velocardiofacial syndrome: a retrospective review of 35 patients.

OBJECTIVE: Because many patients with velocardiofacial syndrome (VCFS) are first examined by otolaryngologists for ear or speech problems before being diagnosed with VCFS, we describe a series of patients with this genetic disorder, which is associated with multiple anomalies, including velopharyngeal insufficiency, cardiac defects, characteristic facial features, and learning disabilities. STUDY DESIGN: We retrospectively analyzed the medical charts and available nasoendoscopic observations for 35 patients who were diagnosed with VCFS and who had a microscopic deletion in chromosome 22q11 as shown by DNA probe and fluorescence in situ hybridization. RESULTS: For most patients, the medical chart documented cardiac anomalies, velopharyngeal insufficiency with hypernasal speech, and characteristic facial features including nasal, auricular, craniofacial, and ocular abnormalities. Incidence of middle ear infection with associated conductive hearing loss was also high and necessitated early placement of pressure equalization tubes. Some patients were treated with adenoidectomy for chronic otitis media; consequently, velopharyngeal insufficiency and hypernasal speech worsened. Nasoendoscopic examination as documented in the medical chart showed occult cleft palate, a small adenoid pad, and pulsation in the muscular wall. CONCLUSION: Otolaryngologists have an important role in diagnosis and treatment of persons with VCFS and therefore should familiarize themselves with the typical history and most frequent head and neck manifestations of this syndrome.

Adolescent↗
PubMed2000

Evaluating the effects of oral prednisolone on recovery after tonsillectomy: a prospective, double-blind, randomized trial.

OBJECTIVES: To investigate the role of a 7-day course of oral prednisolone on recovery from tonsillectomy. STUDY DESIGN: Double-blind, randomized, placebo-controlled trial of 50 consecutive patients, aged 5 years and older, who had no previous or known contraindications to steroid therapy. METHODS: The patients were randomized at the time of surgery to either a 7-day course of daily placebo or prednisolone (dosage: 10 mg per day in patients aged 5-11 y, 0.5 mg/kg in those aged 12 and older). Age, sex, weight, diagnosis, tonsil size (in cm2), additional adenoidectomy, performing surgeon, method of dissection, length of procedure, total blood loss, intraoperative fluid requirement, and length of hospitalization were documented for each patient. During the first postoperative day, morning pain score, paracetamol use, oral fluid intake, temperature, presence of nausea and vomiting, level of activity (low, moderate, or normal), and type of diet (liquid, soft, or normal) were recorded. RESULTS: The steroid group consisted of a greater number of diathermy dissection cases and had significantly less intraoperative blood loss (P value = .022 and .017, respectively). On postoperative days 4 to 7, the steroid group experienced less nausea and vomiting (P value = .01, .04, .04, and .04, respectively). Paracetamol use was less in the steroid group on days 2, 7, and 8 (P value = .03, .02, and .02, respectively). There was no difference between the two groups for the other data measured. CONCLUSION: A 7-day course of corticosteroids may play a limited role in patients' recovery from tonsillectomy.

Adolescent↗
PubMed2001

Post-tonsillectomy bleeding: a meta-analysis.

OBJECTIVE/HYPOTHESIS: To reconcile conflicting reports and opinions of the value of preoperative coagulation studies for patients undergoing tonsillectomy. STUDY DESIGN: Meta-analysis: Articles were identified by MEDLINE search, references from review articles, textbook chapter, and retrieved reports. Independent observers selected prospective trials of patients undergoing tonsillectomy or adenoidectomy and tonsillectomy. Retrospective studies meeting other inclusion and exclusion criteria were included for sensitivity analyses of results. METHODS: Data were abstracted from studies for an end point of bleeding with normal and abnormal coagulation tests. Four prospective studies met all inclusion and exclusion criteria. These four studies were used in the data synthesis. An additional eight retrospective studies met all other criteria and were used in the sensitivity analysis. RESULTS: Pooled analysis of 3384 patients revealed a rate of 3.3% (95% confidence interval [CI], 2.5%-4.1%) for post-tonsillectomy bleeding in patients with normal coagulation studies. A rate of 8.7% (95% CI, 1.5%-15.9%) was obtained for bleeding in patients with abnormal coagulation studies. No significant rate difference in post-tonsillectomy bleeding was demonstrated. CONCLUSION: There is no difference in the rate of post-tonsillectomy bleeding in patients with abnormal coagulation studies as compared with patients with normal coagulation studies obtained preoperatively.

Blood Coagulation Disorders↗
PubMed2002

Ventilation time of the middle ear in otitis media with effusion (OME) after CO2 laser myringotomy.

OBJECTIVE: The aim of this study was to investigate the transtympanic ventilation time, the healing course of the tympanic membrane, the early and late complications, and the recurrence rate of otitis media with effusion (OME) within 6 months after CO2 laser myringotomy with the CO2 laser otoscope Otoscan. STUDY DESIGN: Prospective clinical study. MATERIALS AND METHODS: In this study, laser myringotomy was performed with the CO2 laser otoscope Otoscan in a patient population comprising 81 children (159 ears) with a history of otitis media with effusion (OME) associated with adenoidal and sometimes tonsillar hyperplasia. The procedure on the tympanic membrane was accordingly combined with an adenoidectomy, a CO2 laser tonsillotomy, or a tonsillectomy and therefore performed under insufflation anesthesia. In all ears, approximately 2 mm circular perforations were created in the lower anterior quadrants with a power of 12 to 15 W, a pulse duration of 180 msec, and a scanned area of 2.2 mm in diameter. RESULTS: None of the children showed postoperative impairment of cochleovestibular function such as sensorineural hearing loss or nystagmus. Otomicroscopic and videoendoscopic monitoring documented the closure time and healing pattern of tympanic membrane perforations. The mean closure time was found to be 16.35 days (minimum, 8 days; maximum, 34 days). As a rule, an onion-skin-like membrane of keratinized material was seen in the former myringotomy perforations at the time of closure. At the follow-up 6 months later, the condition of the tympanic membrane of 129 ears (81.1%) could be checked by otomicroscopy and videoendoscopy and the hearing ability by audiometry and tympanometry. The CO2 laser myringotomy sites appeared normal and irritation-free. Two of the tympanic membranes examined (1.6%) showed atrophic scar formation, and 1 (0.8%) had a perforation with a diameter of 0.3 mm. The perforation was seen closed in a control otoscopy 15 months postoperatively. OME recurred in 26.3% of the ears seen intraoperatively with mucous secretion (n = 38) and in 13.5% of the ears with serous secretion (n = 37; P <.05). CONCLUSION: The most important principle in treating OME is ventilation of the tympanic cavity. CO2 laser myringotomy achieves this through a self-healing perforation in which its diameter roughly determines the duration of transtympanic ventilation. Laser myringotomy competes with ventilation tube insertion in the treatment of OME. It may be a useful alternative in the surgical management of secretory otitis media.

Child↗
PubMed2003

Radiofrequency tonsil reduction: safety, morbidity, and efficacy.

OBJECTIVES: To evaluate the safety, morbidity, and efficacy of radiofrequency tissue volume reduction of tonsils using two different surgical techniques and to compare these two techniques with each other and with classic tonsillectomy. STUDY DESIGN: A nonrandomized retrospective review of tonsil reductions was made between 2000 and 2002 using in vivo studies associated with tonsil reduction and tonsillectomy performed either in the hospital operating room or in the outpatient treatment area. METHODS: We studied 150 patients and divided them into three main groups based on surgical technique. Group A consisted of 50 consecutive patients who underwent tonsil "ablation," Group B contained another 50 consecutive individuals who received tonsil "coblation," and Group C consisted of 50 patients who underwent classic tonsillectomy (cold dissection). Each group consisted of two subcategories of children (age range, 1-12 y) and adults (age range, 12-60 y) with chronic tonsillar hypertrophy. Most of the pediatric patients underwent adenoidectomy during the same surgical procedure. Indications for tonsillectomy were those listed by the American Academy of Otolaryngology-Head and Neck Surgery. A retrospective chart review was used to assess procedures, safety, morbidity, and efficacy of tonsil reduction and tonsillectomy. Four specific end points of morbidity were investigated: pain, return to normal diet, return to normal activity, and use of pain medication. Efficacy of tonsillectomy was determined by the clinical observation of the remaining tonsillar tissue and compared with pretreatment photographs of the tonsils. RESULTS: There were no complications in any of the groups. Efficacy was assessed based on the mean tonsil reduction and was found to be 100% for tonsillectomy, 86% for the tonsil coblation technique, but only 53.6% for the ablation technique. Morbidity was minimal in groups A and B and significantly greater in Group C. The number of pain days, narcotic-use days, and days before return to normal diet and activity were greatly reduced in groups A and B when compared with classic tonsillectomy (group C). Pain levels on day 1 were less than 3 (on a scale of 1-10) in groups A and B. The number of pain days and narcotic-use days was less than 4 days in groups A and B. Similarly, most patients returned to solid diet and normal activity by day 4. Pain levels, number of narcotic-use days, and number of days to return to normal diet and activity were significantly higher for classic tonsillectomy. CONCLUSIONS: Tonsil coblation has distinct advantages when compared with tonsil ablation and standard tonsillectomy. Tonsil coblation resulted in greater than 86% elimination of tonsillar tissue in both children and adults. In most patients, pain levels were minimal and limited to the first 48 hours after surgery. Return to normal diet and activity was much earlier in the coblation group versus classic tonsillectomy.

Adolescent↗
PubMed1998

Clinical implications of antibiotic resistance for management of acute otitis media.

Antibiotic resistance to available antimicrobial agents has been constant since the introduction of the sulfonamides in the 1930s. Multidrug-resistant Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae are a concern now because of the importance of these pathogens in infections of the respiratory tract in infants and children. Amoxicillin remains the drug of choice for initial episodes of acute otitis media (AOM) although increase of the dosage schedule to 80 mg/kg/day has been recommended by some investigators. There are 15 additional antimicrobial agents approved by the Food and Drug Administration for the indication of AOM. All approved drugs are clinically effective but some have been suggested to have priority for patients who fail amoxicillin: amoxicillin-clavulanate; an oral cephalosporin such as cefuroxime axetil; and intramuscular ceftriaxone. Management of the child with severe and recurrent disease should include antibiotic prophylaxis but the increased incidence of resistance requires selective use. Prevention of infection may be achieved by innovative techniques for interference with attachment of bacteria to the nasal mucosa such as administration of oligosaccharides in a nasal spray. The currently available polysaccharide pneumococcal vaccines have limited immunogenicity in infants, but the vaccine is useful in children 2 years of age and older who still have recurrent AOM. Children with frequent AOM during the prior respiratory season are candidates also for influenza virus vaccine. If medical management fails to prevent new episodes of AOM in children with severe and recurrent disease, placement of tympanostomy tubes and possible adenoidectomy should be considered.

Acute Disease↗
PubMed1999

A prospective evaluation of the prevalence of submucous cleft palate in patients with isolated cleft lip versus controls.

Although there is an established relationship between cleft lip and overt cleft palate, the relationship between isolated cleft lip and submucous cleft palate has not been investigated. To test the hypothesis that patients with isolated cleft lip have a greater association with submucous cleft palate, a double-armed prospective trial was designed. A study group of 25 consecutive children presenting with an isolated cleft lip, with or without extension through the alveolus but not involving the secondary palate, was compared with a control group of 25 children with no known facial clefts. Eligible patients were examined for the presence of physical criteria associated with classic submucous cleft palate, namely, (1) bifid uvula, (2) absence of the posterior nasal spine, and (3) zona pellucida. Nasoendoscopy was subsequently performed just after induction of general anesthesia, and the findings were correlated with digital palpation of the palatal muscles. Patients who did not satisfy all three physical criteria and in whom nasoendoscopy was distinctly abnormal relative to the control group were classified as having occult submucous cleft palate. Classic submucous cleft palate was found in three study group patients (12 percent), all of whom had flattening or a midline depression of the posterior palate and musculus uvulae on nasoendoscopy and palpable diastasis of the palatal muscles under general anesthesia. An additional six study group patients (24 percent) had similar nasoendoscopic criteria and palpable diastasis of the palatal muscles; they were classified as having occult submucous cleft palate. No submucous cleft palate was identified in the control group. Seventeen patients in the study group had an alveolar cleft with a 53 percent (9 of 17) prevalence of submucous cleft palate. In the present study, classic submucous cleft palate in association with isolated cleft lip was 150 to 600 times the reported prevalence in the general population. All children with an isolated cleft lip should undergo peroral examination and speech/resonance assessment no later than the age of 3 years. Any child with an isolated cleft lip with velopharyngeal inadequacy or before an adenoidectomy should be assessed by flexible nasal endoscopy to avoid missing an occult submucous cleft palate.

Adolescent↗
PubMed2005

Oxymetazoline is equivalent to ciprofloxacin in preventing postoperative otorrhea or tympanostomy tube obstruction.

OBJECTIVE: To compare the effectiveness of ciprofloxacin and oxymetazoline solutions instilled after tympanostomy tube placement in the prevention of postoperative otorrhea and tube occlusion. STUDY DESIGN: Prospective cross-sectional series. METHODS: We reviewed all bilateral myringotomy and tube placement operations performed by two full-time attending pediatric otolaryngologists during a 9 month period. Data from 488 patients who underwent surgery for otitis media were collected. Demographic and clinical variables including age, sex, number of tube insertions in the past, previous adenoidectomy, type of effusion present at surgery, and type of drop prescribed postoperatively were recorded. All patients were evaluated in the office 2 to 4 weeks postoperatively. Multivariate logistic regression analysis was used to estimate the relationship of these variables with the occurrence of otorrhea and tube patency. Odds ratios were calculated. RESULTS: No significant differences in postoperative otorrhea or tube patency were found between ciprofloxacin (Ciloxan) and oxymetazoline solutions (Afrin, Visine LR). CONCLUSION: Oxymetazoline and ciprofloxacin solutions are equivalent in the prevention of postoperative otorrhea and tube occlusion after tympanostomy tube placement. The implications for medication cost and potential adverse reactions are discussed.

Administration, Topical↗