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INTRODUCTION AND OBJECTIVES Pediatric tympanoplasty is still a matter of controversy. Many factors have been associated with the surgical outcome of tympanoplasty in children, including age, size and location of the perforation, surgical technique and Eustachian tube dysfunction. The optimal approach and timing of this surgery remains controversial. This study aims to evaluate the outcomes of pediatric tympanoplasty and analyze factors that may influence the success of this surgery. MATERIALS AND METHODS A retrospective review was conducted which included children from 5 to 15 years old that underwent tympanoplasty with or without ossiculoplasty for chronic tympanic perforation in a tertiary care university hospital over a 6-year period. Patients were divided in two age groups (5 to ≤10 years old and >10 to 15 years old). Children with cholesteatoma or that underwent simultaneous mastoidectomy were excluded. RESULTS 83 cases were included. Average age was 10.7±2.1 years and mean follow-up time was 9 months. Of the cases, 21.7% were revision surgeries. Successful closure of the tympanic membrane perforation was achieved in 76.9% of primary surgeries and 55.6% of revision surgeries. Most of the patients improved their conductive hearing-deficit. No statistical difference in graft failure was noted regarding age, presence of craniofacial dysmorphism and surgical approach. The use of simple graft (temporal muscle fascia or tragus perichondrium) was significantly superior in primary surgery (p

Improving the shape and contour of the nasal tip is a major goal in rhinoplasty. Extreme bulbosity and parenthesis deformity of the nasal tip are both frequently encountered. However, the underlying anatomical features that cause this kind of tip deformity are still not fully understood. To evaluate the relation between the shape of the nasal tip and the anatomical position, orientation and shape of the lateral crura of the lower lateral cartilages and to estimate the incidence of cephalic malposition of lateral crura in Caucasian noses. Nineteen Caucasian cadaver noses were studied, and the alar cartilages were measured and evaluated using a standardized method. Fourteen of the total 38 lateral crura evaluated had cephalic malposition (long axis angle with the midline equal to or less than 30°). Of the nasal tips classified as having parenthesis deformity, 84.6% had cephalic malposition of lateral crura and 46.2% had convex lateral crura. Vertical orientation of the short axis of the lateral crura was no more common in noses with parenthesis deformity of the nasal tip than in other kinds of nasal tip. The incidence of cephalic malposition of the lateral crura in this series of Caucasian noses was 36.8%. There was a statistically significant association between parenthesis deformity of the nasal tip and cephalic malposition of the lateral crura, as well as with convex shape of the lateral crura. No statistically significant association was found between the sagittal angle of the lateral crura and the type of nasal tip. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Introduction: Inverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging. Objective: This study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches. Methods: Retrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p < 0.05 were considered statistically significant. Results: Thirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p = 0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%). Conclusion: Endoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas. Resumo Introdução: Os papilomas invertidos são uma das lesões neoplásicas benignas mais comuns no trato nasossinusal. Devido ao seu comportamento localmente agressivo, tendência para recidivar e potencial de malignização, o tratamento cirúrgico dos papilomas invertidos constitui frequentemente um desafio. Objetivo: Analisar os resultados cirúrgicos dos papilomas invertidos segundo o estadiamento de Krouse, bem como avaliar as diferentes abordagens cirúrgicas. Método: Estudo retrospectivo de pacientes com diagnóstico de papiloma invertido nasossinusal submetidos a tratamento cirúrgico entre 2000 e 2016 em hospital terciário. Casos com acompanhamento inferior a 12 meses foram excluídos. A taxa e o tempo de recidiva foram os principais resultados analisados desfechos avaliados. Valores p < 0,05 foram considerados estatisticamente significativos. Resultados: Foram incluídos 36 casos, com média de idade de 60 anos, predominantemente do sexo masculino (72%). O período de acompanhamento variou de 1 a 16 anos, em uma média de 4,5 anos. Relativamente ao estadiamento, 11,1% dos pacientes foram classificados como estadio Krouse T1, 50% como T2, 30,6% como T3 e 8,3% como T4. A maioria dos casos foi tratada exclusivamente por cirurgia endoscópica (83,3%), com taxa de recidiva de 13,3%. Pacientes tratados com uma técnica combinada ou aberta apresentaram recidiva de 16,7%. Não foram observadas diferenças quanto à taxa de recidiva entre os casos abordados por via endoscópica e os casos tratados com técnica aberta ou combinada. Verificou-se uma associação significativa entre o estadio T3 de Krouse e recidiva de papilomas invertidos (p = 0,023). Todas as recidivas de papilomas invertidos foram observadas até dois anos após a cirurgia. Um caso de transformação maligna foi registrado (2,7%). Conclusão: A cirurgia endoscópica não aumentou as taxas de recidiva e pode ser uma alternativa segura e eficiente às técnicas abertas ou combinadas. Os casos de recidiva do papiloma invertido parecem estar relacionados com a persistência da doença e tendem a ocorrer precocemente após a cirurgia primária. Os estadios T3 de Krouse podem estar associados a uma maior recidiva.

Purpose Platinum-derived chemotherapy is one of the cornerstones in the treatment of central nervous system tumors in children. We aimed to assess the incidence of hearing loss in children after the exposure to platinum drugs. Material and methods Retrospective study of prospectively collected data on children consecutively diagnosed with brain tumors and treated with platinum derivatives at a tertiary referral hospital between January 2006 and December 2015. We analyzed multiples variables, such as: age at diagnosis, tumor location, hydrocephalus, platinum drug type, radiotherapy, and follow-up time. The final sample size was 51 patients. Results The median age at diagnosis was 6 years. The median overall follow-up time was 75 months. The incidence of ototoxicity was 23.5%. Rates of hearing loss with carboplatinum were lower than with cisplatinum. A statistically significant association occurred between the presence of hydrocephalus, radiotherapy exposure, infratentorial tumor location, and ototoxicity after treatment with platinum derivatives. Conclusions Childhood central nervous system tumors nowadays exhibit improved cure and survival rates. However, the ototoxicity resulting from the chemotherapy treatment may accompany patients for the rest of their lives. This study reveals that this occurrence is not negligible, and the association of radiotherapy and the presence of hydrocephalus can be potentiating factors.

Introduction Acute rhinosinusitis accounts for most of the cases of orbital infections and is the most common cause of periorbital oedema in children. Up to 10% of patients with orbital complications of acute rhinosinusitis may experience vision loss and other complications such as meningitis, intracranial abscess or even death. Therefore, these patients require prompt diagnosis and proper treatment. Objectives This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population. Materials and methods A retrospective medical chart review of all children aged under 18 years old who were diagnosed with post-septal orbital complications of acute rhinosinusitis at a tertiary academic hospital, between 01/2007 and 12/2020. Patients were grouped according to the Chandler Classification (groups 2–5). Results Fifty-five children (mean age of 6.91 ± 4.61 years) fulfilled the entry criteria for post-septal orbital complications of acute rhinosinusitis, based on clinical evaluation by an otorhinolaryngologist and CT-scan findings. Forty (72.72%) patients were also evaluated by an ophthalmologist. Most patients were male (76.36%). Twenty-four patients had post-septal cellulitis (43.63%), 21 patients had a subperiosteal abscess (38.18%) and 10 patients had an orbital abscess (18.18%). Eyelid swelling was the most frequent sign, followed by fever. Microbiology varied considerably and gram-positive agents were clearly predominant. Eighteen (32.73%) patients had been treated with oral antibiotics prior to hospital admission, exhibiting a significantly higher risk of recurrence of orbital infection (p = 0.020). Ethmoid and maxillary sinuses were the most involved paranasal sinuses (90.91%). Thirty-three patients (60%) were successfully treated medically, and 22 patients (40%) required surgical drainage. Seven patients (12.73%) developed further complications and six recovered without sequelae. The mean length of hospital stay was 8.0 ± 5.0 days and recurrence of orbital infection occurred in six patients (10.91%). The absolute neutrophil blood count was significantly different amongst Chandler groups (p = 0.021), with higher counts in patients with subperiosteal abscess. The duration of hospitalization was significantly higher in patients submitted to surgery (p Conclusion Post-septal orbital complications of acute rhinosinusitis are infrequent but dangerous events in the paediatric population. Close collaboration with Ophtalmology is paramount, as the child's vision is at risk. Eyelid swelling and proptosis are early signs. CT-scan imaging plays an invaluable role in the diagnosis and decision-making. Predictive indicators for surgery were not found. However, emergency endoscopic nasal surgery with abscess drainage should be considered whenever vision is at risk, if there is no improvement after aggressive medical treatment, and in cases of intracranial complications.

Objectives The aim of this study was to compare thermal injury and depth of necrosis of using different monopolar power settings in partial tonsillectomy and correlate the results with the postoperative pain score. Results The study included a total of 15 patients with mean of age of 5.7 ± 2.57 years. The mean depth of injury was significantly higher for the 25 W side (0.973 ± 0.613) versus the 15 W side (0.553 ± 0.218) (p = 0.023). The postoperative pain score showed no significant differences between both sides. Conclusion The histopathologic depth of thermal injury is significantly higher with the 25 W monopolar microdissection in comparison to the 15 W; however, it does not seem to correlate with the postoperative pain level. Apparently, power settings of 25 W can be safely used for pediatric intracapsular tonsillectomies, without added postoperative morbidity despite the deeper tissue injury observed in the tonsil.

Objectives Management of otogenic cerebral venous thrombosis (OCVT) is controversial. Despite the modern antibiotic era OCVT still represents a potential life-threatening condition. This study aims to report the clinical presentation and management in a series of children with OCTV. The coexisting intracranial complications (ICC), the extent of the surgical treatment and the role of hypocoagulation were the analysed outcomes. Material and Methods Retrospective chart review of patients aged less than 16 years and consecutively treated for OCVT at a tertiary university hospital between January 2007 and March 2015. Results Sixteen children with ages ranging between 25 months and 16 years (9 girls/7 boys) with OCVT were identified. Acute otitis media was the causative factor in the majority of cases (n = 13). The remaining cases resulted from chronic otitis media with cholesteatoma (COMC). Eleven patients were under antibiotic therapy prior to admission. Other ICC were simultaneously present: intracranial abscess (n = 6); otitic hydrocephalus (n = 3); and meningitis (n = 1). Thrombus extension correlated with the presence of additional ICC (p = 0.035). Treatment in all cases comprised of broad-spectrum antibiotics, mastoidectomy, and long-range hypocoagulation with warfarin. Transtympanic ventilation tubes were inserted in all cases but one with COMC. Perioperative sigmoid sinus exposure was performed in seven patients, with drainage of perisinus empyema in three cases. Five children underwent simultaneous craniotomy for intracranial abscess drainage. Follow-up imaging performed in 12 cases revealed partial or complete recanalization in three and seven cases, respectively. After a mean hypocoagulation duration of nine months, no hemorrhagic or major neurologic complications were observed. Conclusions The clinical course of OCVT can be masked by previous antibiotic therapy. As such, a high suspicion index is needed for diagnosis. Simultaneous ICC appears to be more frequently found if an extensive thrombosis was present. The high recanalization rate in this series with low morbidity and no mortality can be obtained with a timely combination of antibiotics, mastoidectomy with transtympanic tube insertion and hypocoagulation. However, the decision to start hypocoagulation and its duration should be undertaken on an individual basis owing the possible adverse effects. Prospective and case-control studies are still needed to better clarify the role of the hypocoagulation treatment in OCVT.

Middle ear actinomycosis is an atypical and exceedingly rare anaerobic infection. The authors report a case of a 7-year-old girl with persistent right side otalgia, conductive hearing loss, and headache. Otoscopic findings included a thickened, intact, and bulging tympanic membrane. Computed tomography imaging revealed soft tissue density filling the middle ear with areas of bone erosion. Typical sulfur granules were found on surgical exploration. Actinomycosis was diagnosed by histopathological examination. Penicillin was prescribed for 5 weeks followed by oral amoxicillin for 6 months. Recovery was uneventful and with a 2-year follow-up, no recurrence or complications were observed.

Introduction The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition. Objective To provide recommendations for the diagnosis and management of type I laryngeal clefts. Methods Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method. Setting Multinational, multi-institutional, tertiary pediatric hospitals. Results Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts. Conclusions This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.

Objective To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia. Methods A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations. Results Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging. Conclusion Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

Objectives To provide recommendations to otolaryngologists, pulmonologists, and allied clinicians for tracheostomy decannulation in pediatric patients. Methods An iterative questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group. Results Twenty-six members completed the survey. Recommendations address patient criteria for decannulation readiness, airway evaluation prior to decannulation, decannulation protocol, and follow-up after both successful and failed decannulation. Conclusion Tracheostomy decannulation recommendations are aimed at improving patient-centered care, quality and safety in children with tracheostomies.

Introduction Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation. Objective Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy. Methods Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method. Results Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: • on a standard definition of Suprastomal Collapse • that there is clinical importance between significant and insignificant collapse • that the gold standard diagnostic modality is endoscopic examination under anesthesia • that the severity of collapse is a major determinant in the surgical approach • that surgical intervention is the first line management in combined anterior and lateral Suprastomal Collapse. Conclusion This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

Gunshot injuries to the head may result in instant death but may cause a wide range of injuries and present challenging diagnostic and management strategies. The temporal bone is involved in 20 to 50% of gunshot wounds to the head and there are scarce data regarding isolated temporal bone firearm in

Purpose To assess the parents' perspective concerning the children's clinical picture before and after supraglottoplasty for the treatment of laryngomalacia (LM). Materials and methods Retrospective study in 110 children diagnosed with LM followed at the Pediatric Otorhinolaryngology outpatient clinics of S. Joao Hospital Center, between 2008 and 2016. Children who underwent supraglottoplasty were reviewed in terms of demographics, symptoms, comorbidities, treatment and follow-up. Parents were interviewed and filled out a structured questionnaire designed to evaluate their perception of the child's clinical picture and their degree of comfort before and after surgery. Results Thirty-one children (28,2%) underwent supraglottoplasty at a median age of 6 months-old. Twelve patients had one or more medical comorbidities. Stridor was present in all children on the pre-operative period and resolved in 92,3% of the cases after supraglottoplasty; shortness of breath persisted in 3,8% in contrast to the previous 57,7%; and feeding difficulties remained in 15,4% children against the 65,4% before the procedure. Failure in thriving was also a pre-operative complaint, that recovered as reported by parents in all children after supraglottoplasty. No surgical complications were reported, and the median hospital stay was two days. In a 0 to 10 points scale, the median level of the parents' comfort with their child's clinical picture before supraglottoplasty was one point which was significantly worse than the mean level of ten points after surgery (p Conclusions In severe cases, LM can have a strong negative impact on family dynamics and functioning. In selected cases, supraglottoplasty can be a safe and effective treatment option which is associated with a high degree of parental satisfaction.

Introduction Middle ear application of gentamicin is a common medical treatment for uncontrolled Meniere’s disease. The objective of the study was to evaluate the impact of endolymphatic hydrops on inner ear delivery. Methods Perilymph gentamicin concentrations and correlation with endolymphatic hydrops in an animal model were assessed. A group of 24 guinea pigs was submitted to surgical obstruction of the endolymphatic sac and duct of the right ear. Gentamicin was applied either to the right ear’s round window niche or through a transtympanic injection. Perilymph specimens were collected at different times. Histologic morphometry was used to evaluate both turn-specific and overall hydrops degree. Results In animals with endolymphatic hydrops, lower concentrations of gentamicin were observed after 20 or 120 minutes of exposure and in both types of administration, when compared to controls. This difference reached statistical significance in the round window niche application group (Mann-Whitney, p = 0,007). A negative correlation between perilymphatic gentamicin concentration and hydrops degree could be observed in both groups, after 120 minutes of exposure (Spearman correlation, round window niche p

Portugal has one of the highest road traffic fatality rates in Europe. A clear association between sleep-disordered breathing (SDB) and traffic accidents has been previously demonstrated. This study aimed to determine prevalence of excessive daytime sleepiness (EDS) and other sleep disorder symptoms among truck drivers and to identify which individual traits and work habits are associated to increased sleepiness and accident risk. We evaluated a sample of 714 truck drivers using a questionnaire (244 face-to-face interviews, 470 self-administered) that included sociodemographic data, personal habits, previous accidents, Epworth Sleepiness Scale (ESS), and the Berlin questionnaire (BQ). Twenty percent of drivers had EDS and 29 % were at high risk for having obstructive sleep apnea syndrome (OSAS). Two hundred sixty-one drivers (36.6 %) reported near-miss accidents (42.5 % sleep related) and 264 (37.0 %), a driving accident (16.3 % sleep related). ESS score ≥11 was a risk factor for both near-miss accidents (odds ratio (OR) = 3.84, p

Objectives This study aimed to evaluate the effectiveness, according to the hearing threshold and language performance, of cochlear implants through a period of 10 or more years of follow-up. Methods A retrospective chart review was conducted. 132 patients were selected from the children's population that underwent cochlear implantation at the Department of Otorhinolaryngology, Centro Hospitalar e Universitario de Coimbra, from 1992 to 2001, with a minimum follow-up period of 10 years. A comparison of the pure-tone and speech audiometric thresholds between two periods (T0 and T1) was performed. T0 refers to the initial evaluation, immediately after the rehabilitation programme, within the first year after cochlear implantation. T1 refers to the most recent annual assessment, carried out in 2010 and 2011. Speech understanding was also evaluated through word and sentence recognition tests. Results No statistically significant differences were found between early and late assessments, in paediatric cochlear implants users, after a 10 years period of cochlear implantation. Both speech and pure-tone audiometry seem to stabilize except for 2000 Hz where the results were even better after 10 years. Factors such as age at time of implantation, duration of deafness, aetiology and exchange of the speech processor do not seem to have a role in auditory performance after a long rehabilitation period. In tests of verbal discrimination rates of words and phrases recognition were of 84.6% and 65.1%, respectively. Conclusions Cochlear implant is an effective treatment for severe to profound hearing loss in children, contributing to a hearing performance and an appropriate language acquisition, currently comparable to normal hearing children. These benefits appear to keep stable over the years. No deterioration was identified.

Objective The aim of the study was to review clinical, imagiologic, and surgical outcomes of tracheal resection in the management of laryngotracheal stenosis. Methods The study used a retrospective analysis of adult patients managed in a tertiary academic hospital who underwent thyrotracheal, cricotracheal, or tracheal end-to-end anastomosis between 1997 and 2006. Results Twelve patients, aged 15 to 79 years old, were included. Prolonged tracheal intubation was the leading cause of stenosis (11 patients) that was classified according to Myer-Cotton (Ann Otol Rhinol Laryngol. 1994;103:319–323) classification as follows: grade II (25%), grade III (58%), and grade IV (17%). The stenosis extension ranged from 1 to 6cm. Surgeries varied from tracheal end-to-end anastomosis (n = 5), cricotracheal anastomosis (n = 4), and thyrotracheal anastomosis (n = 3). Extubation was achieved in 11 patients (92%). One patient maintains a T tube stent. The most common complication was the presence of granulation tissue in the anastomosis region (33%). There was no mortality associated. Conclusions Tracheal resection with primary anastomosis appears to be a successful and safe procedure mainly due to its high decannulation rate and few complications associated.

s of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:79. 30. Penido N, Cruz OLM, Iha LCN, Abreu CEC. Outcome in labyrinthine fistula caused by pronounced cholesteatomatous COM. In: Lim DJ, Bluestone CD, Casselbrant ML, eds. Abstracts of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:183. 31. Jung TTK, John EO, Park SK, Row M. Effect of inflammatory mediators of otitis media on cochlear function. In: Lim DJ, Bluestone CD, Casselbrant ML, eds. Abstracts of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:186. 32. Casselbrant ML, Furman JM, Mandel EM, et al. The long term effect of otitis media on the vestibular system. In: Lim DJ, Bluestone CD, Casselbrant ML, eds. Abstracts of the Eighth International Symposium on Recent Advances in Otitis Media, Ft Lauderdale, Fla, 2003:202. 157 Lim, Recent Advances in Otitis Media 157

HYPOTHESIS: The present study aimed at elucidating whether there are blood vessels in the semitransparent portion of the tympanic membrane. BACKGROUND: The normal semitransparent portions of pars tensa show strikingly few, small-caliber vessels under the otomicroscope. The major portion of a pars tensa seems to be devoid of blood vessels. In inflammatory conditions of the middle ear, the vascular pattern of the tympanic membrane is dramatically altered, and blood vessels traversing the pars tensa can be discernable. METHODS: The study was performed in rats with healthy tympanic membranes and in tympanic membranes obtained from animals with purulent otitis media evoked by inoculation of Str. pneumoniae. The tympanic membrane vessels were dilated by injection of adenosin, and directly afterwards the animal was perfused with china ink. Vessels were also revealed by immunohistochemistry with antibodies for Thy-1 and the von Willebrand factor as well as by detection of carbon particles at an ultrastructural level. RESULTS: Adenosin caused a marked dilation of the mallear and annular vessels. However, no preexisting vasculature was revealed in the normally transparent portions of the pars tensa except single vessels in the posterior quadrant and in the lower quadrants. In Str. pneumoniae-induced acute otitis media, the tympanic membrane thickened, bulged, and discolored. Even then, at 12 hours after inoculation, no vessels could be distinguished in the normally transparent portions of the tympanic membrane. However, at 4 and 7 days of acute purulent otitis media, vessels developed in those areas, most probably through ingrowth of newly formed vessels. CONCLUSION: The results support the view that the semitransparent portions of the pars tensa lack vascularity. In inflammation, new vessels are formed in pars tensa to meet the demand for an increased blood supply.

Myringosclerosis, a common finding after myringotomy, has been recently associated with an increased production of oxygen free radicals. Ascorbic acid's proposed actions include collagen synthesis, antioxidation, and free radical scavenging. The effects of topical ascorbic acid on healing tympanic membranes were studied. Particular attention was given to detecting the presence of myringosclerosis. Twelve Sprague-Dawley rats were bilaterally myringotomized. Their ears were randomized into group A, which received topical ascorbic acid in Gelfoam, group B, which received topical saline solution in Gelfoam, and group C, which received no treatment. The tympanic membranes were harvested on day 13, after routine otomicroscopy. Under light microscopy, the connective tissue layer of the untouched side of the pars tensa was distinctly thicker in group A than in group B or group C. At this level, the extent of sclerotic lesions was significantly less in the ascorbic acid—treated group. It is inferred that topical ascorbic acid reduces the occurrence of myringosclerosis following tympanic membrane perforations in the rat.

Although serious complications of otitis media (OM) such as brain abscess are rare, sequelae of OM such as tympanic membrane perforation and atelectatic tympanic membrane are quite common. Inner ear sequelae can cause hearing loss and speech and language problems. The objectives of this article are to provide a state-of-the-art review on recent articles on complications and sequelae of OM in different anatomic locations, from the tympanic membrane to intracranial sites, as well as hearing loss and speech and language development.Primarily PubMed supplemented by Ovid MEDLINE and the Cochrane Database.All types of articles related to OM complications and sequelae published in English between January 2007 and June 2011 were identified. A total of 127 relevant quality articles are summarized and included in this report.Key findings are summarized based on the following major anatomic locations and categories: tympanic membrane; cholesteatoma; ossicular problems; mucosal sequelae; inner ear sequelae; speech and language development; extracranial areas, including mastoiditis and facial nerve paralysis; intracranial complications; and future research goals. New information and insights were gained to prevent complications and sequelae.Over the past 4 years, progress has been made in advancing the knowledge on the complications and sequelae of OM, which can be used to prevent and treat them effectively. Areas of potential future research have been identified and outlined.

Background and Objectives. The pathogenesis of otitis media (OM) involves a number of factors related to the anatomy, pathology, and cell biology of the middle ear, the mastoid, the Eustachian tube, and the nasopharynx. Although some issues of pathogenesis are fairly well established, others are only marginally indicated by current knowledge, and yet others remain undisclosed. The objective of this article is to provide a state-of-the-art review on recent scientific achievements in the pathogenesis of OM, as related to anatomy, pathology, and cell biology. Data Sources. PubMed, Ovid Medline, and Cochrane Library. Review Methods. Articles published on the pathogenesis of OM and the anatomy, pathology, and cell biology of the middle ear, the mastoid, the Eustachian tube, and the nasopharynx between January 2007 and June 2011 were identified. Among almost 1900 abstracts, the authors selected 130 articles for full article review and inclusion in this report. Results. New knowledge on a number of issues emerged, including cell-specific expression and function of fluid transportation and innate immune system molecules, mucous cell metaplasia, mucin expression, bacterial adherence, and epithelial internalization, as well as the occurrence, composition, dynamics, and potential role of bacterial biofilm. In addition, the potential role of gastroesophageal reflux disease and cigarette smoke exposure has been explored further. Conclusions and Implications for Practice. Over the past 4 years, considerable scientific progress has been made on the pathogenesis of OM, as related to issues of anatomy, pathology, and cell biology. Based on these new achievements and a sustained lack of essential knowledge, suggestions for future research are outlined.

The EXIT procedure (EX utero Intrapartum Treatment) encompasses a multidisciplinary approach to situations in which airway obstruction is anticipated. Uteroplacental circulation is maintained to avoid neonatal hypoxemia while intubation is attempted. Not only is it useful in congenital diaphragmatic hernia with intrauterine tracheal occlusion, but new indications have been proposed. We present two cases in which EXIT procedure was adopted (huge cervical mass with tracheal compression and a highly vascularized cephalocervical mass) for the same purpose on different grounds. Our two cases stress once more the importance of combining fetal ultrasound and magnetic resonance imaging in the characterization of cervical masses and its usefulness in programming the procedure with a multidisciplinary team.

Myringotomy (Myr) is one of the most frequently performed surgical procedures in children. However, events occurring in the early phases, i.e. a matter of hours, following Myr in the acute otitis media (AOM) model have not been described. The aim of the present study was to evaluate the early otomicroscopic and histopathologic reactions of the tympanic membrane (TM) after Myr during the course of AOM (AOM-Myr). The left tympanic bulla from 36 healthy Sprague-Dawley rats was inoculated with Streptococcus pneumoniae type 3. Forty-eight h later, at Day 0, 4 randomized animals were immediately sacrificed and the remaining animals were treated with bilateral Myr. Otomicroscopy and sacrifices were performed in series of 4 animals at 3, 6, 9, 12, 24 and 48 h, and 4 and 7 days. The AOM-Myr TMs were compared to non-infected Myr TMs (non-AOM-Myr). The TMs were then dissected free and routinely processed for light and electron microscopy. AOM developed in all inoculated ears at Day 0. In the pars tensa of the AOM-Myr TMs the reaction of the keratinocyte layer of the perforation border was already evident at 6 h. The lamina propria exhibited a strong inflammatory reaction, which became more organized from 12 h onwards. At Day 4 the perforations were closed in three-quarters of cases. At Day 7 all perforations were healed with a distorted scar. In the non-AOM Myr TMs a strong degranulation of mast cells and edema were found in the pars flaccida at 6 h. A keratin spur at the perforation border was not seen until 24 h. All perforations were patent on Day 7 and myringosclerotic deposits were abundant in these TMs. The infected TMs regenerated faster and closed their perforations at an earlier stage. These findings favor the hypothesis that there is a low risk of chronic perforations when myringotomizing AOM TMs.

Background: acute mastoiditis is the most common intratemporal complication of otitis media. Its management is still a challenge due to potentially serious consequences. This study was designed to evaluate the recent experience with pediatric acute mastoiditis at our institution and to determine if the incidence of this entity is changing over time. Material and methods: retrospective review of records of children with acute mastoiditis treated at the hospital of the Medical School at the University of Porto, Portugal, between July 1993 and June 1998. Criteria for the diagnosis of acute mastoiditis were postauricular swelling and erythema, protrusion of the auricle, and evidence of co-existent or recent otitis media. Results: 43 patients fulfilled the entry criteria. Most were boys (69%). Ages ranged from 8 months to 14 years and 4 months; infants represented 40% of the total. Acute mastoiditis was the first recognized sign of otitis media in 48% of patients. More recent years of the study saw an increase in the number of children referred with acute mastoiditis. Upon admission, 56% were under antibiotic treatment, with an average intake of 5.8 days. All patients were hospitalized; 26 cases recovered after intravenous antibiotics plus myringotomy, and the rest required an additional surgical procedure. The most common organisms recovered from cultures were Streptococcus pneumoniae and Streptococcus pyogenes. In our series, associated complications occurred in 13.9%; facial paralysis in one, and involvement of the central nervous system in five. Conclusions: pediatric acute mastoiditis continues to be a potentially dangerous infection in the antibiotic era. The incidence of this complication may be increasing recently in the community studied. Great care is required of clinicians to reach an early diagnosis in order to promote adequate management and prevent inherently severe complications.

Summary Lateropharyngeal and retropharyngeal abscesses are potentially life threatening infections in children Aim To review the etiologic, clinical, and imaging signs of lateropharyngeal and retropharyngeal abscesses in children as well as treatment-outcomes and complications using a surgical trans-oral approach. Method Retrospective analysis of 11 children, hospitalized in the last 5 years, with a diagnosis of lateropharyngeal (n = 8) and retropharyngeal (n = 3) abscesses, ages ranging from 0 to 12 years old. Charts and CT scans were reviewed. Result The average age of presentation was 3.3 years. Neck stiffness (64%) and odynophagia (55%) were the most common symptoms. Fever (64%), stiff neck (64%), bulging of the oropharyngeal wall (55%), mass in the neck (55%) and lymphadenopathy (36%) were the most prevalent physical findings. All these patients were submitted to surgical drainage using a trans-oral approach in the first 48 hours after admission. About 82% of the patients showed improvement after 48 hours, and 100% after 72 hours, without any complications. Conclusion Based on the good clinical outcomes and low incidence of complications, the present study suggests that antibiotic therapy complemented with a timely surgical treatment, is a valid treatment option in refractory parapharyngeal abscesses.

The aim of this study was to analyse the epidemiology, clinical presentation, diagnostic clues, as biochemical parameters and imaging studies, of children with acute neck infections (ANI) to identify possible independent prognostic factors leading to complications and prolonged hospitalization.Records of children admitted to a tertiary university hospital from January 2008 to December 2014 with a diagnosis of ANIs were reviewed retrospectively. Diseases were categorized according to the site of infection and patients were divided into two groups: children (aged10 years) and adolescents (aged 10-18 years).A total of 102 patients belonged to the children's group and 57 were adolescents. Forty-nine patients (27.2%) received antibiotics prior to presentation. The most frequent ANI was peritonsillar abscess (n = 72). Four peritonsillar abscesses progressed to parapharyngeal and retropharyngeal abscesses (n = 2 respectively). An association between age and type of abscess was found, with most of the retropharyngeal abscesses occurring in children (p = 0.05), and the submandibular abscesses in adolescents (p 0.001). The most frequent symptoms/signs were fever (63.9%) and odynophagia (50.6%). Upon admission, all patients received intravenous antibiotics and 86.8% underwent drainage of the abscess. Cultures were harvested in 87 abscesses and the most frequent pathogen isolated was Streptococcus pyogenes. Signs of airway obstruction occurred in two patients with submandibular abscess, one with peritonsillar and one with parapharyngeal abscess. There were no cases of death or severe sequelae. Recurrent ANIs were observed in eight patients including two infected branchial cysts. Children, presence of multiple abscesses and palpable cervical mass on admission, absence of odynophagia and pharyngeal bulging, surgery with general anaesthesia and surgery after 24 h, were associated with prolonged hospitalization. Presence of toothache and neck pain on admission were identified as predictors of complications.The present study found, that often, the diagnosis and treatment of neck abscesses in paediatric patients is not straightforward, but can achieve a favourable outcome. The primary location of the ANI appears to vary in different paediatric age groups. Younger age, presence of multiple abscesses or a palpable cervical mass on admission, were associated with prolonged hospitalization. Presence of toothache and neck pain on admission was identified as possible predictors of complications.