Radiology quiz case 1. Cystic fibrosis.
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Cystic Fibrosis↗
Biomedical subjects
John McClay
Publications and source records attributed to John McClay.
Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children.
OBJECTIVE: To evaluate the presentations and outcomes of pediatric subperiosteal orbital abscesses (SPOA) secondary to acute sinusitis. STUDY DESIGN: Case series SETTING: Tertiary children's hospital. PATIENTS: Forty-three admissions diagnosed with SPOA by clinical presentation and contrast enhanced computed tomography (CECT) were retrospectively reviewed. MAIN OUTCOME MEASURES: Clinical presentations, CECT dimensions, treatment, outcomes, and microbiology. RESULTS: Eighteen/43 (42%) patients resolved their infection with medical management only, including five children older than nine. Twenty-five/43 (58%) children underwent surgical drainage. Purulence was identified in 22 of 25 surgical patients, and the most common organism was Streptococcus milleri (7 patients). Compared to 22 patients with drained purulence, the 18 patients with abscesses managed medically had significant differences for: chemosis in 2/18 (11.1%) versus 14/22 (63.6%, p=0.001), proptosis in 10/18 (55.6%) versus 20/22 (90.9%, p=0.025), elevated intraocular pressure (IOP) in 0/18 (0%) versus 11/22 (50%, p<0.001), severe restriction of extraocular movements in 1/18 (5.6%) versus 12/22 (54.5%, p=0.002), and length of stay (4.3 versus 5.8 days, p=0.038). The dimensions of medial SPOA managed medically were significantly smaller on CECT compared to surgically drained purulent SPOA: width (0.25 versus 1.46cm, p<0.001), height (0.73 versus 1.35cm, p=0.002), and length (1.1 versus 1.86cm, p=0.004). Persistent morbidities occurred in no patients managed medically and in 2/25 (8%) managed surgically. CONCLUSIONS: Children with small medial SPOA without significant ocular signs may be managed medically with favorable outcomes. Proposed criteria for medical management of medial SPOA include: (1) normal vision, pupil, and retina; (2) no ophthalmoplegia; (3) IOP<20mmHg; (4) proptosis of 5mm or less; and (5) abscess width of 4mm or less. In contrast to prior series, older children with SPOA were managed successfully with medical therapy.
Abscess↗
Clinical trial of photodynamic therapy with meso-tetra (hydroxyphenyl) chlorin for respiratory papillomatosis.
OBJECTIVE: To determine the efficacy of photodynamic therapy (PDT) with meso-tetra (hydroxyphenyl) chlorin (m-THPC) photosensitizer for recurrent respiratory papillomatosis. DESIGN: Parallel-arm, randomized trial of patients requiring surgery at least 3 times yearly with single PDT 6 or 18 months after enrollment and 12-month follow-up. Disease extent was scored and papillomas were removed during direct endoscopy every 3 months after enrollment. SETTING: Tertiary medical centers. PATIENTS: Of 23 patients aged 4 to 60 years enrolled in the study, 15 patients, plus 2 in the late group without PDT owing to airway risk, completed the study. Six patients withdrew voluntarily after PDT. INTERVENTION: Intravenous administration of m-THPC 6 days before direct endoscopic PDT with 80 to 100 J of light for adults and 60 to 80 J for children. MAIN OUTCOME MEASURES: Difference in severity scores between the early and late groups and between pre- and post-PDT scores for all patients. Secondary measures were the associations between baseline characteristics and response and changes in immune response and the prevalence of latent viral DNA. RESULTS: There were significant differences between groups, with marked improvement in laryngeal disease across time after PDT (P = .006). Five of 15 patients were in remission 12 to 15 months after treatment, but there was recurrence of disease after 3 to 5 years. Tracheal disease was not responsive to PDT. No change occurred in the prevalence of latent human papillomavirus DNA. The immune response to virus improved with clinical response. CONCLUSIONS: Use of m-THPC PDT reduces the severity of laryngeal papillomas, possibly through an improved immune response. Failure to maintain remission with time suggests that this is not an optimal treatment.
Adolescent↗
Complications of acute sinusitis in children.
OBJECTIVE: To review the demographic, microbiologic, and outcome data for children with complications of acute sinusitis. STUDY DESIGN AND SETTING: Retrospective review of children admitted with complications of acute sinusitis from January 1995 to July 2002 to a tertiary care children's hospital. RESULTS: One hundred four patients were reviewed with the following complications: orbital cellulitis (51), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis (1), and Pott's puffy tumors (3). Sixty-six percent were males (P < 0.001), and 64.4% presented from November to March (P < 0.001). Patients with isolated orbital complications were younger than patients with intracranial complications (mean, 6.5 versus 12.3 years), had a shorter stay (mean, 4.2 versus 16.6 days), and had shorter duration of symptoms (mean, 5.4 versus 14.3 days; all P < 0.0001). Complete resolution was documented for 54/55 patients with restricted ocular motility, 7/8 with visual loss, 3/3 patients with a nonreactive pupil, 7/7 with neurological deficits, and 2/4 with seizures. The most common organism isolated was Streptococcus milleri (11/36 patients with surgical cultures). No mortalities occurred, and persistent morbidity occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits on presentation, permanent morbidity was low. Streptococcus milleri is a common pathogen with complications of sinusitis in children.
Acute Disease↗
HspE7 treatment of pediatric recurrent respiratory papillomatosis: final results of an open-label trial.
OBJECTIVES: We sought to evaluate the effectiveness of HspE7, a recombinant fusion protein of Hsp65 from Mycobacterium bovis BCG and E7 protein from human papillomavirus 16, to improve the clinical course of pediatric patients with recurrent respiratory papillomatosis. METHODS: An open-label, single-arm intervention study was conducted in 8 university-affiliated medical centers. Twenty-seven male and female patients with recurrent respiratory papillomatosis, ages 2 to 18 years, were enrolled and followed up to 60 weeks. Before enrollment, these patients required surgery on average every 55 days. After a baseline debulking surgery, the patients received HspE7 500 microg subcutaneously monthly, for 3 doses over 60 days. The primary end point was the length of the interval from the last surgery during the treatment period until the first debulking surgery in the posttreatment period, compared with the median intersurgical interval (ISI) of the 4 surgeries before the treatment. RESULTS: The mean of the first posttreatment ISI increased 93% (from 55 days to 106 days; p < .02). The median ISI for all surgeries after treatment was similarly prolonged (mean, 107 days; p < .02), indicating a sustained treatment effect, and was associated with a significant decrease in the number of required surgeries (p < .003). Unexpectedly, the treatment effect was most striking in the 13 female patients, who had statistically significant increases in both the first posttreatment ISI (142%; p < .03) and the median ISI (147%; p < .03). The most common adverse events were mild-to-moderate injection site reactions. CONCLUSIONS: Treatment with HspE7 appears to significantly improve the clinical course in pediatric patients with RRP insofar as it reduces the frequency of required surgeries. These results warrant a confirmatory phase III trial.
Adolescent↗
Endoscopic cauterization of fourth branchial cleft sinus tracts.
OBJECTIVE: To evaluate the effectiveness of endoscopic cauterization as definitive treatment for fourth branchial cleft sinuses. DESIGN: Retrospective chart review with follow-up questionnaire. SETTING: Tertiary care children's hospital. PATIENTS: Ten children (age range, 10 months to 10 years) with fourth branchial cleft sinuses treated with endoscopic cauterization between 1995 and 2002. MAIN OUTCOME MEASURE: Recurrence of neck infections after endoscopic cauterization of fourth brachial cleft sinus tracts. RESULTS: Seven of the 10 patients treated with endoscopic cauterization of the fourth branchial cleft sinuses showed no recurrence with an average follow-up of 3 years. Three of the patients were unavailable for follow-up, but medical records of the hospital showed no additional admissions for those patients for neck masses. No morbidity of the procedure was identified. All patients were discharged the day of surgery. CONCLUSIONS: Endoscopic cauterization of fourth branchial cleft sinuses appears to be an effective alternative to open excision.
Branchial Region↗
Airway foreign body.
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Airway Obstruction↗