Diseases of the salivary glands in infants and adolescents

Maik Ellies, Rainer Laskawi

Abstract
Background: Diseases of the salivary glands are rare in infants and children (with the exception of diseases such as parotitis epidemica and cytomegaly) and the therapeutic regimen differs from that in adults. It is therefore all the more important to gain exact and extensive insight into general and special aspects of pathological changes of the salivary glands in these age groups. Etiology and pathogenesis of these entities is still not yet fully known for the age group in question so that general rules for treatment, based on clinical experience, cannot be given, particularly in view of the small number of cases of the different diseases. Swellings of the salivary glands may be caused by acute and chronic inflammatory processes, by autoimmune diseases, by duct translocation due to sialolithiasis, and by tumors of varying dignity. Clinical examination and diagnosis has also to differentiate between salivary gland cysts and inflammation or tumors.

Conclusion: Salivary gland diseases are rare in childhood and adolescence. Their pattern of incidence differs very much from that of adults. Acute and chronic sialadenitis not responding to conservative treatment requires an appropriate surgical approach. The rareness of salivary gland tumors is particularly true for the malignant parotid tumors which are more frequent in juvenile patients, a fact that has to be considered in diagnosis and therapy.

Introduction
Diseases of the salivary glands are rare in infants and children (with the exception of diseases such as parotitis epidemica and cytomegaly) and the therapeutic regimen differs from that in adults. It is therefore all the more important to gain exact and extensive insight into general and special aspects of pathological changes of the salivary glands in these age groups. Previous studies have dealt with the clinical distribution pattern of the various pathological entities in infants and older children.

According to these studies, important pathologies in these age groups are acute and chronic sialadenitis (with special regard to chronic recurrent parotitis) and secondary inflammation associated with sialolithiasis. The etiology and pathogenesis of these entities in young patients, however, are still not yet sufficiently understood, so that therapeutic strategies based on extensive clinical experience cannot be defined, particularly in view of the small number of patients in the relevant age groups. The acute forms of sialadenitis are mainly caused by viral or bacterial infections. The predominant cause of parotid swelling in infancy is parotitis epidemica.

This disease has its peak incidence between the ages of 2 and 14. Acute inflammation of the parotid gland, with evidence of Staphylococcus aureus, is often seen in neonates and in children with an underlying systemic disease accompanied by fever, dehydration, immunosuppression and general morbidity. Acute inflammation of the submandibular gland, as opposed to that of the parotid is usually due to a congenital anomaly of a salivary duct or an excretory duct obstruction. Reports on sialolithiasis in infants and adolescents, however, are very scarce and are mostly presented as rarities in clinical case reports. For chronic sialadenitis the predominant etiological factors are secretion disorders and immunological reactions. The pathogenesis of chronic recurrent parotitis has still not been completely elucidated and is, next to mumps, the most frequent sialadenitis in infancy.

Neoplastic changes are very rare in children and adolescents, compared to salivary gland inflammations. Their annual incidence in all juvenile age groups is 1 to 2 tumor cases in 100,000 persons. According to Eneroth salivary gland tumors make up 0.3% of all human tumors, and less than 10% of all juvenile head and neck tumors are located in the salivary glands. Only 1% of all head and neck tumors originate in the salivary glands, regardless of patient age. Not only makes this low incidence the establishment of a generally applicable therapeutic regime difficult; this task is not made easier by the circumstance that not more than 5% of all salivary gland tumors are found in the age group of up to 16 years. As a consequence therapies very often lean on experience gained in the last decades from long-term studies for the treatment of adult patients. Primary dysgenetic, and secondary, acquired salivary gland cysts, and other malformations of the salivary glands have to be distinguished early and without doubt from specific benign and, above all, malignant lesions by pathohistological examination.

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Non-allergic rhinitis: a case report and review

Cyrus H Nozad, L Madison Michael, D Betty Lew, Christie F Michael

Abstract
Rhinitis is characterized by rhinorrhea, sneezing, nasal congestion, nasal itch and/or postnasal drip. Often the first step in arriving at a diagnosis is to exclude or diagnose sensitivity to inhalant allergens. Non-allergic rhinitis (NAR) comprises multiple distinct conditions that may even co-exist with allergic rhinitis (AR). They may differ in their presentation and treatment. As well, the pathogenesis of NAR is not clearly elucidated and likely varied. There are many conditions that can have similar presentations to NAR or AR, including nasal polyps, anatomical/mechanical factors, autoimmune diseases, metabolic conditions, genetic conditions and immunodeficiency.

Here we present a case of a rare condition initially diagnosed and treated as typical allergic rhinitis vs. vasomotor rhinitis, but found to be something much more serious. This case illustrates the importance of maintaining an appropriate differential diagnosis for a complaint routinely seen as mundane. The case presentation is followed by a review of the potential causes and pathogenesis of NAR.

Introduction
The term rhinitis can be used to describe many distinct entities with varying pathogeneses, despite similar presentations. Generally, rhinitis is considered allergic if significant inhalant allergy is diagnosed and is considered non-allergic when symptomatology is perennial or periodic and not IgE mediated. Thus non-allergic rhinitis (NAR) comprises a mixed bag of conditions ranging from vasomotor rhinitis (VMR) to hormonally induced rhinitis.

Overall, rhinitis results in significant cost to the world population. In 2002, the direct and indirect costs for allergic rhinitis (AR) were estimated to be $7.3 billion and $4.28 billion, respectively. Given that an estimated 1 in 3 patients with rhinitis are diagnosed with NAR, with 19 million people in the United States alone, it is reasonable to conclude that NAR also results in a significant economic burden.

NAR is a condition primarily seen in adulthood with 70% of cases developing after the age of 20. There is a greater prevalence among females compared to males, and the overall prevalence of NAR in industrialized countries has ranged from 20-40%. The following case presentation is an example of a patient with typical NAR symptoms who fits the epidemiological profile, but who presented atypically, failed to respond to standard therapy and was subsequently found to have a much more serious underlying condition.

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Acute mastoiditis: A one year study in the pediatric hospital of Cairo university

Mosaad Abdel-Aziz, Hassan El-Hoshy

Abstract
Background: Acute mastoiditis is a serious complication of acute otitis media especially in the pediatric age group. This study reports the authors experience in the treatment of children admitted with acute mastoiditis to the Pediatric Hospital of Cairo University throughout the year 2007, also we aimed to evaluate our current management of this serious disease.

Methods: Nineteen children were included in this study, 11 females and 8 males, their ages ranged from 9 months to 11 years. All children were treated with intravenous antibiotic on initial admission, myringotomy was considered for cases that did not respond to medical treatment for 48 hours, while cortical mastoidectomy (with myringotomy) was reserved for cases that presented initially with subperiosteal abscess with or without postauricular fistula, cases with intracranial complications and for cases that showed no response to myringotomy (after 48 hours). Follow up of the patients was carried out for at least 1 year.

Results: Medical management alone was enough in 5 cases (26%); all of them had erythematous tender mastoid on first presentation. Seven cases (37%) needed myringotomy; 2 of them showed no response and they needed cortical mastoidectomy and the other 5 cases responded well except for 1 case that developed post-auricular subperiosteal abscess 2 months later necessitating cortical mastoidectomy with no evidence of recurrence till the end of the follow-up period. Seven cases (37%) presented with subperiosteal abscess and they needed cortical mastoidectomy with myringotomy; they showed no recurrence till the end of the study.

Conclusion: Conservative management is an effective method in the treatment of non-complicated acute mastoiditis, but myringotomy should be considered if there is no response within 48 hours. Cortical mastoidectomy should be used in conjunction with the medical management in the treatment of complicated cases.

Background
Acute mastoiditis is a serious complication of acute otitis media (AOM). It is more common in the pediatric age group as most patients are younger than 4 years, this higher incidence in younger age group reflects the peak age for AOM, however its incidence has been decreased since the revolution of antibiotic therapy. Some recent literature indicated an increase of the disease incidence in last years especially in countries with less antibiotic prescription, while others reported that no increased incidence despite the national restriction guidelines of antibiotics prescription. The disease my cause significant and even life-threatening complications beyond the tympanomastoid system; including subperiosteal abscess, Bezolds abscess, facial paralysis, suppurative labyrinthitis, meningitis, epidural and subdural abscess, brain abscess, lateral sinus thrombophlebitis, and otitic hydrocephalus.

The treatment of acute mastoiditis is variable, ranging from conservative management in the form of parenteral antibiotic therapy to myringotomy (with or without ventilation tube placement) to a more aggressive intervention in the form of mastoidectomy. This study reports the authors experience in the treatment of children admitted with acute mastoiditis to the Pediatric Hospital of Cairo University throughout the year 2007, also we aimed to evaluate our current management of this serious disease in the pediatric population.

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Evaluation of young smokers and non-smokers with Electrogustometry and Contact Endoscopy
Pavlidis Pavlos, Nikolaidis Vasilios, Anogeianaki Antonia, Koutsonikolas Dimitrios, Kekes Georgios and Anogianakis Georgios

Abstract
Background: Smoking is the cause of inducing changes in taste functionality under conditions of chronic exposure. The objective of this study was to evaluate taste sensitivity in young smokers and non-smokers and identify any differences in the shape, density and vascularisation of the fungiform papillae (fPap) of their tongue.

Methods: Sixty-two male subjects who served in the Greek military forces were randomly chosen for this study. Thirty-four were non-smokers and 28 smokers. Smokers were chosen on the basis of their habit to hold the cigarette at the centre of their lips. Taste thresholds were measured with Electrogustometry (EGM). The morphology and density of the fungiform papillae (fPap) at the tip of the tongue were examined with Contact Endoscopy (CE).

Results: There was found statistically important difference (p < 0.05) between the taste thresholds of the two groups although not all smokers presented with elevated taste thresholds: Six of them (21%) had taste thresholds similar to those of non-smokers. Differences concerning the shape and the vessels of the fungiform papillae between the groups were also detected. Fewer and flatter fPap were found in 22 smokers (79%). Conclusion: The majority of smokers shown elevated taste thresholds in comparison to nonsmokers. Smoking is an important factor which can lead to decreased taste sensitivity. The combination of methods, such as EGM and CE, can provide useful information about the vascularisation of taste buds and their functional ability.

Background
Complete loss of taste is rather uncommon because the presence of four major afferent routes for taste provides substantial redundancy to the sensory communication for taste and a substantial back-up system in case of failure of any single nerve. There are two categories of taste measurement, whole mouth and regional tests. A preliminary evaluation of a patient suffering from taste disorders can be performed with the use of colourless solutions of sweet, bitter, sour and salt. More sophisticated is regional chemogustometry whereby chemicals are applied to part of the tongue usinga piece of filter paper or a cotton swab. Regional chemogustometry can also be performed using closed chambers cemented to the tongue.

The simplest regional test for evaluation of taste is EGM. EGM was introduced in the clinical assessment of taste sensitivity during the 1950s. Compared to tests based on chemical solutions, EGM is an efficient clinical tool, used in the evaluation of taste disorders caused by different factors such as middle-ear surgery, Bell's palsy, tumors, and tonsillectomy. Increased application of this method is due to its easiness, the short time required and its quantitative character. CE is a diagnostic technique suitable for head and neck screening. It was developed for observing cell construction in the epithelial surface. The first application of CE was in gynecology. The quality of the images and magnifications obtained with endoscopes, led to the application ofCE in otolaryngology. CE allows for both in vivo and in situ observations of pathology in the superficial layer of the tongue, nasal mucosa, vocal cords in laryngomicrosurgery and nasopharynx.

The effects of smoking on taste sensitivity and olfaction have been studied since the early 60's. However, up to day, only few experimental studies provide histological data about the effects of smoke on the size and shape of the tongue papillae. The aim of this study is to investigate if smokers and non-smokers differ in EGM thresholds on the anterior and posterior tongue and soft palate and if any observed difference, in EGM thresholds on the anterior tongue of smokers vs. non-smokers, can be attributed to a difference in the density or morphology of fungiform papillae at that site.

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Homeopathic treatment of patients with chronic sinusitis: A prospective observational study with 8 years follow-up

Claudia M Witt, Rainer Lüdtke, and Stefan N Willich

Abstract
Background: An evaluation of homeopathic treatment and the outcomes in patients suffering from sinusitis for 12 weeks in a usual care situation.

Methods: Subgroup analysis including all patients with chronic sinusitis (ICD-9: 473.9; 12 weeks duration) of a large prospective multicentre observational study population. Consecutive patients presenting for homeopathic treatment were followed-up for 2 years, and complaint severity, health-related quality of life (QoL), and medication use were regularly recorded. We also present here patient-reported health status 8 years post initial treatment.

Results: The study included 134 adults (mean age 39.8 ± 10.4 years, 76.1% women), treated by 62 physicians. Patients had suffered from chronic sinusitis for 10.7 ± 9.8 years. Almost all patients (97.0%) had previously been treated with conventional medicine. For sinusitis, effect size (effect divided by standard deviation at baseline) of complaint severity was 1.58 (95% CI 1.77; 1.40), 2.15 (2.38; 1.92), and 2.43 (2.68; 2.18) at 3, 12, and 24 months respectively. QoL improved accordingly, with SF-36 changes in physical component score 0.27 (0.15; 0.39), 0.35 (0.19; 0.52), 0.44 (0.23; 0.65) and mental component score 0.66 (0.49; 0.84), 0.71 (0.50; 0.92), 0.65 (0.39; 0.92), 0.74 (0.49; 1.00) at these points. The effects were still present after 8 years with SF-36 physical component score 0.38 (0.10; 0.65) and mental component score 0.74 (0.49; 1.00).

Conclusion: This observational study showed relevant improvements that persisted for 8 years in patients seeking homeopathic treatment because of sinusitis. The extent to which the observed effects are due to the life-style regulation and placebo or context effects associated with the treatment needs clarification in future explanatory studies.

Background
Chronic sinusitis is generally accepted to be a common illness incurring considerable costs, despite limited epidemiological data. It is defined as an inflammation of the nasal mucosa and paranasal sinuses for at least 12 weeks which may cause nasal blockage or congestion, mucous discharge, facial pain or pressure, and/or impaired smell. Polyps, which may or may not be present are increasingly recognized as part of the sinusitis pathology. Several factors have been found to contribute to the disease, namely, insufficient ciliary motility, allergy and asthma, bacterial infection, and more rarely, morphological anomalies, immune deficiencies and Samter's triad (salicylate sensitivity, asthma, nasal polyps). While the role of fungi and hormonal changes during pregnancy are unclear, it may also be an early symptom of systemic disease.

Standard treatment recommendations are to suppress the inflammatory process with corticosteroids, antibiotics may be also necessary to combat opportunistic infections, and possible underlying diseases may require their own specific medication. Saline douching can provide some symptomatic relief. Surgical intervention was found to be as effective as medical treatment, but should be reserved for refractory cases. Some complementary and alternative medical (CAM) treatments might be helpful as adjuvants. It appears that homeopaths are consulted more frequently by patients with acute and chronic sinusitis (13% of the homeopathy group vs. 7% of the conventional group in an observational comparison study), but to date no research has looked into the effects of homeopathy for chronic sinusitis.

Homeopathy is practised in many regions of the world, especially in high-income countries, where it is the most popular treatment form among the traditional, complementary, or alternative medical therapies. Homeopathic prescribing accounts for concomitant symptoms in addition to the predominant pathology, therefore the same main diagnosis may be treated with different remedies in different patients ('individualisation'). The prescribed drugs ('remedies') are under constant debate. They are produced by alternating steps of diluting and agitating a starting substance ('potentiating'). After several repetitions, dilutions beyond Avogadro's number are reached, and the probability approaches zero that even a single molecule of the starting substance
remains present in the drug. Such 'high potencies' are often used, however their effects are the subject of scientific controversy.

Apparently, the inconsistent results seen in meta-analyses of placebo-controlled trials pooling a great variety of diseases and ailments might be a consequence of trial selection. We analyzed the data from our prospective observational study, which globally evaluated details and effects under homeopathic treatment in a usual care situation (3981 patients over 8 years) with respect to diagnosis. This paper presents the 134 adults consulting a homeopathic physician because of chronic sinusitis.

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Correlating the site of tympanic membrane perforation with Hearing loss

Titus S Ibekwe, Onyekwere G Nwaorgu2 and Taiwo G Ijaduola

Abstract
Background: It is recognized that the size of tympanic membrane(TM) perforation is proportional to the magnitude of hearing loss, however, there is no clear consensus on the effect of the location (site) of the perforation on the hearing loss. Hence the study is set to investigate the relationship between the location of perforation on TM and hearing loss.

Methods: A cross-sectional prospective study of consecutive adult patients with perforated TM
conducted in the ENT clinic of University College Hospital Ibadan between January 1st 2005 and July 31st 2006. Instruments used for data collection/processing include questionnaires, video and micro-otoscopy, Pure tone audiometer, image J and SPSS packages.

Results: Sixty-two patients (22-males, 40-females), aged 1675 years (mean = 35.4 +/- 4) with 77 perforated ear drums were studied and 15(24.2%) had bilateral TM perforations, 21 (33.9%) right unilateral and 26(41.9%) left unilateral. The locations of the TM perforations were 60(77.9%) central, 6 (9.6%) antero-inferior, 4(5.2%) postero-inferior, 4(5.2%) antero-superior and 3(3.9%) postero-superior respectively with sizes ranging from 1.51%89.05%, and corresponding hearing levels 30 dB 80 dB (59% conductive and 41% mixed). Fifty-nine percent had pure conductive hearing loss and the rest mixed. Hearing losses (dBHL) increased with the size of perforations (P = 0.01, r = 0.05). Correlation of location of perforations with magnitude of hearing loss in acute TM perorations was (P = 0.244, r = 0.273) and for chronic perforations (p = 0.047 & r = 0.31).

Conclusion: The location of perforation on the tympanic membrane (TM) has no effect on the magnitude of hearing loss in acute TM perforations while it is significant in chronic ones.

Background
Apart from conduction of sound waves across the middle ear, the tympanic membrane, also sub-serves a protective function tothe middle ear cleft and round window niche. Intact tympanic membrane protects the middle ear cleft from infections and shields the round window from direct
sound waves which is referred to as 'round window baffle'. This shield is necessary to create a phase differential so that the sound wave does not impact on the oval and round windows simultaneously. This would dampen the flow of sound energy being transmitted in a unilateral direction from the oval window through the perilymph. It has been found that the effect of the enhanced ratio of the surface area of the tympanic membrane to that of the oval window increases the sound pressure by about 27 decibel (dB) whereas the lever action of ossicles contributes about 3 decibel (dB).

A perforation on the tympanic membrane reduces the surface area of the membrane available for sound pressure transmission and allows sound to pass directly into the middle ear. As a result, the pressure gradient between the 'inner' and 'outer' surfaces of the membrane virtually becomes insignificant. The effectiveness with which the tympanic membrane transmits motion to the ossicular chain is thus impaired along with the level of hearing. It has been established that the larger the perforation on the tympanic membrane, the greater the decibel loss in sound perception. A total absence of the tympanic membrane would lead to a loss in the transformer action of the middle ear. The location of the perforation is believed by some schools of thought to have a significant effect on the magnitude of hearing loss.
For instance, posterior quadrant perforations are believed to be worse than the anterior ones because of the direct exposure of the round window to sound waves and perforations at or near the site of tympanic membrane attachment to manubrium have more severe effects than those of comparable size at different sites. However, some workers believe that there is no significant effect associated with location of the perforation.This divergent opinion, informed undertaking the study, set to investigate the relationship between the location of perforation on TM and the magnitude of conductive hearing loss with a view to contributing to the body of knowledge on this subject.

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