John Manoukian - Academia.edu (original) (raw)
Papers by John Manoukian
Laryngoscope, Aug 29, 2017
Objective: To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal ... more Objective: To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal curriculum designed specifically for otolaryngology residents. Methods: Otolaryngology residents were recruited to participate in a yearly half-day ethical-legal module, the curriculum of which spanned 4 years. Each module included: three simulated scenarios, small-group multisource feedback, and large-group debriefings. Scenarios involved encounters with standardized patients. Residents' ethical-legal knowledge was assessed pre-and postmodule with multiple-choice questions, and ethical reasoning was assessed by a variety of evaluators during the simulated scenario using a locally developed assessment tool. Participants completed an exit survey at the end of each module. Results: Eighteen residents completed four modules from the academic years of 2008 to 2009 to 2011 to 2012. The first year was considered a pilot module, and data were collected for the following 3 years. Knowledge of legal issues improved significantly among residents (mean at pre 5 3.40 and post 5 4.60, P < 0.05). Residents' ethical reasoning skills also improved across years (
Journal of Otolaryngology, 2004
Objective: To evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhin... more Objective: To evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhinoscopy in assessing adenoid size and the relationship of these methods to associated symptoms and thus the severity of the disease. Methods: Children with suspected adenoid hypertrophy underwent standard lateral neck soft tissue radiographs: the percentage of airway occlusion, adenoid to nasopharynx (AN) ratio, airway to soft palate ratio, and adenoid thickness were assessed by a radiologist. The percentage of airway closure was assessed by direct fibre-optic rhinoscopy in an ear, nose, and throat clinic. Associated clinical symptoms were assessed by parents using a standardized questionnaire, evaluating the severity of symptoms (snoring, sleep apnea, mouth breathing, and otitis media) to give a total symptom score out of 16. Results: Nonparametric statistical analysis using Spearman's correlation coefficients was performed on 32 patients. There was a weak correlation, which approaches significance, between the percentage of airway occlusion assessed by fibre-optic rhinoscopy and the total symptom score (r = .344, p = .054). However, this correlation becomes significant when the frequency of otitis media is omitted (r = .367, p = .039). There was also a significant correlation between airway occlusion assessed by rhinoscopy and the percentage of airway occlusion as determined by lateral neck radiography (r = .431, p = .014). There was no correlation between any of the measurements taken by lateral soft tissue neck radiography and total symptom score. Conclusion: Dynamic video rhinoscopy is more accurate at assessing adenoid hypertrophy, and the percentage of airway occlusion, as estimated by video rhinoscopy, is better correlated to the severity of symptoms than are values obtained by lateral neck radiography. Sommaire Objectif: Evaluer l'utilité de la radiographie latérale du cou adynamique et de la vidéo-rhinoscopie dynamique pour mesurer le volume adénoidien et la relation entre ces méthodes et les symptômes et la sévérité de la maladie. Méthode: Nous avons fait passer à 32 enfants, un rayon-X standard des tissus mous du cou et un radiologiste a procédé aux mesures suivantes : le pourcentage d'occlusion des voies respiratoires, le rapport entre les adénoides et la nasopharynx (AN), le rapport entre les voies respiratoires et le palais mou et l'épaisseur des adénoides. Le pourcentage d'obstruction a aussi été évalué par rhinoscopie directe par fibre optique à la clinique externe. Finalement les parents ont évalué sur 16 la sévérité des symptômes en remplissant un questionnaire standardisé évaluant les aspects suivants : ronflement, apnée du sommeil, respiration buccale et une histoire d'otites moyennes. Résultats: Nous avons trouvé une faible corrélation (Spearman) presque significative entre la rhinosocopie par fibre optique et le score de symptômes (r = .344, p = .054). Cette corrélation devient significative quand on omet l'aspect otites moyennes (r = .367, p = .039). On note aussi une corrélation entre l'obstruction mesurée par endoscopie et celle mesurée radiologiquement (r = .431, p = .014). Nous n'avons par contre trouvé aucune corrélation entre les scores radiologiques et les symptômes. Conclusion: La rhinoscopie dynamique par fibre optique est plus précise pour évaluer l'hypertrophie adénoidienne et le pourcentage d'occlusion des voies respiratoires. Cette technique est aussi mieux corrélée avec les symptômes que ne l'est la radiographie latérale.
Journal of Otolaryngology, 2003
Nonmalignant parotid masses in children can have protean etiologies ranging from infective paroti... more Nonmalignant parotid masses in children can have protean etiologies ranging from infective parotitis to a benign neoplastic, vascular, or congenital origin. We review the 10-year experience of a tertiary care pediatric centre with respect to the surgical management of nonmalignant parotid masses. In total, 15 patients with nonmalignant masses of the parotid gland region underwent surgery. Five children were diagnosed with lymphoepithelial cyst or first branchial cleft cyst. Three children were diagnosed with parotid abscess, one of whom had atypical mycobacteria. Other diagnoses included lymphangioma (three cases), chronic inflammation (two cases), and epidermoid cyst (one case). One patient who presented with a parotid cyst was diagnosed postoperatively with plexiform neurofibroma of the facial nerve. She was the only patient with postoperative facial nerve paresis, affecting the orbital branch. Presentation and postoperative complications of these surgically managed nonmalignant parotid masses are reviewed. The history and physical examination are of the utmost importance in predicting the diagnosis, although ultrasonography and computed tomography can be useful. Fine-needle aspiration cytology was not well tolerated by children and appears of little use as the accurate diagnosis was provided by the surgical pathology specimen.
Laryngoscope, Mar 1, 2003
Objectives/Hypothesis The sinus mucosal inflammatory response in adult patients with chronic sinu... more Objectives/Hypothesis The sinus mucosal inflammatory response in adult patients with chronic sinusitis is well documented in the literature. In contrast, little is known about the pathogenesis of this condition in children. The objective of the study was to compare the inflammatory cell profile and the extent of tissue remodeling in the sinus mucosa of children and adults with chronic sinusitis.Study Design Prospective design.Methods Children (n = 7) and adult patients (n = 7) with chronic sinusitis undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no evidence of sinus disease (n = 6) were used as control subjects. Using immunohistochemical analysis, sinus mucosal specimens were assessed for the presence of T lymphocytes, eosinophils, basophils, mast cells, and neutrophils. The extent of submucosal collagen deposition was evaluated in histological sections using van Gieson stain.Results The number of T lymphocytes, eosinophils, and basophils and the amount of subepithelial collagen deposition are significantly higher in the mucosa of both adults and children with chronic sinusitis compared with normal control subjects (P <.01). The number of mast cells is significantly higher in the mucosa of children with chronic sinusitis compared with normal control subjects (P <.01). The number of eosinophils and neutrophils and the amount of subepithelial collagen deposition are significantly greater in adults compared with children with chronic sinusitis (P <.01).Conclusions The sinus mucosal inflammatory profile is similar in adults and children with chronic sinusitis. However, the degree of tissue eosinophilia and remodeling is significantly greater in adult sinus specimens when compared with those of children with chronic sinusitis.
Journal of Otolaryngology, 2004
Anesthesiology, Sep 1, 2003
Background: The aim of this study was to determine the frequency and type of respiratory complica... more Background: The aim of this study was to determine the frequency and type of respiratory complications after urgent adenotonsillectomy (study group) for comparison with a control group of children undergoing a sleep study and adenotonsillectomy for obstructive sleep apnea syndrome. A second aim was to assess risk factors predictive of respiratory complications after urgent adenotonsillectomy. Methods: The perioperative course of children who underwent adenotonsillectomy between January 1, 1999, and March 31, 2001, was reviewed. Two groups of children were identified from two different databases: the hospital database for surgical procedures (the study group) and the sleep laboratory database (the control group). The retrospective chart review focused on the preoperative status (including an evaluation for obstructive sleep apnea), anesthetic management, and need for postoperative respiratory interventions. Results: A total of 64 consecutive cases for urgent adenotonsillectomy were identified, and 54 children met the inclusion criteria. Thirty-three children (60%) had postoperative respiratory complications necessitating a medical intervention; 11 (20.3%) required a major intervention (reintubation, ventilation, and/or administration of racemic epinephrine or Ventolin), and 22 (40.7%) required a minor intervention (oxygen administration). Six children (11.1%) required reintubation in the recovery room for respiratory compromise. Risk factors for respiratory complications were an associated medical condition (odds ratio, 8.15; 95% confidence interval, 1.81-36.73) and a preoperative saturation nadir less than 80% (odds ratio, 5.54; 95% confidence interval, 1.15-26.72). Sixteen (49%) of the medical interventions were required within the first postoperative hour. Atropine administration, at induction, decreased the risk of postoperative respiratory complications (odds ratio, 0.18; 95% confidence interval, 0.11-1.050. Control group: Of 75 children who underwent a sleep study and adenotonsillectomy, 44 had sleep apnea and were admitted to hospital after elective adenotonsillectomy. Sixteen (36.4%) children had postoperative respiratory complications necessitating a medical intervention. Six percent of the children (n ؍ 3) required a major medical intervention. No child required reintubation for respiratory compromise. Conclusions: Severe obstructive sleep apnea syndrome and an associated medical condition are risk factors for postadenoton-sillectomy respiratory complications. Risk reductions strategies should focus on their assessment.
Journal of otolaryngology-head and neck surgery, Jan 28, 2019
Background: Effective communication has been linked to a reduction in adverse events and improved... more Background: Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology-Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency. Methods: For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulationbased clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts. Results: Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across postgraduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner's mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p < 0.05) as assessed by OTL-HNS staff members and peers. No significant improvement across time was found for ratings by non-medical assessors. Conclusion: Implementing an educational program focused on communication skills using a multisource assessment in various contexts has shown to be potentially effective at our institution, and resulted for yearly improvement and consolidation of performance of OTL-HNS residents as judged by faculty and residents. The inclusion of a multisource assessment in the simulation curriculum is key to allow for the representation of different perspectives on communication skills, for both the assessment and the debriefing process. Future studies are needed to explore the possibility of fully integrating this educational program into residence training in order to support deliberate communication skills teaching.
International Journal of Pediatric Otorhinolaryngology, May 1, 2015
An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The prim... more An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The primary medical issues arise from airway obstruction, feeding difficulties and poor oral development, specifically with cleft palate lateral synechia syndrome (CPLSS). Despite this, a paucity of data exists for the clinical management of intra-oral adhesions in this population. We report the cases of a father and daughter diagnosed with CPLSS who presented with respiratory and feeding difficulties at birth undergoing surgical correction. Early surgical ligation of intra-oral bands allows for a stabilization of the airway, improved feeding and oral development with a good long-term outcome.
International Journal of Pediatric Otorhinolaryngology, Apr 1, 2008
Objectives: Determine the exact incidence of pulmonary involvement in recurrent respiratory papil... more Objectives: Determine the exact incidence of pulmonary involvement in recurrent respiratory papillomatosis (RRP); explore available treatments and their effectiveness; determine the characteristics of cases that progress to lung cancer. Data sources: MEDLINE, EMBASE, and the Cochrane Library databases between 1966 and 2007; reference lists of retrieved publication. Study selection: Studies investigating recurrent respiratory papillomatosis with lung involvement. Age limited to 20 years of age to qualify for the diagnosis of juvenileonset RRP. Data extraction: Data pertaining to study design, population demographics, risk factors, site of involvement, investigation including the determination of the human papillomavirus type, treatment, and outcomes including the development of cancer. Data synthesis: No randomized control trials were retrieved. Hundred and one studies met our inclusion criteria (23 cohorts, 4 case series, 72 case reports, 2 open trials) with 161 cases of lung involvement identified. From the cohort studies we could estimate the incidence of lung involvement in RRP at 3.3%. The incidence of cancer in cases with lung involvement was 16%. We could not draw conclusions regarding treatment effectiveness in lung involvement, as that was not evaluated except in case studies. It would nevertheless appear that Interferon is not effective and the use of intravenous Cidofovir needs to be better evaluated. Conclusion: Well-designed, hypothesis-driven randomized control trials and prospective cohort studies are warranted to improve our understanding of the mechanisms underlying the development of lung involvement in RRP, the risks associated with different HPV types, the efficacy of potential therapeutic options as well as the risk of progression to cancer.
The Journal of Allergy and Clinical Immunology, 2002
The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or i... more The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations. and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. ln the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left•hand comer and continuing from left to right in equal sections with small overlaps.
International Journal of Pediatric Otorhinolaryngology, May 1, 2013
This is a case report of a 13 years old boy with a thyroid rupture secondary to a hockey stick bl... more This is a case report of a 13 years old boy with a thyroid rupture secondary to a hockey stick blunt trauma to his neck and a literature review focused on diagnosis and management. There are 14 other cases in the literature, 7 of which required surgical intervention mainly to evacuate a hematoma. The case in this review did not develop any complications. This is the first reported case in the literature of thyroid gland rupture due to a blunt trauma in a child. Patients with thyroid gland rupture should be monitored closely for developing a hematoma or thyroid storm.
The Lancet, May 1, 2004
Exposure to bacterial products in early life could protect against development of atopy. We exami... more Exposure to bacterial products in early life could protect against development of atopy. We examined the effect of bacterial lipopolysaccharide on allergic inflammation and expression of cytokines and lipopolysaccharide receptor (toll-like receptor 4 TLR4) in nasal mucosa of 15 atopic children and ten atopic adults. Explanted mucosa was cultured with allergen with or without lipopolysaccharide (0.1 mg/L) for 24 h. Immunocytochemistry and in-situ hybridisation were used to phenotype the cells and cytokines. In explants from atopic children, lipopolysaccharide prevented allergen-induced T-helper type 2 (Th2) inflammation and upregulated Th1 cytokine reactivity and expression. These effects were blocked by antibody to interleukin 10. In children but not in adults, lipopolysaccharide caused increases of three times in T-cell reactivity, five times in T-cell proliferation, and four times in expression of interleukin 10 compared with mucosa stimulated with allergen alone. This difference in response was mirrored by lipopolysaccharide-induced increases in TLR4 reactivity in children but not adults. TLR4 receptor was expressed by CD3-positive T cells, and TLR4-positive cells contained interleukin 10. Lipopolysaccharide increased expression of cells positive for both CD3 and TLR4; both TLR4 and interleukin 10; and both CD4 and CD25. Lipopolysaccharide inhibits allergic inflammation in nasal mucosa of atopic children by skewing local immune responses from Th2 to Th1 and upregulating production of interleukin 10. These effects are mediated by TLR4. Our results emphasise an important difference between adults and children in their ability to respond to bacterial products. These differences could have a role in normal maturation of the immune system.
Otolaryngology-Head and Neck Surgery, Aug 1, 1999
Scientific Posters P233 had a significant relationship with preoperative diagnosis of malignancy.... more Scientific Posters P233 had a significant relationship with preoperative diagnosis of malignancy. Likewise, hypocalcemia was related to sex and surgical procedure. Serohematoma was linked with age, and hemorrhage was associated with previous radiation of the neck.
The Journal of Allergy and Clinical Immunology, Feb 1, 2003
RATIONALE: Dendritic cells (DC) are critical to the immune response, but to be effective they mus... more RATIONALE: Dendritic cells (DC) are critical to the immune response, but to be effective they must be recruited from the bone marrow to the tissue site for encountering antigen. The migration of DC into peripheral tissues is likely mediated by CC chemokines, but the precise controls for this process still need to be defined. Here we assess the role of chemokine CCL5 (RANTES) and CCR5 (corresponding chemokine receptor) in dendritic cell homing to the lung. In particular, we compare tissue levels of DC and DC subsets recruited to the lungs of wild-type (WT) mice versus mice with targeted null mutations of the genes for CCR5 (CCR5-nuI1) or CCL5 (CCL5-null). METHODS: Lungs from WT, CCR5-nuI1, and CCL5-null mice were used to generate a single cell suspension using DNase-l, collagenase-I, and hyaluronidase. DC were identified by CD 1 lc expression and subsets were analyzed for MHC Class II, CDI lb, B220, CD4, and CD8 expression by flow cytometry. RESULTS: Lungs from WT mice contained slightly but not significantly more DC than lungs from CCR5-or CCL5-null mice (6.0-0.8%, 4.3-+ 0.2%, 4.5-1.1% of total lung ceils, respectively; n=2 per condition). Analysis of subgroup markers showed that 64-78% of DC expressed MHC II, 40-53% expressed CDI lb, 22-28% expressed B220, and 8-14% expressed CD4 or CD8 with no significant differences among lungs from WT, CCR5-, and CCL5-null mice. CONCLUSIONS: CCL5 and CCR5 are not required for homeostatic DC migration to the murine lung under basal conditions, raising the possibility that these interactions may be more relevant during inflammatory conditions.
Pediatric Research, Apr 1, 1996
Allergy & rhinology, 2016
Background: Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinge... more Background: Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinges on surrounding structures and can easily be mistaken for a neoplasm. Objective: The objective of this study was to shed light on this rare entity and report its diagnostic features and treatment outcomes. Methods: A case series conducted in a tertiary health care center. Demographic data, clinical presentation, imaging, cultures, and treatments were recorded. Operative video illustration and key images were obtained. A review of the literature was also performed. Results: A total of five cases were reviewed, four of which were concha bullosa mucoceles and one was a mucopyocele. Three of the patients had some form of previous nasal trauma. Headache and nasal obstruction were the most common symptoms with a nasal mass finding on physical examination. Computed tomography was used in all the patients, and magnetic resonance imaging was used in four of the five patients. Four patients had coexistent chronic rhinosinusitis, and three had positive bacterial cultures. All these patients were treated endoscopically either with middle turbinate marsupialization or subtotal resection. No recurrence has been noted thus far. Conclusion: Concha bullosa mucocele is a rare diagnosis. Imaging characteristics are helpful in considering the diagnosis, although surgical intervention is often necessary to confirm the diagnosis and treat concha bullosa mucocele.
International Journal of Pediatric Otorhinolaryngology, 2002
Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly ... more Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly the tongue. They have, however, been described in all areas of the body. Their presentation in the trachea is exceedingly rare, with their presence in the pediatric trachea being an even rarer occurrence. We describe a case of a granular cell tumor of the trachea in a 10-year-old boy with a dramatic, almost lethal, presentation. This is followed by a review of the literature, including pathology and treatment options.
Laryngoscope, Oct 1, 1997
To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypert... more To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypertrophy (ATH) could be treated by a short course of systemic corticosteroids, we conducted an openlabel pilot study in which standardized assessments of symptomatology, OSAS severity, and adenotonsillar size were performed before and after a 5-day course of oral prednisone, 1.1 0.1 (+ SE) mgkg per day. Outcome measures included symptom severity, adenotonsillar size, and polysomnographic measures of OSAS. Selection criteria included age from 1 to 12 years, ATH, symptomatology suggesting OSAS, an apneahypopnea index (M I) 2 3/hour, and intent to perform adenotonsillectomy. Only one of nine children showed enough improvement to avoid adenotonsillectomy. Symptomatology did not improve after corticosteroid treatment but did after removal of tonsils and adenoids. Polysomnographic indices of OSAS severity did not improve after corticosteroid treatment. After corticosteroids, tonsillar size decreased in only two patients, adenoidal size was only marginally reduced, and the size of the nasopharyngeal airway was not significantly increased. These results sug gest that a short course of prednisone is ineffective in treating pediatric OSAS caused by ATH.
Journal of Otolaryngology, 2002
Orbital complications of sinusitis are uncommon but can result in significant morbidity if not ap... more Orbital complications of sinusitis are uncommon but can result in significant morbidity if not appropriately managed. This study was conducted to evaluate the clinical presentation, diagnosis, management, and outcome of orbital complications of sinusitis in children treated at our institution over a 10-year period. The study retrospectively reviewed cases of 139 children with evidence of orbital complications of sinusitis admitted to the Montreal Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital between January 1990 and March 2000. Factors assessed included the clinical presentation, radiologic findings, management, and outcome (length of admission, complications). Complications were classified as preseptal if they did not penetrate the periorbita. Postseptal complications were defined as those penetrating the periorbita and were further subdivided into cellulitis and abscess categories. Seventy-two percent of patients presented with preseptal cellulitis, 19% with orbital cellulitis, and 9% with subperiosteal abscess. Ophthalmoplegia and proptosis at presentation were found to be predictors of postseptal disease, although computed tomography (CT) was necessary to differentiate between cellulitis and abscess. Preseptal disease resolved with antibiotics in all cases. Postseptal disease was treated medically and in some cases surgically, although surgery did not affect outcome. Preseptal complications of sinusitis can be diagnosed clinically without a CT scan and should be treated with an appropriate course of intravenous antibiotics. Postseptal complications of sinusitis can be diagnosed by the presence of ophthalmoplegia or proptosis and mandate a CT scan to differentiate abscess from orbital cellulitis. Management of these patients should include intravenous antibiotics, reserving surgery for selected cases.
Laryngoscope, Aug 29, 2017
Objective: To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal ... more Objective: To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal curriculum designed specifically for otolaryngology residents. Methods: Otolaryngology residents were recruited to participate in a yearly half-day ethical-legal module, the curriculum of which spanned 4 years. Each module included: three simulated scenarios, small-group multisource feedback, and large-group debriefings. Scenarios involved encounters with standardized patients. Residents' ethical-legal knowledge was assessed pre-and postmodule with multiple-choice questions, and ethical reasoning was assessed by a variety of evaluators during the simulated scenario using a locally developed assessment tool. Participants completed an exit survey at the end of each module. Results: Eighteen residents completed four modules from the academic years of 2008 to 2009 to 2011 to 2012. The first year was considered a pilot module, and data were collected for the following 3 years. Knowledge of legal issues improved significantly among residents (mean at pre 5 3.40 and post 5 4.60, P < 0.05). Residents' ethical reasoning skills also improved across years (
Journal of Otolaryngology, 2004
Objective: To evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhin... more Objective: To evaluate the usefulness of adynamic lateral neck radiographs and dynamic video rhinoscopy in assessing adenoid size and the relationship of these methods to associated symptoms and thus the severity of the disease. Methods: Children with suspected adenoid hypertrophy underwent standard lateral neck soft tissue radiographs: the percentage of airway occlusion, adenoid to nasopharynx (AN) ratio, airway to soft palate ratio, and adenoid thickness were assessed by a radiologist. The percentage of airway closure was assessed by direct fibre-optic rhinoscopy in an ear, nose, and throat clinic. Associated clinical symptoms were assessed by parents using a standardized questionnaire, evaluating the severity of symptoms (snoring, sleep apnea, mouth breathing, and otitis media) to give a total symptom score out of 16. Results: Nonparametric statistical analysis using Spearman's correlation coefficients was performed on 32 patients. There was a weak correlation, which approaches significance, between the percentage of airway occlusion assessed by fibre-optic rhinoscopy and the total symptom score (r = .344, p = .054). However, this correlation becomes significant when the frequency of otitis media is omitted (r = .367, p = .039). There was also a significant correlation between airway occlusion assessed by rhinoscopy and the percentage of airway occlusion as determined by lateral neck radiography (r = .431, p = .014). There was no correlation between any of the measurements taken by lateral soft tissue neck radiography and total symptom score. Conclusion: Dynamic video rhinoscopy is more accurate at assessing adenoid hypertrophy, and the percentage of airway occlusion, as estimated by video rhinoscopy, is better correlated to the severity of symptoms than are values obtained by lateral neck radiography. Sommaire Objectif: Evaluer l'utilité de la radiographie latérale du cou adynamique et de la vidéo-rhinoscopie dynamique pour mesurer le volume adénoidien et la relation entre ces méthodes et les symptômes et la sévérité de la maladie. Méthode: Nous avons fait passer à 32 enfants, un rayon-X standard des tissus mous du cou et un radiologiste a procédé aux mesures suivantes : le pourcentage d'occlusion des voies respiratoires, le rapport entre les adénoides et la nasopharynx (AN), le rapport entre les voies respiratoires et le palais mou et l'épaisseur des adénoides. Le pourcentage d'obstruction a aussi été évalué par rhinoscopie directe par fibre optique à la clinique externe. Finalement les parents ont évalué sur 16 la sévérité des symptômes en remplissant un questionnaire standardisé évaluant les aspects suivants : ronflement, apnée du sommeil, respiration buccale et une histoire d'otites moyennes. Résultats: Nous avons trouvé une faible corrélation (Spearman) presque significative entre la rhinosocopie par fibre optique et le score de symptômes (r = .344, p = .054). Cette corrélation devient significative quand on omet l'aspect otites moyennes (r = .367, p = .039). On note aussi une corrélation entre l'obstruction mesurée par endoscopie et celle mesurée radiologiquement (r = .431, p = .014). Nous n'avons par contre trouvé aucune corrélation entre les scores radiologiques et les symptômes. Conclusion: La rhinoscopie dynamique par fibre optique est plus précise pour évaluer l'hypertrophie adénoidienne et le pourcentage d'occlusion des voies respiratoires. Cette technique est aussi mieux corrélée avec les symptômes que ne l'est la radiographie latérale.
Journal of Otolaryngology, 2003
Nonmalignant parotid masses in children can have protean etiologies ranging from infective paroti... more Nonmalignant parotid masses in children can have protean etiologies ranging from infective parotitis to a benign neoplastic, vascular, or congenital origin. We review the 10-year experience of a tertiary care pediatric centre with respect to the surgical management of nonmalignant parotid masses. In total, 15 patients with nonmalignant masses of the parotid gland region underwent surgery. Five children were diagnosed with lymphoepithelial cyst or first branchial cleft cyst. Three children were diagnosed with parotid abscess, one of whom had atypical mycobacteria. Other diagnoses included lymphangioma (three cases), chronic inflammation (two cases), and epidermoid cyst (one case). One patient who presented with a parotid cyst was diagnosed postoperatively with plexiform neurofibroma of the facial nerve. She was the only patient with postoperative facial nerve paresis, affecting the orbital branch. Presentation and postoperative complications of these surgically managed nonmalignant parotid masses are reviewed. The history and physical examination are of the utmost importance in predicting the diagnosis, although ultrasonography and computed tomography can be useful. Fine-needle aspiration cytology was not well tolerated by children and appears of little use as the accurate diagnosis was provided by the surgical pathology specimen.
Laryngoscope, Mar 1, 2003
Objectives/Hypothesis The sinus mucosal inflammatory response in adult patients with chronic sinu... more Objectives/Hypothesis The sinus mucosal inflammatory response in adult patients with chronic sinusitis is well documented in the literature. In contrast, little is known about the pathogenesis of this condition in children. The objective of the study was to compare the inflammatory cell profile and the extent of tissue remodeling in the sinus mucosa of children and adults with chronic sinusitis.Study Design Prospective design.Methods Children (n = 7) and adult patients (n = 7) with chronic sinusitis undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no evidence of sinus disease (n = 6) were used as control subjects. Using immunohistochemical analysis, sinus mucosal specimens were assessed for the presence of T lymphocytes, eosinophils, basophils, mast cells, and neutrophils. The extent of submucosal collagen deposition was evaluated in histological sections using van Gieson stain.Results The number of T lymphocytes, eosinophils, and basophils and the amount of subepithelial collagen deposition are significantly higher in the mucosa of both adults and children with chronic sinusitis compared with normal control subjects (P <.01). The number of mast cells is significantly higher in the mucosa of children with chronic sinusitis compared with normal control subjects (P <.01). The number of eosinophils and neutrophils and the amount of subepithelial collagen deposition are significantly greater in adults compared with children with chronic sinusitis (P <.01).Conclusions The sinus mucosal inflammatory profile is similar in adults and children with chronic sinusitis. However, the degree of tissue eosinophilia and remodeling is significantly greater in adult sinus specimens when compared with those of children with chronic sinusitis.
Journal of Otolaryngology, 2004
Anesthesiology, Sep 1, 2003
Background: The aim of this study was to determine the frequency and type of respiratory complica... more Background: The aim of this study was to determine the frequency and type of respiratory complications after urgent adenotonsillectomy (study group) for comparison with a control group of children undergoing a sleep study and adenotonsillectomy for obstructive sleep apnea syndrome. A second aim was to assess risk factors predictive of respiratory complications after urgent adenotonsillectomy. Methods: The perioperative course of children who underwent adenotonsillectomy between January 1, 1999, and March 31, 2001, was reviewed. Two groups of children were identified from two different databases: the hospital database for surgical procedures (the study group) and the sleep laboratory database (the control group). The retrospective chart review focused on the preoperative status (including an evaluation for obstructive sleep apnea), anesthetic management, and need for postoperative respiratory interventions. Results: A total of 64 consecutive cases for urgent adenotonsillectomy were identified, and 54 children met the inclusion criteria. Thirty-three children (60%) had postoperative respiratory complications necessitating a medical intervention; 11 (20.3%) required a major intervention (reintubation, ventilation, and/or administration of racemic epinephrine or Ventolin), and 22 (40.7%) required a minor intervention (oxygen administration). Six children (11.1%) required reintubation in the recovery room for respiratory compromise. Risk factors for respiratory complications were an associated medical condition (odds ratio, 8.15; 95% confidence interval, 1.81-36.73) and a preoperative saturation nadir less than 80% (odds ratio, 5.54; 95% confidence interval, 1.15-26.72). Sixteen (49%) of the medical interventions were required within the first postoperative hour. Atropine administration, at induction, decreased the risk of postoperative respiratory complications (odds ratio, 0.18; 95% confidence interval, 0.11-1.050. Control group: Of 75 children who underwent a sleep study and adenotonsillectomy, 44 had sleep apnea and were admitted to hospital after elective adenotonsillectomy. Sixteen (36.4%) children had postoperative respiratory complications necessitating a medical intervention. Six percent of the children (n ؍ 3) required a major medical intervention. No child required reintubation for respiratory compromise. Conclusions: Severe obstructive sleep apnea syndrome and an associated medical condition are risk factors for postadenoton-sillectomy respiratory complications. Risk reductions strategies should focus on their assessment.
Journal of otolaryngology-head and neck surgery, Jan 28, 2019
Background: Effective communication has been linked to a reduction in adverse events and improved... more Background: Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology-Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency. Methods: For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulationbased clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts. Results: Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across postgraduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner's mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p < 0.05) as assessed by OTL-HNS staff members and peers. No significant improvement across time was found for ratings by non-medical assessors. Conclusion: Implementing an educational program focused on communication skills using a multisource assessment in various contexts has shown to be potentially effective at our institution, and resulted for yearly improvement and consolidation of performance of OTL-HNS residents as judged by faculty and residents. The inclusion of a multisource assessment in the simulation curriculum is key to allow for the representation of different perspectives on communication skills, for both the assessment and the debriefing process. Future studies are needed to explore the possibility of fully integrating this educational program into residence training in order to support deliberate communication skills teaching.
International Journal of Pediatric Otorhinolaryngology, May 1, 2015
An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The prim... more An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The primary medical issues arise from airway obstruction, feeding difficulties and poor oral development, specifically with cleft palate lateral synechia syndrome (CPLSS). Despite this, a paucity of data exists for the clinical management of intra-oral adhesions in this population. We report the cases of a father and daughter diagnosed with CPLSS who presented with respiratory and feeding difficulties at birth undergoing surgical correction. Early surgical ligation of intra-oral bands allows for a stabilization of the airway, improved feeding and oral development with a good long-term outcome.
International Journal of Pediatric Otorhinolaryngology, Apr 1, 2008
Objectives: Determine the exact incidence of pulmonary involvement in recurrent respiratory papil... more Objectives: Determine the exact incidence of pulmonary involvement in recurrent respiratory papillomatosis (RRP); explore available treatments and their effectiveness; determine the characteristics of cases that progress to lung cancer. Data sources: MEDLINE, EMBASE, and the Cochrane Library databases between 1966 and 2007; reference lists of retrieved publication. Study selection: Studies investigating recurrent respiratory papillomatosis with lung involvement. Age limited to 20 years of age to qualify for the diagnosis of juvenileonset RRP. Data extraction: Data pertaining to study design, population demographics, risk factors, site of involvement, investigation including the determination of the human papillomavirus type, treatment, and outcomes including the development of cancer. Data synthesis: No randomized control trials were retrieved. Hundred and one studies met our inclusion criteria (23 cohorts, 4 case series, 72 case reports, 2 open trials) with 161 cases of lung involvement identified. From the cohort studies we could estimate the incidence of lung involvement in RRP at 3.3%. The incidence of cancer in cases with lung involvement was 16%. We could not draw conclusions regarding treatment effectiveness in lung involvement, as that was not evaluated except in case studies. It would nevertheless appear that Interferon is not effective and the use of intravenous Cidofovir needs to be better evaluated. Conclusion: Well-designed, hypothesis-driven randomized control trials and prospective cohort studies are warranted to improve our understanding of the mechanisms underlying the development of lung involvement in RRP, the risks associated with different HPV types, the efficacy of potential therapeutic options as well as the risk of progression to cancer.
The Journal of Allergy and Clinical Immunology, 2002
The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or i... more The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations. and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. ln the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left•hand comer and continuing from left to right in equal sections with small overlaps.
International Journal of Pediatric Otorhinolaryngology, May 1, 2013
This is a case report of a 13 years old boy with a thyroid rupture secondary to a hockey stick bl... more This is a case report of a 13 years old boy with a thyroid rupture secondary to a hockey stick blunt trauma to his neck and a literature review focused on diagnosis and management. There are 14 other cases in the literature, 7 of which required surgical intervention mainly to evacuate a hematoma. The case in this review did not develop any complications. This is the first reported case in the literature of thyroid gland rupture due to a blunt trauma in a child. Patients with thyroid gland rupture should be monitored closely for developing a hematoma or thyroid storm.
The Lancet, May 1, 2004
Exposure to bacterial products in early life could protect against development of atopy. We exami... more Exposure to bacterial products in early life could protect against development of atopy. We examined the effect of bacterial lipopolysaccharide on allergic inflammation and expression of cytokines and lipopolysaccharide receptor (toll-like receptor 4 TLR4) in nasal mucosa of 15 atopic children and ten atopic adults. Explanted mucosa was cultured with allergen with or without lipopolysaccharide (0.1 mg/L) for 24 h. Immunocytochemistry and in-situ hybridisation were used to phenotype the cells and cytokines. In explants from atopic children, lipopolysaccharide prevented allergen-induced T-helper type 2 (Th2) inflammation and upregulated Th1 cytokine reactivity and expression. These effects were blocked by antibody to interleukin 10. In children but not in adults, lipopolysaccharide caused increases of three times in T-cell reactivity, five times in T-cell proliferation, and four times in expression of interleukin 10 compared with mucosa stimulated with allergen alone. This difference in response was mirrored by lipopolysaccharide-induced increases in TLR4 reactivity in children but not adults. TLR4 receptor was expressed by CD3-positive T cells, and TLR4-positive cells contained interleukin 10. Lipopolysaccharide increased expression of cells positive for both CD3 and TLR4; both TLR4 and interleukin 10; and both CD4 and CD25. Lipopolysaccharide inhibits allergic inflammation in nasal mucosa of atopic children by skewing local immune responses from Th2 to Th1 and upregulating production of interleukin 10. These effects are mediated by TLR4. Our results emphasise an important difference between adults and children in their ability to respond to bacterial products. These differences could have a role in normal maturation of the immune system.
Otolaryngology-Head and Neck Surgery, Aug 1, 1999
Scientific Posters P233 had a significant relationship with preoperative diagnosis of malignancy.... more Scientific Posters P233 had a significant relationship with preoperative diagnosis of malignancy. Likewise, hypocalcemia was related to sex and surgical procedure. Serohematoma was linked with age, and hemorrhage was associated with previous radiation of the neck.
The Journal of Allergy and Clinical Immunology, Feb 1, 2003
RATIONALE: Dendritic cells (DC) are critical to the immune response, but to be effective they mus... more RATIONALE: Dendritic cells (DC) are critical to the immune response, but to be effective they must be recruited from the bone marrow to the tissue site for encountering antigen. The migration of DC into peripheral tissues is likely mediated by CC chemokines, but the precise controls for this process still need to be defined. Here we assess the role of chemokine CCL5 (RANTES) and CCR5 (corresponding chemokine receptor) in dendritic cell homing to the lung. In particular, we compare tissue levels of DC and DC subsets recruited to the lungs of wild-type (WT) mice versus mice with targeted null mutations of the genes for CCR5 (CCR5-nuI1) or CCL5 (CCL5-null). METHODS: Lungs from WT, CCR5-nuI1, and CCL5-null mice were used to generate a single cell suspension using DNase-l, collagenase-I, and hyaluronidase. DC were identified by CD 1 lc expression and subsets were analyzed for MHC Class II, CDI lb, B220, CD4, and CD8 expression by flow cytometry. RESULTS: Lungs from WT mice contained slightly but not significantly more DC than lungs from CCR5-or CCL5-null mice (6.0-0.8%, 4.3-+ 0.2%, 4.5-1.1% of total lung ceils, respectively; n=2 per condition). Analysis of subgroup markers showed that 64-78% of DC expressed MHC II, 40-53% expressed CDI lb, 22-28% expressed B220, and 8-14% expressed CD4 or CD8 with no significant differences among lungs from WT, CCR5-, and CCL5-null mice. CONCLUSIONS: CCL5 and CCR5 are not required for homeostatic DC migration to the murine lung under basal conditions, raising the possibility that these interactions may be more relevant during inflammatory conditions.
Pediatric Research, Apr 1, 1996
Allergy & rhinology, 2016
Background: Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinge... more Background: Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinges on surrounding structures and can easily be mistaken for a neoplasm. Objective: The objective of this study was to shed light on this rare entity and report its diagnostic features and treatment outcomes. Methods: A case series conducted in a tertiary health care center. Demographic data, clinical presentation, imaging, cultures, and treatments were recorded. Operative video illustration and key images were obtained. A review of the literature was also performed. Results: A total of five cases were reviewed, four of which were concha bullosa mucoceles and one was a mucopyocele. Three of the patients had some form of previous nasal trauma. Headache and nasal obstruction were the most common symptoms with a nasal mass finding on physical examination. Computed tomography was used in all the patients, and magnetic resonance imaging was used in four of the five patients. Four patients had coexistent chronic rhinosinusitis, and three had positive bacterial cultures. All these patients were treated endoscopically either with middle turbinate marsupialization or subtotal resection. No recurrence has been noted thus far. Conclusion: Concha bullosa mucocele is a rare diagnosis. Imaging characteristics are helpful in considering the diagnosis, although surgical intervention is often necessary to confirm the diagnosis and treat concha bullosa mucocele.
International Journal of Pediatric Otorhinolaryngology, 2002
Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly ... more Granular cell tumors are benign neoplasms found most commonly in the head and neck, particularly the tongue. They have, however, been described in all areas of the body. Their presentation in the trachea is exceedingly rare, with their presence in the pediatric trachea being an even rarer occurrence. We describe a case of a granular cell tumor of the trachea in a 10-year-old boy with a dramatic, almost lethal, presentation. This is followed by a review of the literature, including pathology and treatment options.
Laryngoscope, Oct 1, 1997
To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypert... more To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypertrophy (ATH) could be treated by a short course of systemic corticosteroids, we conducted an openlabel pilot study in which standardized assessments of symptomatology, OSAS severity, and adenotonsillar size were performed before and after a 5-day course of oral prednisone, 1.1 0.1 (+ SE) mgkg per day. Outcome measures included symptom severity, adenotonsillar size, and polysomnographic measures of OSAS. Selection criteria included age from 1 to 12 years, ATH, symptomatology suggesting OSAS, an apneahypopnea index (M I) 2 3/hour, and intent to perform adenotonsillectomy. Only one of nine children showed enough improvement to avoid adenotonsillectomy. Symptomatology did not improve after corticosteroid treatment but did after removal of tonsils and adenoids. Polysomnographic indices of OSAS severity did not improve after corticosteroid treatment. After corticosteroids, tonsillar size decreased in only two patients, adenoidal size was only marginally reduced, and the size of the nasopharyngeal airway was not significantly increased. These results sug gest that a short course of prednisone is ineffective in treating pediatric OSAS caused by ATH.
Journal of Otolaryngology, 2002
Orbital complications of sinusitis are uncommon but can result in significant morbidity if not ap... more Orbital complications of sinusitis are uncommon but can result in significant morbidity if not appropriately managed. This study was conducted to evaluate the clinical presentation, diagnosis, management, and outcome of orbital complications of sinusitis in children treated at our institution over a 10-year period. The study retrospectively reviewed cases of 139 children with evidence of orbital complications of sinusitis admitted to the Montreal Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital between January 1990 and March 2000. Factors assessed included the clinical presentation, radiologic findings, management, and outcome (length of admission, complications). Complications were classified as preseptal if they did not penetrate the periorbita. Postseptal complications were defined as those penetrating the periorbita and were further subdivided into cellulitis and abscess categories. Seventy-two percent of patients presented with preseptal cellulitis, 19% with orbital cellulitis, and 9% with subperiosteal abscess. Ophthalmoplegia and proptosis at presentation were found to be predictors of postseptal disease, although computed tomography (CT) was necessary to differentiate between cellulitis and abscess. Preseptal disease resolved with antibiotics in all cases. Postseptal disease was treated medically and in some cases surgically, although surgery did not affect outcome. Preseptal complications of sinusitis can be diagnosed clinically without a CT scan and should be treated with an appropriate course of intravenous antibiotics. Postseptal complications of sinusitis can be diagnosed by the presence of ophthalmoplegia or proptosis and mandate a CT scan to differentiate abscess from orbital cellulitis. Management of these patients should include intravenous antibiotics, reserving surgery for selected cases.