[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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  Patients with Townes-Brocks syndrome (TBS) exhibit polydactyl, atresia ani and a variety of ear anomalies including congenital external ear atresia and profound hearing impairment. We reported a case of TBS that demonstrated profound hearing impairment due to inner ear malformation. A cochlear implant was chosen as a hearing device for this patient. Three dimensional re-construction imaging was useful for preoperative planning of the cochlear implant.

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  A 7-year-old girl suffering from fever and swelling of the anterior neck was referred to our hospital. The patient was admitted and was diagnosed with purulent thyroiditis. She was administered antibiotics intravenously and thyroiditis was cured. Barium meal roentgenogram demonstrated left-sided pyriform sinus fistula. The pyriform sinus fistula was supposed to be the route of infection in this case. Two months later, she developed thyroiditis again. The patient and her parents decided that she should undergo surgery.
  During the operation, initially, direct esophagoscopy was conducted. The orifice of the pyriform sinus fistula could be identified in the apex of the pyriform sinus. Dye was instilled in the pyriform sinus fistula. This method enabled us to distinguish the pyriform sinus fistula from surrounding tissues without any difficulty in the operating field. We conducted only a fistelectomy without thyroidectomy. The postoperative course was uneventful and she has shown no recurrence. This method is supposed to be very effective to identify a pyriform sinus fistula.

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  Drug sensitivity and the resistance rate (drug susceptibility and gene analysis) were investigated in 5,720 strains of Streptococcus pneumoniae detected in the nasopharynx of children with upper airway infection who visited our hospital between 2003 and 2007. Changes in penicillin G sensitivity of S. pneumoniae showed biphasic peaks every year, but the peaks in 2003 to 2005 were 0.12 and 2.0 μg/ml, while those in 2006 and 2007 were 0.06 and 2.0 μg/ml, showing a change. Regarding the resistance rate presented as rates of PSSP, PISP, and PRSP, the rate of PRSP exceeded 50% in 2003, but decreased to about 37% in 2007, while the rate of PSSP was lower than 10% in 2003, but exceeded 25% in 2007. The reduction of the rate of RPSP and increase in the rate of PSSP were marked after, compared to those before 2006. The combined rate of conversion to resistance of PRSP and PISP exceeded 90% in 2003, but decreased to slightly below 75% in 2007. On investigation of pbp gene mutation, strains showing mutation of all pbp1a, 2b, and 2x genes (gPRSP) were the most frequently detected, accounting for about 60%. However, the rate decreased with time from nearly 70% in 2003 to below 60% in 2007. Strains with mutations of pbp2x, pbp1a+2x, and pbp2b+2x accounted for about 10%, respectively. Almost all strains exhibited pbp gene mutation (gPSSP) in 2003, but the rate of strains without this mutation increased to nearly 10% in 2007. Changes in erythromycin sensitivity showed biphasic peaks every year. One peak was lower than 0.12 μg/ml, and the other was higher than 2.0 μg/ml. The rate of strains with a less than 0.12 μg/ml sensitivity tended to decrease, while that of strains with sensitivity higher than 2.0 μg/ml tended to increase. Regarding the resistance rate, the rates of erythromycin susceptible S. pneumoniae (EMSSP), erythromycin-intermediate resistant S. pneumoniae (EMISP), and erythromycin resistant S. pneumoniae (EMRSP) did not change in any year, and EMSSP accounted for about 13%, EMISP for about 2%, and EMRSP for about 85%. On the detection of macrolide resistance genes, mefA and ermB, strains with only ermB were the most frequently detected, accounting for about 40–50%, in all years, those with mefA alone accounted for about 30%, those with neither gene accounted for 10–15%, and those with both mefA and ermB accounted for about 5–15%. The rate of strains with neither gene did not change, but those with mefA alone decreased with time, and those with ermB alone and both mefA and ermB increased.

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  We examined six ears of six patients who had a congenital middle ear cholesteatoma that was removed by myringotomy. All cases had a relatively small cholesteatoma located on the antero-superior quadrant (ASQ-type). Computerized tomography showed that the cholesteatomas were about 3 mm in diameter in all cases. We had removed the cholesteatoma by myringotomy. Only one case has recurred, but five cases are currently doing well without evidence of recurrence.
  Myringotomy is moderately invasive and an excellent method for removal of a small congenital middle ear cholesteatoma of the ASQ-type.

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  We report three cases of pediatric chronic sinusitis, two involving chronic cough and one otitis media with effusion, for which medical interventions were not effective. X-ray and MRI were used to diagnose these cases as chronic sinusitis. Symptoms of chronic sinusitis disappeared as the result of several maxillary antral irrigation treatments administered via the natural ostium using a Killian-Kubo cannula. This therapeutic method is not invasive for children, making iterative operations possible. We recommend that this no-longer-utilized method undergo re-evaluation as a future treatment for childhood sinusitis.

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  A simplified test for exploring the cause of delayed development of speech and language in children 3–5 years of age was developed in my clinic. The test consists of four subtests: a test that requires a child to name six pictures including a cat, pigeon, goldfish, watermelon, rice bowl, and clock; a test that requires a child to point the picture corresponding to one of the six words presented with a normal voice; the same test performed with a whispered voice; and a test in understanding of questions related to the six pictures. The results obtained from 53 clinical cases demonstrated that this test can roughly classify patients into one of four groups: abnormal language development caused by psychosocial problems, delayed language development resulting from hearing impairment, central language disorders, and motor speech disturbances associated with clumsiness syndrome or neuromuscular disorders.

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  In the one-year period between June 2003 and May 2004, 1,052 infants and children under 15 years of age with acute otitis media or acute rhinosinusitis visited our hospital. From these patients, 1,322 strains of Streptococcus pneumoniae were isolated, and tested for antimicrobial susceptibility by the broth microdilution method, as well as for mutations in the penicillin-binding protein (pbp) gene and the macrolide-resistance genes by PCR. According to the CLSI guidelines, 145 (11.0%), 544 (41.1%), and 633 (47.9%) strains were classified as PSSP, PISP, and PRSP, respectively, and 59 (4.5%), 391 (29.6%), and 872 (65.9%) strains were classified as gPSSP, gPISP, and gPRSP, respectively. We identified the macrolide-resistance genes mefA and ermB in 447 (33.8%) and 593 (44.9%) strains, respectively, both genes in 97 strains (7.3%), and neither of them in 185 strains (14.0%). The number of pbp gene mutations increased with the percentage of strains with mutations in macrolide-resistance genes. In terms of MIC90, MERP and VCM (0.5 μg/mL) were most active, followed by CTX, CDTR, and LVFX (1.0 μg/mL), then by PCG, CFPM, CZOP, and CVA/AMPC (2.0 μg/mL). The MIC90s of other antimicrobials were all 4.0 μg/mL, indicating the emergence of significant resistance mutations. The relationships between pbp gene mutations and drug susceptibility in terms of MIC90s were as follows. The MIC90 of PCG for gPSSP was 0.12 μg/mL, that for gPISP ranged from 0.12 μg/mL to 2.0 μg/mL according to the number of pbp gene mutations, and that for gPRSP was 4.0 μg/mL, indicating that a greater number of pbp gene mutations are associated with a higher value of MIC90. The MIC values of other β–lactam antibiotics showed similar tendencies. The MIC90 of CAM for strains with no macrolide−resistance gene was 0.12 μg/mL, and those for strains with the mefA or ermB gene or both were more than 2 μg/mL. The MIC90s of CLDM for strains with the mefA gene or no resistance gene were 0.12 μg/mL, and those for strains with the ermB gene or both the mefA and ermB genes were 1 μg/mL. Thus, there was little difference in the frequency of resistance of S. pneumoniae between the classification under the CLSI guidelines and that based on pbp gene mutations identified by PCR. Susceptibility to β–lactam antibiotics was lower overall than that reported previously. With the increase in pbp gene mutations, resistance to β–lactam antibiotics has increased, resulting in decreased susceptibility to CAM and CLDM. Therefore, further surveillance is needed of antimicrobial resistance by drug sensitivity testing and genetic analysis using PCR.

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  The major causes of recurrent otitis media are considered to be 1) the immunological immaturity of infants, 2) an increase in the prevalence of multidrug-resistant bacteria, and 3) changes in the social and family environment. In addition, gastroesophageal reflux disease (GERD) should be considered as an additional possible cause of intractable recurrent otitis media.
  We encountered four cases of otitis-prone children with GERD. In these cases, it was extremely difficult to treat the otitis media, as the patients had taken antibacterial drugs for a long time in addition to undergoing surgical treatments, including tympanostomy and insertion of ventilation tubes. Furthermore, three of the patients had associated respiratory tract symptoms that were difficult to treat. It was possible to diagnose GERD by combining 24-hour esophageal pH monitoring, upper esophagography, and esophageal scintigraphy.
  The main treatment methods are educating the parents on GERD and daily nutritional guidance. H2 receptor antagonists and mosapride citrate are prescribed. However, these treatments have not been sufficiently effective at our hospital.

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  In 2001, American Academy of Pediatrics (AAP) has recommended that the diagnosis of acute bacterial sinusitis (ABS) in children ≦6 years of age is based on clinical criteria of persistent symptoms which are defined as daytime cough (which may be worse at night) and nasal discharge (of any quality) persisting for >10 days without evidence of improvement.
  We recruited children with ABS ≦6 years of age who were diagnosed according to AAP 2001 guideline from March 2008 through February 2009 at our pediatric practice and prescribed amoxicillin (AMPC) with a dose of 80 mg/kg/day, 3 divided doses, for 3 days as the first-line antibiotic to manage ABS.
  Only 16 children, the mean age 2.8±1.8 years, were diagnosed. The high dose AMPC was effective in 13 children (78.6%), who were completed the antibiotic treatment by added the same doses AMPC for 2 more days. The three treatment failure cases were changed antibiotic from AMPC to azithromycin (AZM) as the second-line antibiotic to eliminate possible causative pathogen, Haemophilus influenzae, which might be thought to be intracellular, biofilm forming or drug resistant. AZM was was effective in all three cases.

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  We reported two cases with an inverted tooth in nasal cavity diagnosed as a foreign body at first. Case1 was a 6-year-old boy who complained of nasal obstruction. A hard white mass was observed in the right nasal cavity and was considered to be a foreign body. Under general anesthesia, the mass was removed under transnasal endoscopy and was found to be a supernumerary tooth. Case2 was an 8-year-old boy who visited an ear-nose and throat clinic complaining of otalgia and was diagnosed with acute otitis media. During the medical examination, a hard white mass was found in the right nasal cavity by chance, and the patient was referred to our hospital. The patient was diagnosed as having an inverted supernumerary tooth by CT. The mass was removed by the same approach as Case1. Those two cases suggest that clinicians should consider the presence of an inverted tooth when a foreign body-like mass is observed in nasal cavity.

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  Ninety-five cases who had received a tracheotomy between 1997 and 2007 at Kanagawa Children's Medical Center were retrospectively reviewed. Fifty-four of the 95 cases were less than one year old when they underwent tracheostomy. The most frequent causative diseases were tracheomalachia, subglottic stenosis, and neurological disease. Decannulation was accomplished in thirty-three cases (35%), but 17 of the 33 patients required surgical treatment for the decannulation. Thirty-two of 33 the patients who were decannulated had mobility equal to walking. On the other hand, 31 of 38 live patients who were not decannulated had mobility less than walking. Patients whose mobility is less than walking seem to be difficult to decannulate.

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  Drug sensitivity and resistance (drug susceptibility and gene analysis) were investigated in 5,297 strains of Haemophilus influenzae detected in the nasopharynx of children with upper airway infection who visited our hospital between 2003 and 2007. Changes in ampicillin sensitivity of H. influenzae were showing biphasic peaks every year, but the peaks in 2003 to 2007 showed a change each year. The resistance rates presented as rates of β-lactamase-negative, ampicillin-resistant (BLNAR), low BLNAR, BLNAR, and β-lactamase-positive, ampicillin-resistant (BLPAR) strains, the rate of low BLNAR and BLNAR exceeded 45% in 2004, but decreased to about 10% in 2007, while the rate of BLNAS was about 55% in 2003, but exceeded 70% in 2007. However the rate of BLPAR strains exceeded 10% in 2007. Strains showing no mutation of pbp genes were the most frequently detected in 2003, but from 2004 to 2007, strains showing mutation of both pbp3–1 and 2 (gBLNAR) were the most frequently detected, accounting for about 40–50%. The rate of strains with the TEM gene and mutation of both pbp3–1 and 2 increased year by year. The resistance rates, presented as rates of gBLNAS, gLow BLNAR, gBLNAR, and gBLPAR, gLow BLPACR, and gBLPACR, the rates of gBLNAS and gLow BLNAR, decreased yearly, and the rates of gBLNAR in 2007 increased twice as much as in 2003. The rates of strains with the TEM gene (gBLPAR, gLow BLPACR, and gBLPACR) in 2007 was about twice that in 2003.

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