Academic
Selected journal articles written or co-written by Dr. Nina Shapiro:
Tonsils/Adenoids | |
Adenotonsillar Enlargement in Pediatric Patients Following Solid Organ Transplantation Objective: To evaluate the management of adenotonsillar hypertrophy in pediatric patients after transplantation.
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Adenotonsillar Hypertrophy and Epstein-Barr Virus in Pediatric Organ Transplant RecipientsObjectives/Hypothesis: Epstein-Barr virus–related (EBV-related) lymphoid hyperplasia of the tonsils and adenoids is a precursor to post-transplantation lymphoproliferative disorder (PTLD). The incidence of post- transplantation adenotonsillar hypertrophy, a poten- tial early sign of PTLD or EBV-related lymphoid hyperplasia, is not known. We sought to identify potential risk factors for adenotonsillar hypertrophy manifested as EBV-related hyperplasia and early PTLD in the pediatric solid organ transplant population. Study Design: Cross-sectional analysis. Methods: We developed a 65-point questionnaire concerning obstructive sleep disorder and upper respiratory tract infections and an 8-point focused physical examination, to identify prevalence of and risk factors for adenotonsillar hyper- trophy in the pediatric transplant population. We evaluated 120 pediatric solid organ transplant recipients by parental questionnaire and focused adenotonsillar physical examination. Parental understanding and attitudes of pediatric obstructive sleep apnea and adenotonsillectomyObjective: To explore parental perceptions and knowledge of pediatric obstructive sleep apnea (OSA) and adenotonsillectomy. Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative carePostoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Children’s Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group (Pf0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) (Pf0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting. The validity of the OSA-18 among three groups of pediatric patientsObjective: To compare the signs and symptoms of obstructive sleep apnea syndrome in three groups of pediatric patients; solid organ transplant recipients, healthy children, and children with leukemia; in order to examine the effects of chronic illness on the obstructive sleep apnea–18-item questionnaire and to investigate its validity as a screening tool for obstructive sleep apnea in the pediatric solid organ transplant population. |
Airways | |
Rigid Tracheobronchoscopy–Induced Bacteremia in the Pediatric PopulationObjective: To assess the incidence of bacteremia following rigid tracheobronchoscopy in children to deter- mine whether use of prophylactic antibiotics is warranted in pediatric patients at risk for perioperative endocarditis Tracheal stenosis and congenital heart disease in patients with Down syndrome: diagnostic approach and surgical optionsUpper airway obstruction is a prevalent feature in patients with Down syndrome. However, these patients may be completely asymptomatic in the early months of life. The recognition of a problem within the airway quite often occurs when these children present for cardiac surgery, diagnostic radiography with sedation, or during the induction and intubation for anesthesia. Tracheal stenosis is rare in the general population, but is seen somewhat more frequently in patients with Down syndrome. The incidence of tracheal stenosis in children with congenital heart disease, which is seen in 40% of patients with Down syndrome, has been reported to be 1.2%. Patients with Down syndrome also tend to have other upper airway obstructive pathology such as nasopharyngeal, oropharyngeal, and subglottic compromise. These entities, combined with the high incidence of cardiac disease, put these children at risk for acute and chronic cardiopulmonary compromise. We present two patients with Down syndrome and congenital heart disease who were found to have significant tracheal stenosis at the time of their cardiac surgery. The perioperative management of their airway defects including diagnostic evaluation and treatment modalities are discussed. Structural Airway Anomalies in Patients with DiGeorge Syndrome: A Current ReviewDiGeorge Syndrome is a genetic disorder characterized by either absence or hypoplasia of the thymus and the parathyroid glands. Patients with this syndrome also have a high incidence of cardiovascular malformations and facial dysmorphism. Structural airway anomalies have also been described, albeit infrequently. Tracheoesophageal fistula, short trachea with reduced numbers of tracheal rings, abnormal thyroid cartilage, laryngomalacia, tracheo- malacia, and bronchomalacia have been recognized in these patients. We review all previously reported patients with DiGeorge syndrome and lower airway anomalies. In addition, we present 2 patients with DiGeorge syndrome who were each found to have an aberrant right tracheal bronchus. Structural airway anomalies can be a cause of morbidity and mortality in patients with DiGeorge syndrome. Prompt, thorough evaluation of the upper and lower airway in these patients is essential. |
Familial bilateral abductor vocal cord paralysisVocal cord paralysis is the second most common cause of stridor in the neonate, following laryngo-malacia. While unilateral paralysis occurs more frequently, bilateral paralysis can present with more severe symptomatology, most notably high-pitched inspiratory stridor and respiratory distress. Infants often require immediate intubation and eventual tracheotomy. Other presenting symptoms may include weak cry, cough, cyanosis, difficulty feeding, and aspiration. The majority of bilateral true vocal paralysis cases can be attributed to structural abnormalities of the central nervous system, such as Arnold-Chiari malformation, meningomyelocele, and meningocele [20]. Familial clustering of bilateral paralysis in the absence of other syndromes or features is rare. This case describes a father and sonwith isolated bilateral abductor vocal cord paralysis without other associated symptoms or syndrome. A Scheduled Protocol for the Treatment of Juvenile Recurrent Respiratory Papillomatosis With Intralesional CidofovirObjective: To assess the efficacy of treating juvenile recurrent respiratory papillomas with intralesional cidofovir using a scheduled treatment protocol. Tuberculous Mediastinal Mass Presenting With Stridor in a 3-Month-Old ChildA 3-month-old boy with a history of intermittent stridor was found to have obstructive emphysema on chest x-ray. Further investigations found a mediastinal mass compressing the carina and left mainstem bronchus. The mass was excised and found to be of tuberculous origin. Tracheotomy Tube Placement in Children Following Cardiothoracic Surgery: Indications and OutcomesPurpose: To review the indications for and outcomes of children requiring tracheotomy tube placement following cardiothoracic surgery, charts were reviewed retrospectively at a tertiary care center for fifteen children who had undergone tracheotomy tube placement following cardiothoracic surgery between 1994 and 2000. |
Ears | |
Genetic testing as part of the Early Hearing Detection and Intervention (EHDI) processHearing loss is the most common human birth defect occurring in 1 to 3 per thousand infants.1 Recent evidence for a critical period for language acquisition promoted the adoption of Early Detection and Hearing Intervention (EHDI) programs in nearly every state.1 Universal newborn hearing screening by bedside audiometric testing is rapidly becoming standard of care. Demographic Disparities Among Children With Frequent Ear Infections in the United StatesObjectives/Hypothesis: To evaluate current racial/ethnic and socioeconomic disparities in the prevalence of frequent ear infections (FEI) among children in the United States. Otitis media in children with vertically-acquired HIV infection: the Great Ormond Street Hospital experienceHuman immunodeficiency virus (HIV) infection continues to be a vexing problem in the pediatric population. Otitis media, a common entity in immunocompetent as well as immunocompromised children, is prevalent in pediatric patients with HIV infection. Recurrent infections and complications secondary to otitis media are also common in this population. The purpose of this review was to evaluate the records of a large group of children with HIV infection undergoing treatment for otitis media at a tertiary care center. Incidence of infections, severity of infections, and pathogens responsible were the key points of data collection in relation to each patient’s HIV clinical and immunologic classification. We reviewed 72 patients with vertically-acquired HIV infection undergoing treatment at the Hospital for Sick Children, Great Ormond Street, London. All patients were born to HIV infected mothers of sub-Saharan African origin. A total of 32 (44.4%) of these children presented to our institution with one or more episodes of otitis media, six of whom suffered systemic complications secondary to middle ear pathology. Middle ear culture data, when available from actively draining ears, was similar to those of immunocompetent children in the general population. The most common complications were systemic bacteremia and recalcitrant infections requiring intravenous antibiotic therapy. Severity of immunosuppression was associated with higher incidence and severity of otitis media. Otitis media in an HIV infected child must be treated aggressively at its outset in an attempt to minimize possible complications. Administration of prophylactic antibiotics to these children may reduce the frequency of acute and chronic infections. Improvement in immunologic status using antiretrovirals or protease inhibitors is a primary goal in diminishing the severity of otitis media as well as other infections in these children. |
Infant hearing loss and connexin testing in a diverse populationPurpose: Previous studies of connexin-related hearing loss have typically reported on mixed age groups or adults. To further address epidemiology and natural history of connexin-related hearing loss, we conducted a longitudinal study in an ethnically diverse cohort of infants and toddlers under 3 years of age. Our study compares infants with and without connexin-related hearing loss to examine differences in the prevalence of connexin and non-connexin-related hearing loss by ethnic origin, detection by newborn hearing screening, phenotype, neonatal risk factors, and family history. This is the first study to differentiate infants with and without connexin-related hearing loss. Screening and Management of Adult Hearing Loss in Primary CareContext: Hearing loss is the third most prevalent chronic condition in older adults and has important effects on their physical and mental health. Despite these effects, most older patients are not assessed or treated for hearing loss. Objective: To review the evidence on screening and management of hearing loss of older adults in the primary care setting. Prelingual Siblings of Children With GJB2 Hearing LossNewborn hearing screening is currently being implemented in the United States and other countries, allowing early identification of and intervention for hearing loss in neonates. Also, genetic testing is clinically available for the GJB2 gene, which codes for the connexin 26 protein, and the results have begun to explain the cause of a significant number of cases of hearing loss. However, the current limited knowledge about the natural history of GJB2-related hearing loss in the postnatal period, particularly as it relates to age at diagnosis of the hearing loss, raises important clinical and ethical questions that need to be addressed regarding the evaluation of prelingual siblings of children identified with GJB2-related hearing loss. |
Sinus | |
The Diagnostic Accuracy of Computed Tomography in Pediatric Chronic RhinosinusitisObjective: To determine the accuracy of computed tomography (CT) in the diagnosis of pediatric chronic rhinosinusitis (CRS). | |
Head and Neck | |
Complications and Determinants of Length of Stay for Inpatient Pediatric Otolaryngologic ProceduresObjective: To identify clinical factors associated with morbidity, mortality, and length of stay (LOS) for inpatient pediatric otolaryngologic procedures. Third branchial cleft anomaly presenting as a retropharyngeal abscessBranchial cleft anomalies are congenital developmental defects that typically present as a soft fluctuant mass or fistulous tract along the anterior border of the sternocleidomastoid muscle. However, branchial anomalies can manifest atypically, presenting diagnostic and therapeutic challenges. Error or delay in diagnosis can lead to complications, recurrences, and even life-threatening emergencies. We describe a case of an infected branchial cleft cyst that progressed to a retropharyngeal abscess in a 5-week-old female patient. The clinical, radiographic, and histologic findings of this rare presentation of branchial cleft cyst are discussed. Increased Female Authorship in Otolaryngology Over the Past Three DecadesObjective: To identify changing trends in female authorship and publication in the otolaryngology lit- erature. Methods: All articles published in the four major otolaryngology journals in each of the years 1978, 1988, and 1998 were reviewed. The authorship panel of each article was examined for number of authors, gender, educational degree category, and subspecialty area of publication. Data were analyzed for trends in female authorship and the association of gender with the other design variables. |
Staging and survival for sinus cancer in the pediatric populationObjective: To determine histology, staging, and survival for pediatric sinus cancer. Population-Based Outcomes for Pediatric Thyroid CarcinomaObjectives/Hypothesis: The objective was to deter- mine clinical features and clinical outcomes for pediatric thyroid carcinoma. Study Design: Crosssectional analysis of national cancer database. Methods: The Surveillance, Epidemiology, and End Results database (1988–2000) was surveyed, extracting all cases of pediatric thyroid carcinoma. Clinical features including age, gender, tumor type, tumor size, nodal disease, treatment modality, and survival variables were retrieved. Kaplan-Meier survival analysis was conducted to determine actuarial survival according to histological type. Cox regression analysis was conducted to determine prognostic factors affecting survival in pediatric carcinoma. Evaluation and management of benign, non-congenital tongue masses in childrenTongue masses in children are rarely encountered. When seen, they are most commonly congenital in origin. Congenital lesions in the anterior region may be hemangiomas or lymphatic malformations. Posterior and midline congenital lesions include thyroglossal duct cysts, lingual thyroid gland, dermoids, choristomas, and heterotopic gastric cysts. The location of these lesions in the region of the foramen cecum is secondary to embryologic disruption at the junction of the anterior two- thirds and posterior one-third of the tongue during development. Benign tongue lesions that are not secondary to embryologic disturbance are quite rare. We describe three children who presented with benign, non-congenital lingual neoplasms. Diagnostic evaluation included radiologic imaging to evaluate extent of the mass and to rule out concomitant thyroid abnormalities. Complete excision is most often curative. Close follow-up is indicated to monitor for postoperative recurrence. |
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