I often feel like a pediatric historian, for when I left my hospital training and entered the practice of pediatrics, our scientific knowledge, judged hy that of today, was highly inadequate. We had no antihiotics; no prophylactic inoculations except smallpox, diphtheria, and tetanus; no treatment for cardiac defects and kidney ailments. Rickets was seen frequently. Icterus gravis neonatorum was not uncommon. Insulin had only heen used therapeutically for diabetes a few years previously and many pediatricians were still treating the condition by resorting solely to strict diet care. These are a few indications of the state of pediatric practice in the early 1930s.
Once, during these years, a pediatrician in the New York area tabulated the frequency of illnesses among his patients. Leading the list were infections of the ears, nose, and throat. These were more severe in those days for there were no antibiotics available and, as a result, there were a greater number of cases of otitis media, some resulting in mastoiditis; cases of severe tonsillitis; at times retropharyngeal abscesses; and numerous cases of severe cervical adenitis often necessitating lancing.
Today, infections in the ears, nose, and throat are still the most common bacterial conditions confronting the practicing pediatrician, in spite of the amazing results of antibiotic therapy. This present issue of Pediatric Annals is an up-to-date review of the subject and is under the Guest Editorship of Dr. Herman Felder, Clinical Associate Professor of Otolaryngology at the University of Pittsburgh School of Medicine.
Dr. Felder initiates the symposium with a discussion of "The Use of Tympanostomy Tubes." He opens the article with the statement that "The use of tympanostomy tubes has been the best thing that has happened for the treatment of ear disease since antibiotics." By this he does not infer that tubes should be inserted in every case of severe otitis media. He clearly presents the indications for tubal insertion and deals with questions all pediatricians ask: How long should the tubes remain inserted? Is there potential hearing loss from recurrent ear infections without tympanostomy.7 Can children go swimming with the tubes in place? Is the anesthetizing of the child for tubal placement a safe procedure? And finally, is the cost of the procedure plus the anesthetist plus the hospitalization a worthwhile investment? All of these questions are well answered by Dr. Felder on the basis of his experience. The answers are well taken, for it is noted that Dr. Felder has in 23 years performed over 15,000 operations for the insertion of tympanostomy tubes. The article should prove a valuable guide in directing pediatricians in the care of children with recurrent attacks of otitis media, and in reassuring parents of these children.
The second contribution covers a subject of great importance to all practicing pediatricians. It deals with the "Clinical Diagnosis of Neck Lumps" and is contributed by Dr. Jacob Friedberg, Assistant Professor, Department of Otolaryngology at the University of Toronto, and on the Active Staff of the Department of Otolaryngology of the Hospital tor Sick Children in Toronto.
All of us are aware of the frequency of enlarged lymph nodes in the necks of children, and the great majority of these are inflammatory in origin. However, a certain number of these nodes are of other etiologies. These rarer entities are often difficult to diagnose but, as Dr. Friedberg demonstrates in this article, "with an appropriate history and physical examination and an orderly approach, a reliable diagnosis will usually be forthcoming."
The paper is divided into four specific sections: lateral neck lumps, submandibular masses, midline masses, and periauricular lumps. The numerous entities are carefully described with their diagnostic features. This is an excellent article, well worth preserving for future reference. The hope is to make the diagnosis accurately and clinically, avoiding invasive approaches.
The next article discusses the "Diagnosis and Management of Acute Sinusitis" and has been written by Dr. Ellen R. WaId, Associate Professor of Pediatrics, Division of Infectious Diseases and Ambulatory Care, University of Pittsburgh School of Medicine and the Children's Hospital of Pittsburgh.
Sinus infections are not uncommon in children and, unless occluded by mucosal swelling, will drain without too much difficulty, with the exception of the maxillary sinus. Dr. WaId clearly defines the signs and symptoms of acute sinusitis, taking into account the type of discharge, duration of discharge, odor of breath, and the occasional appearance of periorbital edema. She follows with a discussion of the diagnostic methods.
It is interesting to note that cultures of the nose and throat are usually not predictive of the infecting organism. It is important, therefore, to find an effective antibiotic. Dr. WaId discusses this problem and notes that febrile patients with sinusitis will respond with amazing rapidity to the proper antibiotic. She notes that with the latter treatment the child will rapidly become afebrile, and within 48 hours there will be a remarkable reduction in nasal discharge and cough. Irrigation and drainage of the infected sinus is also discussed as well as the questionable use of decongestants.
The following contribution to the symposium covers a potentially critical occurrence in the early years of most, if not all, children - the swallowing or inhaling of foreign bodies. The discussion of this important subject has been contributed by Dr. Ellen Friedman, Assistant Professor of Otolaryngology at Harvard University Medical School and Senior Associate at Children's Hospital, Boston.
This paper presents very clearly the potential dangers of a lack of adequate history, a misdiagnosis, or of delay in removal of the foreign body. There was a time, some years ago, before we realized the dangers of fluoroscopy, when most pediatricians had a fluoroscope in their private offices. We practitioners of that time fluoroscoped every child suspected of having swallowed or inhaled a foreign object. We searched for the foreign body in the digestive tract and the respiratory tract as well. We carefully watched for deviation of the mediastinum or respiration, and we viewed the child laterally as well as anterior-posteriorly. I believe we visualized most of the inspired or ingested objects. EMDr. Friedman specifies the most recent approach to diagnosis and treatment, taking into consideration the location of the foreign body, its size and shape, and the manner of removal. This is an extremely informative article and should be of great value in directing all pediatricians to the best approach and care of children who swallow or inhale foreign objects.
The final article discusses a fairly difficult problem of childhood and adolescence. "Dizziness in Children" has been written by Dr. Sidney N. Busis, Clinical Professor of Otolaryngology, University of Pittsburgh School of Medicine.
It is usually not too difficult to determine the cause of dizziness if it follows a traumatic incident or if there is evidence of otitis media. But the etiology is much more difficult to determine when attacks are momentary or last only a few minutes. Also, if attacks of dizziness suggest symptoms of Meniere's or a migraine attack, the solution is often difficult.
There are other rarer causes of dizziness which Dr. Busis discusses ranging from tumors of the brain and temporal lobe epilepsy to the dizziness and lightheadedness that may occur with emotional stress. Where possible the article presents diagnostic features for the majority of the conditions which must be considered when evaluating the symptoms of dizziness among pediatric patients.