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Is Adenoid Hypertrophy Associated with Childhood Afebrile Seizure?
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Adenoids (nasopharyngeal tonsils), being part of Waldeyer’s ring, are masses of lymphoid tissues located at the junction of the roof and the posterior wall of the nasopharynx. Adenoids play an important role in the development of the immune system and serve as a defence against infections, being the first organs that come into contact with respiratory and digestive antigens. The causes of adenoid hypertrophy are not fully known. They are most likely associated with aberrant immune reactions, infections, environmental exposures and hormonal or genetic factors. The aim of this review is to summarise the current knowledge of adenoid hypertrophy in children and associated diseases. Adenoid hypertrophy has many clinical manifestations that are frequent in the paediatric population and is accompanied by various comorbidities.
Seizure is one of the most common neurologic disorders in pediatric emergency department visits. Early detection of epilepsy development in children with afebrile seizures is important. We identified predictors of epilepsy development in children with their first afebrile seizure. In this retrospective multicenter study, we enrolled pediatric patients aged 1 month to 18 years who presented with afebrile seizures at the emergency department from January 2017 to December 2020. Multivariable logistic regression analysis was performed to identify factors associated with epilepsy development. A total of 417 pediatric patients were enrolled, 161 (38.6%) of whom developed epilepsy. From the multivariable logistic regression analysis, older age at onset (2–5 years, odds ratio [OR] 2.611, p = 0.010; 11–15 years, OR 3.138, p = 0.003; 16–18 years, OR 4.292, p = 0.002), longer seizure duration of more than 10 min (OR 4.869, p = 0.006), two or more seizures (OR 2.378, p = 0.004), lethargy (OR 2.341, p = 0.021), and a lactate level > 2.27 mg/dL (OR 4.205, p < 0.001) were significant predictors for the development of epilepsy in children experiencing their first afebrile seizure.
Background
Electroencephalogram and neuroimaging in pediatric patients with new-onset afebrile seizures are performed to detect any underlying pathological severe condition that may require emergent neuro-intervention and guide prognosis. This study aims to determine the predictors of abnormal EEG and neuroimaging in children presenting to the emergency department with new-onset afebrile seizures.
Methods
This single-center cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan, from July 01, 2019, to June 30, 2021. All patients aged one month to 18 years who presented with new-onset afebrile seizures were included. Demographic and clinical data were recorded, including age, gender, seizure type, duration of seizure, associated signs and symptoms, and disposition. Multivariable regression analysis was applied to determine the predictors of abnormal EEG and CT scan or MRI findings.
Results
Out of 201 participants, most patients were in the infantile age group (41.3%), with an equal gender distribution. The most common type of seizure was generalized onset 152 (75.6%). EEG was performed on a total of 126 patients (62.7%) and out of these patients, 67 patients (53.1%) had abnormal findings. In a multivariable analysis, the age group of 5 to 10 years and seizure duration of more than 5 min were significantly associated with higher odds of abnormal EEG findings. In contrast, only the focal onset of seizure was significantly associated with higher odds of abnormal neuroimaging findings.
Conclusion
The study emphasizes the need for a protocol regarding the performance of EEG and neuroimaging in children presenting to the ED with new-onset afebrile seizures that would aid emergency physicians in the direction of appropriate management, thus ensuring a better quality of patient care and outcomes.
Diagnostic techniques for spinal pathologies have been developed in accordance with advances in technology. Accurate diagnosis of spinal pathology is essential for appropriate management of spinal diseases. Since the development of X-rays in 1895 and computed tomography (CT) in 1967, several diagnostic imaging modalities have been utilized for detecting spinal pathologies, including radiography, CT, magnetic resonance imaging, and radionuclide imaging. In addition to diagnostic imaging technologies, electrodiagnostic tests, including electromyography and nerve conduction studies, play a significant role as diagnostic tools, as spinal diseases are mostly profoundly associated with pathologies of the neural structures, such as the spinal cord and nerve root, and extent of injury at the structure cannot be adequately detected by conventional imaging techniques. In patient-specific treatment strategies, usage of diagnostic modalities is of great importance; thus, we should be aware of the basic details and approaches of the different diagnostic modalities. In this review, the authors discuss the details of the technologies that aid in the diagnosis of spinal pathologies.
Background
Intermittent hypoxemia can cause changes in certain brain structures. However, in pediatric patients with obstructive sleep apnea (OSA) caused by adenotonsillar hypertrophy (ATH), there is only limited information on the effect of ATH-induced OSA on brain structures. This study sought to investigate alterations in amygdala and hippocampal volumes in children with OSA by ATH.
Material/Methods
Magnetic resonance imaging scans were applied in children who had ATH-induced OSA (ATH/OSA) and in healthy children. Amygdala and hippocampus volumes and adenoid sizes were measured on MRI volumetric images. The ratio of adenoid size/nasopharyngeal depth was used to describe the severity of adenoid hypertrophy. The clinical variables of the involved subjects were investigated.
Results
One hundred ATH/OSA children and 100 healthy children without ATH/OSA participated in the study. The ATH/OSA children had higher amygdala volumes and amygdala/hippocampus volume ratios but lower hippocampus volumes than healthy controls, and the amygdala/hippocampus volume ratios were correlated with disease duration and hypoxemia conditions. However, our data showed that amygdala/hippocampus volume ratios were not correlated with the ratios of adenoid size/nasopharyngeal depth in the ATH/OSA children. In addition, the ratio of adenoid size/nasopharyngeal depths in ATH/OSA children was higher than that in healthy children in each subgroup based on the age of participants.
Conclusions
Compared to healthy controls, amygdala/hippocampus volume ratios are increased in children with ATH/OSA.
Chronic hypobaric hypoxia in high‐altitude areas is closely related to the occurrence of many neurological diseases. Among these diseases, epilepsy is a common disease of the nervous system that is difficult to diagnose and treat, with a long treatment cycle. As of 2019, there were more than 70 million epilepsy patients worldwide, including 10 million in China. Studies have shown that chronic hypoxia promotes the occurrence and development of epilepsy, and elucidation of the relationship between chronic hypoxia and epilepsy is important for studying the pathogenesis of epilepsy and exploring the potential characteristics of epilepsy and new drug targets for epilepsy. In this article, we review the factors that may cause increased seizure susceptibility in chronic hypoxia and consider the potential relationship between chronic hypobaric hypoxia and seizure susceptibility in high‐altitude areas and prospects surrounding related research in the future.
Background: Otitis media (OM) is a major health problem that usually results from adenoid hypertrophy.
Diagnosis is based on symptoms like mouth breathing and imaging studies like lateral neck radiography (LNR).
Adenoid-nasopharyngeal ratio (A/N ratio) is one of the most important and most widely used criteria in LNR
study that could estimate the real size of adenoid gland measurements. However, there are huge controversies
regarding LNR rules in the management of patients with OM.
Objective: This study aimed to determine Adenoid Nasopharyngeal Ratio (A/N ratio) in children with otitis
media with effusion (OME) and its relation with different factors.
Methods: This was a cross-sectional study on OME suspected children who needed adenoidectomy. The study
was conducted from the fall to winter of 2016 on patients referred to ENT clinics of Mashhad University of
Medical Sciences. Before surgery, all children underwent standard LNRs and indirect laryngoscopy to assess
adenoidal size, and nasopharyngeal length, and A/N ratio. After adenoidectomy, pathologic analysis was
performed for assessment of pathologic size. SPSS 21 was used for data analyzing using Pearson’s correlation,
independent t test and Mann-Whitney U test (p
This study aimed to retrospectively investigate the factors related to pediatric obstructive sleep apnea–hypopnea syndrome (OSAHS) with attention deficit hyperactivity disorder (ADHD) in children younger than 6 years and those older than 6 years.
A total of 437 children who were hospitalized due to OSAHS between January 2014 and December 2014 were retrospectively reviewed. The children were further divided into OSAHS group and OSAHS + ADHD group. The general characteristics, OSA-18 quality of life, intention-hyperactivity score, and polysomnographic parameters (apnea–hypopnea index and the lowest oxygen saturation) were collected and compared between groups.
There were 298 boys and 139 girls with the male to female ratio of 2.14:1. ADHD was found in 146 children including 105 boys and 41 girls with the male to female ratio of 2.56:1. Of these children, 31.62% and 35.46% had concomitant ADHD in children aged 4 to 5 years and those aged 6 to 11 years, respectively. In children aged 4 to 5 years, the incidence of allergic rhinitis was significantly higher (P = .016) and the adenoid hypertrophy was more severe (P = .001) in those with concomitant ADHD. In children aged 6 to 11 years, the tonsil hypertrophy was more severe in those with concomitant ADHD (P = .019). In children with concomitant ADHD, OSA-18 score was higher than in those with OSAHS alone (P < .001). Higher frequency of respiratory events (P < .001) and more severe hypoxia (P < .001) were found in children with concomitant ADHD than in those with OSAHS alone.
As high as 30% of OSAHS children have concomitant ADHD, and the incidence of ADHD in OSAHS children is increasing over age. Boys are more likely to develop OSAHS and incidence of ADHD in OSAHS boys is higher than in OSAHS girls. In addition, risk factors of ADHD also vary between age groups. The ADHD is related to the severity of allergic rhinitis and adenoid hypertrophy in children aged 4 to 5 years, and to the severity of tonsil hypertrophy in children aged 6 to 11 years. Hypoxia may be an important factor causing ADHD. OSAHS should be treated as early as possible to reduce the incidence of ADHD in children.
Two antithetic terms, hypoxia and hyperoxia, i.e., insufficient and excess oxygen availability with respect to needs, are thought to trigger opposite responses in cells and tissues. This review aims at summarizing the molecular and cellular mechanisms underlying hypoxia and hyperoxia in brain and cerebral tissue, a context that may prove to be useful for characterizing not only several clinically relevant aspects, but also aspects related to the evolution of oxygen transport and use by the tissues. While the response to acute hypoxia/hyperoxia presumably recruits only a minor portion of the potentially involved cell machinery, focusing into chronic conditions, instead, enables to take into consideration a wider range of potential responses to oxygen-linked stress, spanning from metabolic to genic. We will examine how various brain subsystems, including energetic metabolism, oxygen sensing, recruitment of pro-survival pathways as protein kinase B (Akt), mitogen-activated protein kinases (MAPK), neurotrophins (BDNF), erythropoietin (Epo) and its receptors (EpoR), neuroglobin (Ngb), nitric oxide (NO), carbon monoxide (CO), deal with chronic hypoxia and hyperoxia to end-up with the final outcomes, oxidative stress and brain damage. A more complex than expected pattern results, which emphasizes the delicate balance between the severity of the stress imposed by hypoxia and hyperoxia and the recruitment of molecular and cellular defense patterns. While for certain functions the expectation that hypoxia and hyperoxia should cause opposite responses is actually met, for others it is not, and both emerge as dangerous treatments.
Obstructive sleep apnea (OSA) is commonly associated with neurocognitive impairments that have not been consistently related to specific brain structure abnormalities. Knowledge of the brain structures involved in OSA and the corresponding functional implications could provide clues to the pathogenesis of cognitive impairment and its reversibility in this disorder.
To investigate the cognitive deficits and the corresponding brain morphology changes in OSA, and the modifications after treatment, using combined neuropsychologic testing and voxel-based morphometry.
A total of 17 patients treatment-naive to sleep apnea and 15 age-matched healthy control subjects underwent a sleep study, cognitive tests, and magnetic resonance imaging. After 3 months of treatment, cognitive and imaging data were collected to assess therapy efficacy.
Neuropsychologic results in pretreatment OSA showed impairments in most cognitive areas, and in mood and sleepiness. These impairments were associated with focal reductions of gray-matter volume in the left hippocampus (entorhinal cortex), left posterior parietal cortex, and right superior frontal gyrus. After treatment, we observed significant improvements involving memory, attention, and executive-functioning that paralleled gray-matter volume increases in hippocampal and frontal structures.
The cognitive and structural deficits in OSA may be secondary to sleep deprivation and repetitive nocturnal intermittent hypoxemia. These negative effects may be recovered by consistent and thorough treatment. Our findings highlight the importance of early diagnosis and successful treatment of this disorder.
Seizures account for 1% of all pediatric emergency department (ED) visits. The aim of this study was to analyze the clinical spectrum and prevalence rates of various etiologies in children with a first attack of acute seizure disorder in the ED.
We evaluated 319 children who presented to the ED at the Changhua Children's Hospital with a first attack of seizure disorder from 2005 to 2007. Variables including demographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography, diagnoses and hospital course were compared between patients with seizures and fever, and patients with seizures without fever. These variables were also compared between patients with simple and complex febrile seizures and among different age groups.
Among these 319 patients, 218 (68%) presented with seizures and fever and 299 (94%) children were younger than 6 years of age. Generalized tonic-clonic seizures were the most common type (71.2%). Febrile seizures (62.1%) were the main etiology of the first seizure (p < 0.001). Seizures caused by severe electrolyte imbalance or hypoglycemia were noted in three patients. Abnormal brain images were noted in 16 (26%) of 61 patients, most (12/16, 75%) of whom had abnormal histories and physical or neurologic examinations.
Primary care pediatricians should evaluate children presenting to the ED with a first seizure for age, coexistence of fever, seizure type, associated symptoms and history of head injury. We suggest that electrolytes, blood sugar and emergent brain imaging studies should be arranged based on detailed history-taking and thorough physical examinations, but should not be performed routinely.
We evaluated the efficacy of mometasone furoate aqueous nasal spray in decreasing adenoid size and reducing the severity of chronic nasal obstruction symptoms in children affected by adenoidal hypertrophy.
Sixty children were recruited in a 2-stage, randomized, placebo-controlled trial. All patients complained of chronic nasal obstruction symptoms, and nasal endoscopy showed >75% choanal obstruction attributable to adenoid pads. In the first stage, 30 patients (group A) underwent mometasone treatment (50 microg per nostril per day) for 40 days, and 30 children (group B) received placebo. In the second stage, at the end of the first 40-day treatment period, patients in group A who showed subjective and objective clinical improvement were divided into 2 subgroups; group A1 (11 children) received topical intranasal steroid treatment on alternate days for the first 2 weeks per month, whereas group A2 (10 children) continued daily mometasone treatment for the first 2 weeks per month. After 3 months, all children were reassessed.
Fifty-seven children completed the study according to the protocol. After the first treatment period, the severity of symptoms and adenoid size decreased for 21 patients (77.7%) in group A. No improvement was observed in the placebo group. After 3 months of additional therapy, group A2 patients demonstrated a more-pronounced reduction in adenoid size compared with group A1 patients. No statistically significant change in symptoms was identified. Mometasone treatment was well tolerated by all patients.
Mometasone furoate aqueous nasal spray may be considered useful in decreasing adenoid pad size and the severity of symptoms related to adenoidal hypertrophy. Children with adenoidal hypertrophy that is not associated with tonsillar hypertrophy should be considered for intranasal mometasone treatment before surgery is planned.
First seizures are often perceived as devastating events by patients and their families due to the fear of having a life-long disease. One in 10 people experiences one or more seizures during their lifetime, while 1 in 26 people develops epilepsy. Acute symptomatic seizures are often related to a provoking factor or an acute brain insult and typically do not recur. Careful history and clinical examination should guide clinicians' management plans. Electroencephalography and brain imaging, preferably with epilepsy-specific magnetic resonance imaging, may help characterize both etiology and risk of seizure recurrence. Antiepileptic drugs should be initiated in patients with newly diagnosed epilepsy. In patients without an epilepsy diagnosis, the decision to prescribe drugs depends on individual risk factors for seizure recurrence and possible complications from seizures, which should be discussed with the patient. Counseling about driving and lifestyle modifications should be provided early, often at the first seizure encounter.
Introduction
The primary goals of emergency department (ED) clinicians when dealing with a pediatric patient experiencing a seizure are to control the seizure and prevent seizure-related complications. After stabilizing the patient, the clinician should determine whether the patient is likely to have recurrent seizures that may need treatment such as antiepileptic drugs (AEDs). The early identification of pediatric seizure patients at high risk for recurrence can be of great help in consulting with their parents. This study aimed to identify predictors of seizure recurrence in pediatric patients who visited the ED for first-onset afebrile seizure.
Methods
This retrospective study was conducted with pediatric patients aged 1 month to 18 years who visited our ED for afebrile seizure from January 2016 to March 2020. Children with a known seizure disorder, known underlying genetic or metabolic disorder, or acute trauma history, and those lost to follow-up were excluded. Multivariable logistic regression analysis was performed to identify factors associated with seizure recurrence.
Results
A total of 253 pediatric patients were included in the study. Seizure recurrence was observed in 117 patients (46.3%). From the multivariable logistic regression analysis, older age at onset (11–15 years, odds ratio [OR] 5.781, p = 0.001; 16–18 years, OR 6.223, p = 0.002), a longer seizure duration (1–5 min, OR 3.043, p = 0.002; 6–10 min, OR 5.629, p = 0.002; >10 min, OR 8.882, p = 0.002), blood pH under 7.2 (OR 8.308, p = 0.015), and a glucose level over 144 mg/dL (OR 6.408, p = 0.030) were significantly associated with seizure recurrence. The area under the receiver operating characteristic curve for the multivariable logistic regression analysis was 0.774.
Conclusion
Age at onset ≥11 years, a longer seizure duration, acidosis, and hyperglycemia were predictors of seizure recurrence in children who had experienced first-onset afebrile seizure.
Children with long-standing obstructive sleep apnea (OSA) show evidence of neural injury and functional deficits in behavioral and cognitive regulatory brain regions that are reflected in symptoms of altered cognitive performance and behaviors. While we earlier showed reduced gray matter volume and increased and reduced regional cortical thicknesses, such structural changes give little indication of the underlying pathology. Brain tissue integrity in pediatric OSA subjects can reflect the nature and extent of injury or structural adaptation, and can be assessed by entropy tissue texture, a measure of local changes in signal intensity patterns from high-resolution magnetic resonance images. We collected high-resolution T1-weighted magnetic resonance images from 10 pediatric OSA (age, 7.9 ± 1.1 years; apnea-hypopnea-index, 8.8 ± 3.0 events/hour; body-mass-index, 20 ± 6.7 kg/m2; 7 male) and 8 healthy controls (age, 8.8 ± 1.6 years; body-mass-index, 19.6 ± 5.9 kg/m2; 5 female). Images were bias-corrected and entropy maps calculated, individual maps were normalized to a common space, smoothed, and compared between groups (ANCOVA; covariates: age, gender; SPM12, uncorrected-threshold p < 0.005). No significant differences in age (p = 0.48), gender (p = 0.59), or body-mass-index (p = 0.63) emerged between groups. In OSA children, several brain sites including the pre-frontal cortex, middle and posterior corpus callosum, thalamus, hippocampus, and cerebellar areas showed reduced entropy values, indicating tissue changes suggestive of acute insults. No regions showed higher entropy values in OSA. Children suffering from OSA display predominantly acute tissue injury in neural regions principally localized within autonomic, respiratory, cognitive, and neuropsychologic control, functions that correspond to previously-reported comorbidities associated with OSA. A range of acute processes, including hypoxia/re-oxygenation, repeated arousals, and episodic hypercarbia, may have contributed to regional brain tissue integrity changes in pediatric OSA.
Epilepsy is the number one neurological disorder in children in western society. Childhood epilepsy is highly comorbid with psychopathology. Although neurological and biological factors may partially explain the increased risk of psychopathology in children with epilepsy, social contextual factors are also important to understanding development of psychopathology in children with epilepsy. The current paper examines the development of children with epilepsy utilizing Bronfenbrenner's micro-, meso-, exo-, and macrosystem social contexts. Negative interpersonal interactions within the microsystems and the ripple effect of social context at the other levels may contribute to increased risk for psychopathology.
Nasopharyngeal adenoid hypertrophy (NAH) is a typical benign lesion. Due to involution, nasopharyngeal lymphatic tissue usually is not found in adults beyond the 30th to 40th year of life. However, occasionally NAH has been recognized after the 50th or 60th year. The aim of this study is to identify the frequency of NAH and to analyze its MRI findings in different age groups. From 2007 to 2011, 6693 MR investigations of the head were performed at our institution. MRI was obtained with a 1.5 T MRI device. NAH was identified in 18.0% of the patients. The frequency of NAH varied from 60.3% to 1.0% in the different age groups. The mean size of NAH was 23.2 ± 4.5 mm in cranio-caudal, 31.1 ± 5.2 mm in left-right, and 14.2 ± 4.1 mm in the anterior-posterior direction. The left-right and cranio-caudal sizes of NAH were largest in the 0–9 age group and decreased with age. On T1-w images most lesions (95.4%) were hypointense in comparison to the adjacent musculature. On T2-w fat-saturated images 82.4% of the lesions were hyperintense. After intravenous administration of contrast medium most lesions showed a slight enhancement (58.6%). Moderate enhancement was seen in 32.4% and a marked enhancement was identified in 9.0%. In the 0–9 age group most lesions showed a slight enhancement. Cysts within NAH were identified in 433 cases (35.9%). The frequency of cysts increased continuously with age, namely from 10.9% to 65.2%.
Introduction:
Children with adenoid hypertrophy (AH) commonly suffer from sleep disordered breathing (SDB). SDB is associated with various neurocognitive problems. The aim of our study is to assess the cognitive function in those patients using cognitive event related potentials (ERPs).
Methods:
Twenty- three patients with moderate to severe AH were compared with twenty healthy controls. The intelligence quotient (IQ) was done for the all study participants. The latencies of the N200, P300 peaks and the amplitudes of the N200/P300 components of ERP were recorded. The above variables were measured at baseline for both patients and control groups and 2 months after adenoidectomy for the patient group.
Results:
There was no significant difference between patients and controls regarding full IQ scales. P300 latency was significantly prolonged in patient group compared to the healthy controls. Moreover, postoperative P300 latency was significantly reduced compared to the preoperative P300 latency. Postoperative P300 latency was not statistically different from healthy controls data.
Conclusions:
P300 latency delay may reflect some sort of cognitive impairment in patients with AH. This delay was reversible after adenoidectomy. ERPs may help for assessment of cognitive functions in patients with AH.
Whether to treat a patient after a first unprovoked seizure is controversial. This prospective study aimed to clarify the time course to recurrence and risk factors for seizure recurrence after a first unprovoked seizure in children.
Participants were recruited between July 1, 1997, and June 30, 2009. Eligible candidates were children between 1 month and 15 years old who presented with their first unprovoked afebrile seizure. After enrollment, Recurrence of seizures was investigated. All participants were followed for at least 2 years. Statistical analysis used log-rank for bivariate analysis to check associations and hazard ratios (HR) of variables and clinical outcome (recurrence) during follow-up.
Of 73 subjects, 42 (57.5%) experienced recurrence. The overall product-limit estimate of recurrence was 61.9% at 6 months, 85.7% at 1 year, and 95.2% at 2 years after seizure onset, respectively. Incidence of recurrence with partial and generalized seizures was 69.0% and 31.0%, respectively. Children with partial seizures experienced recurrence significantly more often than those with generalized seizures (p<0.001). Recurrent seizures occurred after normal findings on EEG in 21.4%, after generalized spike-and-wave complexes in 16.7%, and after focal epileptic discharge in 61.9%. Children with focal epileptic discharge showed recurrence significantly more often than children with normal EEG findings (p<0.001).
This study suggest that the time course to seizure recurrence after first unprovoked seizure may be within 1 year, and particularly within 6 months and that partial seizure and abnormal EEG with focal epileptic discharge may be risk factors for seizure recurrence.
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The role of electroencephalography (EEG) in the work-up of febrile seizure (FS) remains controversial. We investigated the importance of EEG characteristics, especially the localizations of paroxysmal discharges, as predictors for subsequent epilepsy. Patients were referred from the outpatient department for EEG within 7-20 days after the seizure. EEGs were classified as paroxysmally abnormal based on the presence of spikes, sharp waves, or spike-wave complexes, whether focal or generalized, that were considered abnormal for age and state. Of 119 patients with FS, 26 (21.8%) revealed paroxysmal abnormality on EEG and 9 (7.6%) developed epilepsy. Of nine patients with later epilepsy, 6 (66.7%) revealed paroxysmal EEG abnormality. Of 26 patients with paroxysmal abnormality, 6 (23.1%) developed epilepsy. Of 10 patients with generalized paroxysmal spike and wave activity, one (10%) developed epilepsy. Of seven patients with rolandic discharge (RD), two (28.5%) developed epilepsy. Of four patients with paroxysms in the frontal region, three (75%) developed epilepsy. Of five patients with paroxysms in the occipital region, none developed epilepsy. Compared with generalized EEG foci, the relative risk (RR) for patients with frontal EEG foci was 27.0. Patients with frontal EEG paroxysms had a significantly higher risk of developing epilepsy than those with paroxysms in other regions of EEG foci (p=0.035). These findings suggest that patients with FS presenting with frontal paroxysmal EEG abnormalities may be at risk for epilepsy. In patients with frontal paroxysmal EEG abnormalities, serial EEG should be performed, even though it does not contribute to treatment.
To investigate the presenting characteristics of new-onset afebrile seizures in infants (age 1-24 months) and the yield of neuroimaging.
Prospective data were obtained from a standardized evaluation and management plan mandated by a critical care pathway. A total of 317 infants presented with new-onset afebrile seizures between 2001 and 2007. EEG was performed on 90.3%, head CT was obtained on 94%, and MRI was obtained on 57.4%.
We found half of the infants had partial features to their seizures, yet evidence for primary generalized seizures was rare. The majority had more than 1 seizure upon presentation. Seizures in this age group tended to be brief, with 44% lasting less than 1 minute. EEG abnormalities were found in half. One-third of CTs were abnormal, with 9% of all CTs requiring acute medical management. Over half of MRIs were abnormal, with cerebral dysgenesis being the most common abnormality (p < 0.05). One-third of normal CTs had a subsequent abnormal MRI-only 1 resulted in altered medical management.
Infantile seizures are usually brief, but commonly recurrent, and strong consideration should be made for inpatient observation. Acute imaging with CT can alter management in a small but important number of infants. Due to the superior yield, strong consideration for MRI should be given for all infants, as primary generalized seizures are rare, and there is a high rate of cerebral dysgenesis.
The developmental history of the embryonic germ disk is briefly traced through the bilaminar, trilaminar, and bodyfold stages with emphasis on the pharyngeal arches, pouches, and clefts. This is followed by a discussion of the genesis and adult anatomy of the tonsillar tissues.
The Quality Standards Subcommittee of the American Academy of Neurology develops practice parameters as strategies for patient management based on analysis of evidence. For this practice parameter, the authors reviewed available evidence on evaluation of the first nonfebrile seizure in children in order to make practice recommendations based on this available evidence.
Multiple searches revealed relevant literature and each article was reviewed, abstracted, and classified. Recommendations were based on a three-tiered scheme of classification of the evidence.
Routine EEG as part of the diagnostic evaluation was recommended; other studies such as laboratory evaluations and neuroimaging studies were recommended as based on specific clinical circumstances.
Further studies are needed using large, well-characterized samples and standardized data collection instruments. Collection of data regarding appropriate timing of evaluations would be important.
Conclusions regarding the significance and appearance of the adenoids incidentally noted on magnetic resonance (MR) scans of the brain largely rely on observations of previously published plain film data. In order to determine the age specific appearance of normal adenoid tissue as measured on sagittal T1-weighted midline MR images, we evaluated 189 patients without a history or clinical evidence of adenoid disease, who were sequentially referred for an MR scan of the brain. The thickness of the adenoid pad was measured to the nearest 1 mm along a line through the pharyngeal tubercle constructed perpendicular to the anterior clival surface. Patients were grouped according to age. Normal subjects demonstrated an age specific variation in the size of the pad with the maximal size being attained in early childhood and then steadily decreasing in later childhood and adulthood (P = 0.0001). The adenoids were largest in the 7-10 years age group (mean, 14.59 mm) and steadily declined to 4.83 mm by 60 years of age. Previous surgery had no effect on adenoid measurement (P = 0.582). Magnetic resonance scans provide an excellent method for assessing the adenoid pad.
The lymphoid tissue of Waldeyer's ring, and particularly the nasopharyngeal tonsil (adenoids), appears to be functionally comparable to nasal-associated lymphoid tissue in rodents. Antigen-stimulated lymphoid follicles give rise to: (a) clonal B-cell expansion; (b) B-cell receptor affinity maturation; (c) positive selection of B cells according to receptor affinity for antigen; (d) differentiation to B memory cells and plasma cells; and (e) variable induction of the joining (J)-chain gene. B-cell differentiation is also important to promote downstream isotype switching of the immunoglobulin (Ig) heavy chain constant genes. For tonsillar B cells, this process gives mainly rise to IgG and IgA plasma cells, partially associated with J-chain expression. Because the J chain is a key peptide in the polymer structure of secretory IgA, tonsils and adenoids may provide B cells for mucosal effector sites. Thus, several observations suggest that these lymphoid organs generate polymeric IgA (pIgA)-expressing B cells that migrate to the upper airway mucosa, lacrimal glands and salivary glands. Accordingly, the nasal route of vaccination induces secretory IgA-dependent regional mucosal immunity and will also enhance systemic immunity. Although the pIgA-producing capacity of tonsillar B cells is considerably decreased in children with recurrent tonsillitis, a conservative attitude towards adenotonsillectomy appears immunologically desirable, particularly in the young age group.
It remains controversial whether pediatric adenotonsillectomy ultimately results in decreased serum immunoglobulin levels and if so whether such a decrease is associated with increased susceptibility to upper respiratory tract infections (URIs).
To evaluate changes in serum immunoglobulin levels in relation to occurrence of URIs in children participating in a randomized controlled trial on the effectiveness of adenotonsillectomy.
A total of 300 children aged 2 to 8 years, with symptoms of recurrent throat infections or tonsillar hypertrophy, were randomly assigned to either adenotonsillectomy or watchful waiting (WW). Serum samples were collected at baseline and at 1-year follow-up. Occurrence of throat infections and other URIs during first-year follow-up was recorded in a diary by the child's parents.
Paired serum samples were available for 123 children (63 in the adenotonsillectomy group and 60 in the WW group). IgG1 and IgG2 levels decreased but remained within the reference range for age in both study arms. IgM and IgA levels decreased as well but remained elevated. The IgA level in the adenotonsillectomy group decreased in significantly greater degree compared with the WW group, but this difference disappeared in cases where children experienced frequent URIs. In general, no relation between immunoglobulin levels and the number of throat infections or URIs at 1-year follow-up was found.
Immunoglobulin levels of children undergoing adenotonsillectomy decreased from elevated to slightly elevated or reference values for age during 1-year follow-up irrespective of treatment (adenotonsillectomy or WW). IgA showed a greater decrease in the adenotonsillectomy group but rose to levels comparable with the WW group in cases of frequent URIs. This finding indicates that the remaining mucosa-associated lymphoid tissue can compensate for the loss of tonsil and adenoid tissue.
Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society
- D Hirtz
- S Ashwal
- A Berg
- D Bettis
- C Camfield
- P Camfield
- Hirtz
Obstructive sleep apnea: Brain structural changes and neurocognitive function before and after treatment
- N Canessa
- V Castronovo
- S F Cappa
- M S Aloia
- S Marelli
- A Falini
- Canessa