Management of Snoring in Children

(Hong Kong—The Hong Kong Practitioner, October 2000, p. 495.) Up to 10 percent of children are reported to snore almost every night. Because any narrowing of the upper airway can predispose children to snoring, it can be caused by a wide range of clinical conditions, including adenoid enlargement, hypertrophy of nasal turbinates or retro-gnathia. Most childhood cases are caused by primary snoring and are not associated with hypoventilation, apnea, sleep disturbance or daytime symptoms. Any associated rhinitis or upper respiratory conditions should be managed and good sleep patterns should be encouraged. More serious cases of snoring may be associated with upper airway resistance syndrome or even obstructive sleep apnea. In these conditions, disturbance of sleep from hypoxia can lead to such daytime symptoms as inattention, hyperactivity, sleepiness and headache. Sleep polysomnography may be necessary for diagnosis, but may be difficult to perform in young children because most do not cooperate.

Update on Celiac Disease

(Australia—Australian Family Physician, September 2000, p. 835.) Celiac disease most commonly affects persons of Western European decent. In Australia, the prevalence may be more than one per 300 to 500 persons. Many of these cases remain subclinical while many more are misdiagnosed. Diagnosis can also be delayed because the presentation is highly variable. Celiac disease is an autoimmune response to the ingestion of prolamines in the gluten contained in wheat, barley and rye. The prolamines form complexes with tissue transglutaminase and these complexes stimulate an antigenic response from the mucosal T cells of the small intestine. The resulting damage to the intestinal mucosa can cause malabsorption. Clinically, celiac disease may present as a spectrum of conditions, from severe malabsorption to vague gastrointestinal symptoms and anemia in adults. An increasing number of cases are recognized as part of the diagnostic investigation of unexplained female infertility, recurrent miscarriage, disorders of calcium metabolism, or anemia secondary to iron or folate deficiency. Although biopsy of the small intestine is the conclusive diagnostic test, immunoglobulin A antibody tests that measure transglutaminase or endomysial antibodies are becoming more widely available. The management of celiac disease depends on the elimination of gluten from the diet and the correction of nutritional deficiencies. Support groups can be invaluable in maintaining compliance and helping families to manage the condition.

Navicular Stress Fracture

(Australia—Australian Family Physician, September 2000, p. 875.) Stress fracture of the navicular is the most likely diagnosis in a patient who presents with severe, increasing midfoot pain following an increase in exercise. To locate the navicular, the ankle should be dorsiflexed so that the insertion of the tibialis anterior into the medial cuneiform bone is apparent. The navicular is immediately proximal and will be tender to palpation if stress fracture is present. Patients with navicular stress fractures report increasing pain and difficulty in walking. Plain radiograph may fail to detect any abnormality or may show a fracture line or sclerosis, depending on the time since injury. Bone scan or computed tomography (CT) may be necessary to make the diagnosis. The management of navicular fractures requires six weeks of nonweightbearing, usually by applying a cast below the knee. A graded mobilization program should follow with the progression guided by CT evidence of healing. Surgical internal fixation and bone grafting may be required for delayed union.

Bacterial Skin Infections

(Great Britain—The Practitioner, October 2000, p. 836.) Infections involving hair follicles can be caused by different organisms and may result in different clinical presentations. Acute folliculitis, which usually occurs on the neck, beard area, buttocks or thighs, often follows abrasion or chemical injury that has allowed infection by Staphylococcus aureus. Topical antiseptic treatment is adequate for most cases, although some patients may benefit from systemic flu-cloxacillin or topical antibiotics such as mupirocin ointment. Severe cases of folliculitis can progress to form furuncles or carbuncles in which there are necrosis and deep infection of the follicle that spreads to surrounding tissue. These conditions require systemic antibiotic therapy as well as local management plus a search for underlying predisposing causes, such as diabetes. In sycosis, the beard area can become studded with pustules caused by subacute or chronic infection of hair follicles by S. aureus. While severe cases require systemic antibiotic therapy, most cases respond to treatment with a chlorhexidine wash.