International Journal of Pediatric Otorhinolaryngology 2021-10-23

Stenting versus stentless repair for bilateral choanal atresia: A systematic review of the literature

Leo Gundle, Shilpa Ojha, Joseph Hendry, Harry Rosen

Publication date 09-10-2021


Bilateral choanal atresia requires prompt surgical intervention. Surgeons have historically used stents in the repair process, however their efficacy has come into question in recent years. We performed a systematic review to investigate, primarily, whether stents enjoy more favourable outcomes compared to stentless repair. We also explored the use of operative adjuncts, such as steroids, antibiotics, mitomycin C and KTP laser. We performed a search of the Medline and Embase databases using a search strategy developed with the assistance of an academic librarian. Only full peer reviewed articles were included. Abstracts, posters, case reports and proceedings of academic conferences were excluded. We identified 48 unique articles for inclusion, composed of a meta-analysis, two randomised control trials and 45 case series. Pooled analysis of the two randomised control trials yielded no statistically significant difference in choanal patency between stented and stentless repair, but a statistically significant reduction in complications, specifically granulation tissue formation, was found in stentless repair. Data from case series were, overall, of mixed quality, making factors contributing to successful outcomes difficult to elucidate. Overall, there is a lack of high quality evidence to support the use of either a stented or stentless approach to bilateral choanal atresia repair, however stentless repair may experience fewer complications. Operative techniques, such as the use of mucosal flaps, are worthy of future study. Authors call for future high quality randomised control trials to investigate this uncommon but important condition.

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Erythropoietin levels in children with obstructive sleep apnea

Nick D. Kalogritsas, Vasileios A. Lachanas, Panagiotis Liakos, Emmanuel I. Alexopoulos, Despoina Beka, Efthymia Petinaki, Jiannis Hajiioannou, George Simos, Charalampos E. Skoulakis

Publication date 08-10-2021


High serum erythropoietin (EPO) levels have been reported in adult patients with obstructive sleep apnea (OSA), however there is a lack of related literature in children with OSA. The main objective of this study was to explore the potential use of EPO as a pediatric OSA biomarker by exploring the relationship between serum EPO levels and the presence of pediatric OSA. A prospective study was conducted on children (4-12 years old) referred for overnight PSG. Thirty (30) consecutive children with mild. 30 consecutives with moderate, and 30 consecutives with severe OSA (OSA group), as well as 30 consecutive children with AHI≤1 (non-OSA group) were recruited. Morning blood specimens after PSG studies were obtained in order to compare EPO levels. Finally, 115 children included for analysis. Non-OSA group consisted of 29 children (mean age: 6.93 ± 2.10) and OSA-group of 86 children (mean age: 6.78 ± 2.53). Mean EPO values for the non-OSA and OSA groups were 5.46 ± 2.29 mIU/ml and 8.33 ± 4.10 mIU/ml respectively. OSA-group had significant higher EPO levels than non-OSA (P: 0.01) while EPO levels were significantly correlated with AHI (p < 0.001). Our study showed that serum EPO levels of children with OSA are significantly higher than those without OSA and correlate significantly with AHI. These results suggest that EPO may be considered as a biomarker candidate for pediatric OSA. Since this may be the first study on the topic further research is needed.

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Psychosocial status of patients with unilateral and bilateral microtia before auricular reconstruction surgery

Yue Fan, Weijiao Liu, Xinmiao Fan, Xiaomin Niu, Xiaowei Chen

Publication date 05-10-2021


Microtia can profoundly influence health-related quality of life. The aim of this study was to investigate the psychosocial status of children and adolescents with unilateral and bilateral microtia before reconstruction surgery. Eighty-six patients with microtia from Peking Union Medical College Hospital (54 with unilateral microtia and 32 with bilateral microtia) responded to structured interviews before reconstruction surgery. The 3 clinically validated questionnaires were the Piers-Harris Children's Self-concept Scale (PHCSS), the Social Anxiety Scale for Children (SASC), and the Children's Loneliness Scale (CLS). Scores from the PHCSS and SASC were compared with Chinese norms. The total scores of the unilateral and bilateral groups were compared for all three questionnaires. Males with unilateral and bilateral microtia had significantly different PHSCC scores than norms (both P < 0.05), and male patients overall had a total score that was 10.61 ± 2.20 points lower than female patients overall. Patients who were 7-9 years-old in the unilateral group and 10 to 13 years-old in the bilateral group had lower total PHSCC scores than norms of the same age (both P < 0.05). There was no significant difference between patients and norms in the 14-16 years-old group. The SASC scores of patients were significantly higher than the norms (P < 0.05). The CLS score was significantly lower in the unilateral group than in the bilateral group (50.17 ± 14.63 vs. 61.38 ± 13.24, P < 0.05), but these two groups did not significantly differ in PHCSS and SASC scores. Compared to Chinese norms, children with unilateral and bilateral microtia had lower self-concept, especially males and those who were 7-13 years-old. Patients with microtia also had increased social anxiety and loneliness. Patients with bilateral microtia were more likely to report loneliness than those with unilateral microtia.

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Prognostic factors in the management of pediatric subglottic stenosis

Sarah Debs, Aasif A. Kazi, Dustin Bastaich, Leroy Thacker, Rajanya S. Petersson

Publication date 04-10-2021


We report outcomes of endoscopic interventions in the management of pediatric subglottic stenosis (SGS), and factors that lead to open airway reconstruction. A retrospective cohort review of all pediatric patients with SGS, treated by a single surgeon, at a tertiary academic medical center from 2012 to 2020 was conducted. Variables recorded included patient demographics, initial grade of stenosis, gestational age, length of intubation, comorbidities as well as total number of interventions. A total of 47 patients were included in the study, of which 51% (n = 24) were female. Laryngotracheal reconstruction (LTR) was performed in 49% (n = 23) of patients. Decannulation was achieved in 25 of 32 tracheostomized patients. Fifteen patients did not have tracheostomy. There was a significant difference in gestational age (28.7 ± 5.36 vs 33.2 ± 6.13), initial grade of stenosis (2.3 ± 0.82 vs 1.6 ± 0.88), and total number of interventions (5.7 ± 2.8 vs 2.3 ± 1.5) when stratifying patients proceeding to LTR versus not (p < 0.05). There was no significant difference, however, in the length of intubation between the two groups. Of the comorbidities recorded, none were found to have a significant impact on the outcome. Subglottic stenosis is a challenging condition to treat, often requiring multiple interventions including LTR. We propose a set of risk factors that may assist in the treatment of SGS patients with certain comorbidities to minimize interventions and maximize outcomes.

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Management of post-septal complications of acute rhinosinusitis in children: A 14-year experience in a tertiary hospital

Manuel Martins, Sónia Pires Martins, Carla Pinto-Moura, Vitor Leal, Jorge Spratley

Publication date 02-10-2021


Acute rhinosinusitis accounts for most of the cases of orbital infections and is the most common cause of periorbital oedema in children. Up to 10% of patients with orbital complications of acute rhinosinusitis may experience vision loss and other complications such as meningitis, intracranial abscess or even death. Therefore, these patients require prompt diagnosis and proper treatment. This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population. A retrospective medical chart review of all children aged under 18 years old who were diagnosed with post-septal orbital complications of acute rhinosinusitis at a tertiary academic hospital, between 01/2007 and 12/2020. Patients were grouped according to the Chandler Classification (groups 2-5). Fifty-five children (mean age of 6.91 ± 4.61 years) fulfilled the entry criteria for post-septal orbital complications of acute rhinosinusitis, based on clinical evaluation by an otorhinolaryngologist and CT-scan findings. Forty (72.72%) patients were also evaluated by an ophthalmologist. Most patients were male (76.36%). Twenty-four patients had post-septal cellulitis (43.63%), 21 patients had a subperiosteal abscess (38.18%) and 10 patients had an orbital abscess (18.18%). Eyelid swelling was the most frequent sign, followed by fever. Microbiology varied considerably and gram-positive agents were clearly predominant. Eighteen (32.73%) patients had been treated with oral antibiotics prior to hospital admission, exhibiting a significantly higher risk of recurrence of orbital infection (p = 0.020). Ethmoid and maxillary sinuses were the most involved paranasal sinuses (90.91%). Thirty-three patients (60%) were successfully treated medically, and 22 patients (40%) required surgical drainage. Seven patients (12.73%) developed further complications and six recovered without sequelae. The mean length of hospital stay was 8.0 ± 5.0 days and recurrence of orbital infection occurred in six patients (10.91%). The absolute neutrophil blood count was significantly different amongst Chandler groups (p = 0.021), with higher counts in patients with subperiosteal abscess. The duration of hospitalization was significantly higher in patients submitted to surgery (p < 0.001). Post-septal orbital complications of acute rhinosinusitis are infrequent but dangerous events in the paediatric population. Close collaboration with Ophtalmology is paramount, as the child's vision is at risk. Eyelid swelling and proptosis are early signs. CT-scan imaging plays an invaluable role in the diagnosis and decision-making. Predictive indicators for surgery were not found. However, emergency endoscopic nasal surgery with abscess drainage should be considered whenever vision is at risk, if there is no improvement after aggressive medical treatment, and in cases of intracranial complications.

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Evaluation of the factors affecting the necessity for revision surgery in choanal atresia

Levent Aydemir, Comert Sen, Hakan Kara, Saim Pamuk, Mustafa Caner Kesimli, Senol Comoglu, Meryem Nesil Keles Turel

Publication date 03-10-2021


This study aims to compare the effects of different surgical techniques for congenital choanal atresia (CCA), and particular emphasis is given to the analysis of the factors affecting the surgical outcome. The necessity for revision surgery and surgical outcomes were retrospectively investigated in patients undergoing revision surgery according to a recently proposed classification system. A retrospective study was conducted on patients operated for CCA between January 2007 and December 2018 at a university hospital. Data in the medical records, including patient age when the initial surgery was performed, gender, additional anomalies and medical conditions, the duration of gestation, side and type of atresia, type of surgery and need for revision surgery were reviewed. Forty-five patients treated for CCA in our university hospital were screened. The mean follow-up duration was 82.16 months. Revision surgery was required in 9 of 26 cases, which are included in the study (34.6%). Fourteen patients presented with bilateral CCA, while 12 were unilateral cases. Sixteen patients (61.5%) had comorbid medical conditions. While the removal of vomer and mucoperiosteal flap use affects successful surgical repair, no differences were observed in choanal atresia type, laterality, use of stent and the presence of additional medical conditions. The most important factors affecting surgical success for CCA are the removal of the vomer and closure of all bare bone tissues using a mucoperiosteal flap. Use of stents provides no additional benefit, apart from preventing synechiae formation.

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Tonsillectomy and hematologic malignancy: Should routine pediatric tonsillectomy specimens be sent to pathology?

Kaitlyn Tholen, Olivia Kalmanson, Christian R. Francom, Jeremy D. Prager

Publication date 02-10-2021


Routine pediatric tonsillectomy ± adenoidectomy (T ± A) is one of the most common procedures for children worldwide, accounting for approximately 2000 procedures per year at our institution. To determine the utility of pathologic analysis of routine, nonsuspicious pediatric tonsil specimens, we investigated the incidence of hematologic and lymphoid malignancy diagnosed at the time of or following T ± A. Retrospective review of patients 0-18 years undergoing T ± A between 2012 and 2020 with or without pathologic analysis. Included were 14,141 patients who underwent routine T ± A (mean age 11 ± 4.6 years, 48% female). Of these, tonsils of 2464 patients were sent to pathology, where zero were found to harbor malignancy. Seven patients (0.050%) developed malignancy after T ± A. Of these, 4 had unremarkable tonsils per pathology, and 3 did not have tonsils analyzed. There were 5 cases of Acute Lymphocytic Leukemia (ALL, 0.035%), 1 case of Acute Myeloid Leukemia (0.007%), and 1 case of Lymphoma (0.007%). The average length of time from T ± A to diagnosis was 2.4 ± 1.8 years. No cases of occult malignancy were identified in specimens from routine T ± A with pathologic analysis, even among patients who later developed malignancy. This study suggests that sending routine pediatric T ± A specimens for formal pathologic analysis is an inefficient use of resources without appreciably improving the quality and safety of patient care.

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Indications and clinical outcome in pediatric tracheostomy: Lessons learned

L.L. Veder, K.F.M. Joosten, M.D. Zondag, B. Pullens

Publication date 01-10-2021


Indications for tracheostomy have changed over the last decades and clinical outcome varies depending on the indication for tracheostomy. By gaining more insight in the characteristics and outcome of the tracheostomized pediatric population, clinical care can be improved and a better individual prognosis can be given. Therefore, we studied the outcome of our pediatric tracheostomy population in relation to the primary indication over the last 16 years. We retrospectively included children younger than 18 years of age with a tracheostomy tube in the Erasmus Medical Center, Sophia children's hospital. The primary indication for tracheostomy, gender, age at tracheostomy, age at decannulation, comorbidity, mortality, closure of a persisting tracheocutaneous fistula after decannulation, surgery prior to decannulation and the use of polysomnography were recorded and analyzed. Our research group consisted of 225 children.
Reasons for a tracheostomy were first divided in two major diagnostic groups: 1) airway obstruction group (subgroups: laryngotracheal obstruction and craniofacial anomalies) and 2) pulmonary support group (subgroups: cardio-pulmonary diseases and neurological diseases). Children in the airway obstruction group were younger when receiving a tracheostomy (3.0 months vs. 31.0 months, p < 0.05), they were tracheostomy dependent for a longer time (median 21.5 months vs. 2.0 months, p < 0.05) and they required surgery more often (74.5% vs. 8.3%, p < 0.05) than the children in the pulmonary support group. The decannulation rate of children with a laryngotracheal obstruction is high (74.8%), but low in all other subgroups (craniofacial anomalies; 38.5%, cardio-pulmonary diseases; 34.6% and neurological diseases; 52.9%). Significantly more children (36.7%) died in the pulmonary support group due to underlying comorbidity, mainly in the cardio-pulmonary diseases subgroup. Surgery for a persisting tracheocutaneous fistula was performed in 34 (37.8%) children, with a significant relationship between the duration of the tracheostomy and the persistence of a tracheocutaneous fistula. No cannula related death occurred during this study period. Main indications for a tracheostomy were airway obstruction and pulmonary support. Children in the airway obstruction group were younger when receiving a tracheostomy and they were tracheostomy dependent for a longer period. Within the airway obstruction group, the decannulation rate for children with laryngotracheal stenosis was high, but low for children with craniofacial anomalies. In the pulmonary support group, the decannulation rate was low and the mortality rate was high. Surgery for a persisting tracheocutaneous fistula was frequently needed.

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WRISTOX2 is a reliable tool to diagnose obstructive sleep apnoea syndrome

Surendran Thavagnanam, Shih Ying Hng, Anna Marie Nathan, Kah Peng Eg, Karuthan Chinna, Siti Hajar bte Turbirin, Jessie Anne de Bruyne

Publication date 28-09-2021


Overnight pulse oximetry is an alternative to polysomnography (PSG) in diagnosing obstructive sleep apnoea syndrome, but its sensitivity is reported to be low. To determine the (a) diagnostic accuracy, interobserver reliability and reliable oxygen desaturation index of 4% (ODI This cross-sectional study included children aged 1-18 years old, undergoing a fully attended overnight PSG for suspected obstructive sleep apnoea syndrome. The Nonin 3150 Wrist Ox One hundred and sixty-two children with a mean (SD) age of 9.3 (±3.5) years (range 2 years 6 months old - 17 years old) were included after excluding 18 children (poor oximetry data [n = 16] and incomplete PSG [n = 2]). Interobserver agreement of the Wrist Ox Overnight pulse oximetry with the Nonin 3150 Wrist Ox

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Socio-demographic profile and its influences on rehabilitation in children undergoing revision cochlear implantation – MERF experience

Ruchima Dham, Sandhya Dharmarajan, Rahul Kurkure, Raghu Nandhan Sampath Kumar, Mohan Kameswaran

Publication date 25-09-2021


Revision cochlear implant surgery (RIS) is an unusual and unfortunate event, but not an uncommon occurrence in today's time, with more and more children being implanted. It is accepted that a pediatric cochlear implant recipient may require one or two revision procedures during their lifetime. The indication of RIS can be due to a multitude of causes like trauma, device failure (hard failure or soft failure), infection at the implant site, electrode extrusion, device migration, magnet migration, and upgradation in the technology. Scenarios, where the child is deprived of hearing once again is worrisome for the family. And, they need financial and psychological assistance as well. (1) To scrutinize the socio-demographic profile of children who underwent RIS. (2)To profile the social, intellectual, and economic backgrounds of these families. A retrospective, observational, non-interventional, cohort study conducted at the Implantation otology department of Madras ENT Research Foundation (MERF), Chennai, Tamil Nadu, India. (1) Detailed medical records of all the children who satisfied the inclusion criteria were reviewed.(2)This was followed up by a telephonic interview with the guardian of the consenting patients, to obtain further data based on a customized questionnaire. Of the 99 children who underwent RIS, 80 families consented to be part of the study. (1) Cause of revision implant surgery and Family system Risk estimate.(2) Correlation of sex, family system, patient non-compliance to habilitation, and residential area with RIS.(3) Correlation of the residential area of the patient with completion of 1-year habilitation. A significant association observed between RIS and Sex (P = 0.03). A significant co-relation between patient non-compliance to habilitation and cause of revision implant surgery observed (P = 0.02). A significant co-relation was seen between residential area (Rural/Urban) and cause of RIS (P = 0.02). A statistically significant correlation seen with the residential area (Rural/Urban) of the child and completion of 1-year habilitation (P = 0.01). Uni-variant association was found between patients that have completed one year of habilitation, patient compliance, and modified Kuppuswamy Socio-Economic status. The current data has aided in refining our institutional management protocols and predicting high-risk candidates who may need revision surgery in the future. Based on the data, all cochlear implantees and their families especially in the lower socio-economic strata, are now being meticulously educated about device care, the possible reasons for failures, and the importance of timely re-intervention.

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Impact of the novel coronavirus on surgical practices at a tertiary pediatric hospital: A 3 year cross-sectional study

Ashley M. Lloyd, Hengameh K. Behzadpour, Habib G. Zalzal, Ishwarya S. Mamidi, Hannah R. Crowder, Claire M. Lawlor, Diego Preciado, Brian K. Reilly

Publication date 20-09-2021


The novel coronavirus (COVID-19) forced unprecedented changes in pediatric otolaryngology workflow in the early pandemic, particularly due to the postponement of elective procedures. In turn, this has impacted timely treatment of patients and ability to train residents and fellows. The objective is to characterize how surgical practices in pediatric otolaryngology have been impacted by the pandemic through a cross sectional analysis over three years. This cross-sectional study focuses on patients who underwent surgical procedures within the department of otolaryngology at a single tertiary pediatric hospital. Descriptive statistical analysis was used to compare subsets of patients from pre-pandemic in 2019, early-pandemic in 2020, and late-pandemic in 2021. Operative volume decreased by 87.57% in the early pandemic and 36.86% in the late pandemic. In the early pandemic, the greatest decreases were seen in airway reconstruction (100%), adenotonsillectomy (96.4%), adenoidectomy (94.7%), myringotomy with tympanostomy tube insertion (94.6%), frenulectomy (94.1%), and sinonasal procedures (93.3%), while in the late-pandemic adenotonsillectomy (42.4%) and myringotomy with tympanostomy tube insertion (70.1%) remained reduced when compared to pre-pandemic volume. Increased average case lengths in the early-pandemic (78.28 ± 51.95 min) and late-pandemic (71.91 ± 70.76 min) were observed when compared to pre-pandemic (52.26 ± 39.20 min) (p < 0.001). An increased proportion of multidisciplinary cases were completed in 2020 and 2021 (p < 0.001). In the 2020, 25% of cases were completed without trainee involvement. There was an overall decrease in case numbers for trainees and increase in cases without their involvement when compared to 2019 and 2021. The COVID-19 pandemic resulted in a decrease in pediatric otolaryngology surgical procedures, particularly at the onset of the pandemic. While surgical trainees saw a dramatic reduction in case numbers early on, one year into the pandemic case volume is increasing and trending to pre-pandemic numbers. More complex cases, as represented by patients requiring longer operative times, inpatient status, and more frequently multidisciplinary care, were seen in the early pandemic, while drastic reductions were seen in routine outpatient procedures.

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Vestibular testing in children – The suppression head impulse (SHIMP) test

J. Nguyen, J. Berger, I. Curthoys, V. Held, L. Zaubitzer, R. Hülse, N. Rotter, A. Schell

Publication date 20-09-2021


The incidence of vestibular disorders and vertigo during childhood is increasing and pediatric clinicians have become more sensitive to children's balance disorders; thus, there is a need for appropriate detection test procedures for peripheral vestibular hypofunction. In order to ensure a reliable diagnosis and minimize misdiagnosis, a standardized clinical procedure via careful history and clinical examination is recommended. However, children, especially, are often unable to verbalize "vertigo" in a concrete manner, which often necessitates a consultation with a pediatrician holding nonspecific symptoms. The so-called suppression of the head impulse test (SHIMPs) represents a modification of the video head impulse test (HIMP) and is used for a more sensitive assessment of residual vestibular functions. In adults, SHIMPs are already an established diagnostic method. Nevertheless, to date, nothing is known about the applicability and standard values in childhood. In this monocentric, prospective study, we investigated whether SHIMPs enable a sensitive functional analysis of the vestibular system in healthy children of different ages. For this purpose, SHIMPs were performed in 40 children aged 3-18 years. In this study, we demonstrated that SHIMPs can be easily performed in children (3-18 years). It is vital that the test be appropriately explained for children to ensure sufficient test tolerance and compliance. SHIMPs are a helpful supplement to clinically established vestibular tests such as the HIMP in pediatric vestibular balance disorder diagnostics and can be integrated into the clinical routine, especially in children who have minimal verbal abilities or understanding of the instructions for HIMP. Similar to the HIMP, SHIMPs are characterized by a short test duration and a high tolerance.

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The important role of RPS14, RPL5 and MDM2 in TP53-associated ribosome stress in mycophenolic acid-induced microtia

Yangyang Lin, Corstiaan C. Breugem, Saskia M. Maas, Bernadette S. de Bakker, Gaofeng Li

Publication date 20-09-2021


Mycophenolate embryopathy (ME) is a congenital malformation induced by mycophenolic acid (MA). Microtia is the most common ME phenotype. This study aimed to identify the key genes in the pathological process of microtia caused by mycophenolate mofetil (MM) through bioinformatics methods, to explore the potential pathogenesis, and to provide a direction for future genetic research on aetiology. Genes related to MM and microtia were obtained from the Gene Cards database for bioinformatics. Metacore was used to identify and visualize the upstream and downstream gene relationships in the protein-protein interaction (PPI) results of these genes. The cluster Profiler R software package was used to simulate and visualize the enrichment results based on data from Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. Fifty-nine genes were associated with microtia and MM/MA. The hub genes with the most significant effects on MM/MA-induced microtia pathogenesis included tumour protein P53 (p53), MDM2 proto-oncogene (MDM2), ribosomal protein L5 (RPL5) and ribosomal protein S14 (RBS14). The GO term with the most enriched genes was peptidyl-tyrosine phosphorylation. For the KEGG terms, there was significant enrichment regarding the haematopoietic cell lineage, apoptosis, p53 signalling, proteasome and necroptosis. We propose that an axis composed of MA, microtia, TP53 and related genes is involved in ME pathogenesis. The important role of TP53-associated ribosome stress in ME pathogenesis is consistent with our previous findings from MA-induced cleft lip and palate. Deregulation of genes protective against TP53 overexpression, such as MDM2, could be a strategy for constructing a microtia animal model.

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Acetylsalicylic acid suppression of the PI3K pathway as a novel medical therapy for head and neck lymphatic malformations

Juliana Bonilla-Velez, Kathryn B. Whitlock, Sheila Ganti, Kaitlyn Zenner, Chi Vicky Cheng, Dana M. Jensen, Minh-Hang M. Pham, Ryan M. Mitchell, William Dobyns, Randall A. Bly, James T. Bennett, John P. Dahl, Jonathan A. Perkins

Publication date 20-09-2021


Head and neck lymphatic malformations (HNLM) are caused by gain-of-function somatic mutations in PIK3CA. Acetylsalicylic acid (ASA/aspirin) is thought to limit growth in PIK3CA-mutated neoplasms through PI3K pathway suppression. We sought to determine if ASA could be beneficial for HNLM. Retrospective case series of patients (0-18 years) offered ASA (3-5 mg/kg/day) for HNLM treatment (2010-2018). Clinical and treatment characteristics, patient-reported symptom improvement, medication tolerance, compliance, and complications were recorded. Treatment response was determined by change in patient/caregiver-reported symptoms, or HNLM size [complete (resolved), partial (decreased), or stable]. Fifty-three patients were offered ASA, 23 (43%) accepted (median age 10 years, IQR 6-14). Compared to patients who declined, patients receiving ASA were more likely to have extensive malformations: ex-utero intrapartum treatment procedure, bilateral malformations, oral cavity location, ≥2 invasive treatments, or tracheotomy (p < 0.05). All patients with tissue available had PIK3CA mutations (13/23). Treatment indications included oral pain/blebs (12, 52%), recurrent pain/swelling (6, 26%), or sudden/persistent swelling (5, 22%). Treatment plan was commonly one 81 mg tablet daily (19, 83%) for 3-12 months (8, 42%). Therapeutic adherence was reported by 18 patients (78%). Symptoms improved in 18 patients [78%; decreased pain (9, 39%) and swelling (8, 35%)]. Treatment resulted in partial (14, 61%) or complete response (4, 17%). Three patients developed oral bleb bleeding, which resolved with medication discontinuation. ASA seems to be a well-tolerated, low-risk medication for HNLM treatment. This pilot study suggests that it often improves symptoms and reduces HNLM size. Further prospective, randomized studies are warranted to comprehensively assess indications, safety, and efficacy. Level 4.

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Socioeconomic factors associated with readmission following pediatric tonsillectomy

Ashley M. Lloyd, Hengameh K. Behzadpour, Ian Schonman, Md Sohel Rana, Alexandra G. Espinel

Publication date 12-09-2021


We aim to analyze factors associated with readmission after tonsillectomy to understand socioeconomic factors associated with readmission. Single institution retrospective study of pediatric patients undergoing tonsillectomy over an 8 year study period, comparing patients who required readmission for bleeding concerns or pain/dehydration to those who did not require readmission. Of the 14,152 tonsillectomy patients, 508 (3.6%) were readmitted with 423 (83.3%) for bleeding concerns and 85 (16.7%) for pain or dehydration. Overall readmission was more likely in age >6 years (OR: 1.61, 95% CI: 1.34-1.92, P < 0.001), while poverty level below 10% (OR: 0.79, 95% CI: 0.66-0.94, P = 0.008) and parental college education above 25% (OR: 0.79, 95% CI: 0.65-0.96, P = 0.016) were associated with lower incidence of overall readmission. For patients readmitted for bleeding concerns, age >6 years (OR 1.66, 95% CI: 1.37-2.02, P < 0.001) was associated with readmission on multivariate analysis. Within the pain/dehydration group, African American race was associated with increased readmission rates, while poverty level below 10% and parental college education above 25% were associated with decreased readmission rates. Socioeconomic factors and age play a role in readmission rates following pediatric tonsillectomy.

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Endoscopic inlay cartilage and perichondrium myringoplasty for repairing large perforations in teenagers

Zhengcai Lou, Kangfeng Jin, Junzhi Sun

Publication date 11-09-2021


This study compared the long-term graft success rates and hearing outcomes of overlay-underlay and underly cartilage myringoplasty for repairing large perforations in Teenagers. prospective, randomized study. Tertiary referral center. Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups:intervention group (n = 39) and control group (n = 41). The graft success rate, hearing improvement, and complications were compared between the two groups. A total of 80 patients were included in this study. The graft success rate was 100% in the intervention group and 95.1% in the control group at postoperative 3 months, the difference wasn't significant (P = 0.496). Also, the graft success rate was not significantly different between the two groups at 12 months postoperatively (100.0% vs 87.8%, p = 0.073). However, the difference of graft success rate was significant between the two groups at 24 months postoperatively (97.4% vs 75.6%, p = 0.012). CT examination revealed well-pneumatized middle ears 24 months after surgery in both group. However, epithelial pearls near the umbo were seen at 31 months postoperatively in one patient in the observation group. Compared to the endoscopic cartilage with perichondrium composite graft underlay technique, endoscopic perichondrial graft overlay and cartilage underlay had a better long-term graft success rate and lower rate of long-term re-perforation in teenagers. However, the graft technique had no effect on hearing outcome.

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Clinical experience of paediatric self-expanding foam cuffed tracheostomy tubes

A. Carter, A. Hall, V. Thorpe, L. Cochrane, J. Cooke

Publication date 04-10-2021


Use of self-expanding foam-filled tracheostomy tube cuffs (Bivona® FOME cuf®) in paediatrics has become a recent practice within our institution for patients with intractable aspiration. The current literature, clinical indications and subsequent management is lacking. We present our experience with a cohort of children with a foam-cuffed tracheostomy tube managed at Great Ormond Street Hospital, describing their indications and outcomes, as well as routine and emergency management. Our tracheostomy patient population was reviewed and those with a Bivona® FOME cuf® tracheostomy tube were identified and reviewed. The indications for foam-cuffed tracheostomy tube insertion, progress, and further management, including emergency care, were reviewed. Ten patients were identified, all with a chronic history of respiratory infections secondary to aspiration being the leading indication. All patients had an ongoing improvement in their chest function following insertion with no episodes of cuff trauma. One patient had difficulty when a port line was accidently cut, which resulted in difficulty of removal, and we outline a strategy for dealing with this. The foam-cuffed tracheostomy tube is a useful tracheostomy tube to use in the management of chronic aspiration in children with poor chest health, however due to the lack of knowledge and experience they can prove to be a difficult tube to manage. Further educational information should be available as to the indications, routine care and emergency management of Bivona® FOME cuf® tracheostomy tubes. We believe they represent a useful option for institutions to consider in the paediatric population.

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What is the relationship between the size of the adenoids and nasal obstruction? A systematic review

Christian Calvo-Henriquez, Ana María Branco, Jerome R. Lechien, Alberto Maria-Saibene, Maria Victoria DeMarchi, Beatriz Valencia-Blanco, Borja Boronat-Catalá, Jesús Rangel-Chávez, Carlos Martin-Martin

Publication date 20-09-2021


adenoidectomy is one of the most common surgical procedure in pediatric otolaryngology practice. Clinical guidelines (such as the Spanish or American) suggest adenoidectomy when the enlargement of the adenoids is associated with nasal obstruction. Nasal endoscopy and cephalograms are adequate methods to estimate the size of the adenoids. However, they do not measure nasal patency. This systematic review is designed with the objective of exploring the relationship between adenoid size and nasal ventilation through rhinomanometry. 3 authors members of the YO-IFOS rhinology study group independently analyzed the data sources (Pubmed, the Cochrane Library, EMBASE, SciELO) for papers assessing both nasal resistance and/or nasal airflow in rhinomanometry and adenoid size by any method (endoscopy, cephalogram, direct examination). A total of 10 studies with a total population of 969 participants met the inclusion criteria. 5 authors explored the size of the adenoids through endoscopy. 4 authors explored the adenoids through lateral cephalograms. Finally, a further 2 authors explored adenoid size studying the resected tissue. Five studies explored the correlation between adenoid size and nasal resistance in rhinomanometry, which ranged from 0.20 to 0.84. Finally, 5 studies used nasal decongestant. It was found higher sensitivity and specificity, a higher area under the curve for the receiver operating characteristic curve, and higher correlation with adenoid size for rhinomanometry under nasal decongestion. Up to now, there is no ideal diagnostic method for adenoid hypertrophy. Therefore, it seems prudent to use a combination of all currently available tools, as they provide complementary, rather than supplementary information. Available evidence suggests that rhinomanometry combined with nasal decongestant could help to elucidate the existence of nasal obstruction in intermediate cases of adenoid hypertrophy, as well as throw light on other possible causes for nasal obstruction, mainly turbinate hypertrophy.

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Neonatal respiratory distress due to a third or fourth branchial pouch sinus: A systematic review

M. Matthijs Fockens, Carlijn E.L. Hoekstra

Publication date 16-09-2021


Third and fourth branchial pouch sinuses can be rare causes of respiratory distress in neonates. An overview of this distinct clinical entity is missing in literature. To aid clinicians in recognizing and adequately treating this unique entity, we conducted a systematic review to discuss patient characteristics, diagnostic considerations and treatment strategy. MEDLINE and EMBASE were searched from inception to December 29th Thirty-nine studies describing 56 patients (66% male, aged 0-30 days) were analyzed. Symptoms included cervical mass (76.8%), stridor (55.4%), dyspnea (35.7%) and cyanosis (17.9%) due to a third (39.3%) or fourth (60.7%) branchial pouch sinus. Intubation was performed before treatment in 31.3%. The piriform sinus opening was identified with rigid endoscopy in 81.1%. Surgery was the treatment of choice in the majority of patients (85.7%), with a success rate of 100% and a complication rate of 10.7%. Endoscopic cauterization was successful in 40% and endoscopic cauterization followed by sclerotherapy was successful 100%, with no complications. Third or fourth branchial pouch sinuses can lead to respiratory distress in neonates. It is important to recognize this distinct clinical picture for adequate diagnosis and treatment. Rigid endoscopy is indicated to demonstrate an opening in the piriform sinus and provides the opportunity to directly perform treatment with endoscopic cauterization. If this is insufficient to relief respiratory symptoms due to a persistent cyst, sclerotherapy or surgical excision should be considered.

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Radiofrequency ablation turbinoplasty improves the sense of smell in pediatric patients: A prospective study

Christian Calvo-Henriquez, Franklin Mariño-Sánchez, Jerome R. Lechien, Byron Maldonado-Alvarado, Antonino Maniaci, Juan Maza-Solano, Gabriel Martínez-Capoccioni, J.Carlos Neves, Carlos Martin-Martin

Publication date 15-10-2021


The olfactory sense is of paramount importance for the adequate development of a child. Olfactory loss in children might have different origins. One of the most common is conductive, when nasal obstruction prevents odorants from reaching the olfactory epithelium. Rhinitis and turbinate enlargement have been proven to diminish the sense of smell in pediatric patients. A common treatment for resistant rhinitis in these patients is turbinate radiofrequency ablation (TRA). However, despite an increasing research effort in this field, there are no studies instrumentally assessing olfaction in children undergoing turbinate surgery to date. This study was designed with the aim of assessing changes in olfaction through validated instrumental tools in pediatric patients undergoing TRA for the first time. A prospective uncontrolled intervention clinical trial design was conducted. Two cohorts of children ranging 4-15 years old were consecutively selected from a third level referral Hospital and subjected to the universal sniff test (U-Sniff), alcohol sniff test (AST), and sniffin sticks threshold test (SST) before and 1, 3 and 6 months after surgery. Cohort A consisted of children solely undergoing TRA. Cohort B consisted of children on whom adenoidectomy and TRA had been performed. Additionally, a cohort of Spanish healthy controls, paired by sex and age, were asked to perform the U-Sniff. A total of 81 participants with a mean age of 10.31 ± 2.56 years were included. Fifty-three patients underwent TRA exclusively and 28 were subjected to associated adenoidectomy. Despite a tendency toward improvement in the U-sniff scores, there were no statistically significant differences after surgery. However, statistically significant differences were obtained for threshold tasks measured with SST and AST, revealing differences at 1, 3 and 6 months after surgery compared to preoperative scores. In summary, this research demonstrated adequate levels in the sense of smell regarding identification tasks, but decreased olfactory threshold scores in pediatric patients suffering from TE. TRA, alone or with adenoidectomy, improved smell threshold scores, but had no significant effect on identification tasks.

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School-based hearing screening in Sweden – An evaluation of current practices

Adriana Cuasquen Cadena, Nina Lindholm, Karin Stenfeldt

Publication date 12-10-2021


Routines for school hearing screening vary between municipalities in Sweden, and no study has been carried out to investigate how this is conducted throughout the country. The aim of the present study was to determine the extent of school hearing screening, and how it is performed in all the municipalities in Sweden. An online survey was used to collect information on school hearing screening from municipalities in Sweden (N = 290). The survey included questions on the performance of hearing screening, including stimulus level and frequencies tested, the criteria for referral for further hearing evaluation, as well as the equipment and room used for testing, and who carried out the screening. Questions were also included on experience of, and attitudes towards hearing screening. Answers were received from 225 municipalities (response rate 78%). Universal school hearing screening was performed in 202 municipalities, while in the other municipalities hearing screening was performed when a child was evaluated due to speech delay or learning difficulties. Many different protocols were used involving different stimulus levels, frequencies, and referral criteria. The most common was testing with pure tone audiometry with a lowest stimulus level of 20 dB HL at five frequencies, 500-6000 Hz. Hearing screening was usually performed in the preparation class (6 years of age), while in other municipalities it was performed in year 1 (7 years of age). Hearing screening was usually performed once in primary school, while some municipalities carried out screening once in primary school and once in high school. More rarely, hearing screening was conducted twice in primary school. In 25 % of the municipialities, newly arrived immigrant children were screened. Difficulties in performing hearing screening were reported, such as lack of soundproof rooms, lack of time and technical difficulties. There was an opinion among the participants that identifying students with hearing loss is important, as it affects their learning ability and communication skills. and they expressed a desire for national guidelines. Hearing screening is performed in the vast majority of municipally run schools in Sweden. The way in which screening was performed varied regarding the stimulus level and frequencies used, as well as the criteria for referral to a specialist. The attitude towards hearing screening was positive among the participants. Hearing screening of newly immigrated children is important as their previous medical history is often unknown. There is a need for national guidelines on hearing screening of Swedish schoolchildren. Efforts must continue to ensure that the same level of healthcare regarding children's hearing is provided throughout the whole of Sweden.

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Readability analysis of Spanish language patient-reported outcome measures in pediatric otolaryngology

Shambavi J. Rao, Joseph C. Nickel, Eleanor P. Kiell, Noel I. Navarro, Lyndsay L. Madden

Publication date 11-10-2021


Pediatric otolaryngology encompasses interactions with a young patient, parent and/or guardian, and the provider. As healthcare transitions toward patient-centered care, clinicians are using direct tools of measurement such as patient-reported outcome measures (PROM) as a modality of communication between the patient and healthcare provider. Therefore, literacy levels of both the patient and their parent or guardian must be considered. Moreover, PROMs administered in pediatric audiology and otolaryngology in Spanish were found to be above the recommended reading level. Assessing the readability of Spanish translated PROMs is vital in providing safe, accurate, and quality care. The goal of this study is to analyze the readability of PROMs in pediatric otolaryngology and assess their compliance with readability recommendations. Pediatric otolaryngology PROMs were identified from Powell's systematic review on pediatric otolaryngology PROMs. Spanish pediatric otolaryngology PROMs were selected from a literature search through Pub Med (pubmed.ncbi.nlm.nih.gov) and Google scholar databases (scholar.google.com). After completion of the literature search, seven PROMs were identified. Only four PROMs Spanish validations included the translation of the PROM in their publication. The authors of the remaining PROMs were contacted via email. Ultimately, eight pediatric otolaryngology PROMs were included in this study. The PROMs included were assessed by a Latin Spanish translator for grammar, syntax, and comprehension ease. Four out of eight PROMs (50%) included in our study had readabilities above the recommended sixth-grade level.
The following PROMs were noted with readabilities above the recommended level: tonsil & adenoid health status instrument (TAHSI), the nasal quality of life survey (SN-5), Spanish pediatric voice handicap index (P-VHI), and velopharyngeal insufficiency effects on life outcome (VELO). Currently, some Spanish translated pediatric PROMs are written at a reading level above the recommended range for patients and their families.

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Pediatric thyroglossal duct cyst excision: A NSQIP-P analysis of 30-day complications

Ayman A. Mustafa, Nicole M. Favre, Matthew J. Kabalan, Michele M. Carr

Publication date 11-10-2021


Identify and compare clinical risk factors, perioperative sequelae, and surgical complications of infants age 2 or younger to children above age 2 undergoing thyroglossal duct cyst (TGDC) excision. Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric Database (2014-2018). Study population includes pediatric patients (≤18 years) who underwent excision of TGDC. Infants aged 2 years or younger were compared to children older than 2 years. A total of 3052 cases were identified. There were 375 infants with an age of 2 years or younger and 2977 children who were older than 2 years. Mean age at time of surgery was 6.3 years, with a female-to-male ratio of 1:1.1. Following hospital discharge, there were 70 related readmissions and 3 related reoperations. There was no statistically significant gender (p = .270) or ethnic (p = .122) differences between groups. Additionally, a history of prematurity (p = .759) and postoperative admission status (ie, inpatient versus outpatient, p = .697) were not statistically significantly different between groups. Lastly, general complication rates between age groups including Clostridium difficile colitis, occurrences of bleeding and blood transfusion, surgical site infections, related readmission, and reoperation were not statistically significantly different. TGDC excision was not shown to be associated with increased risk when performed in infants age 2 or younger compared to children older than age 2.

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Early preclinical evaluation of a novel, computer aided designed, 3D printed, bioresorbable posterior cricoid scaffold

Ross Michaels, Harsha Ramaraju, Sara J. Crotts, Scott J. Hollister, David A. Zopf

Publication date 11-09-2021


The posterior cricoid split with rib graft is a procedure that elegantly corrects pediatric posterior glottic stenosis and subglottic stenosis. Currently, the procedure requires harvesting of rib cartilage which leaves room for optimization. With use of three dimensional printing technology, our objective was to design a device that would negate the need for costal cartilage harvesting in this procedure. An optimized, novel polycaprolactone scaffold was designed using computer aided design software and three dimensional printing. A pilot proof of concept study was conducted with implantation of the device in three porcine animal subjects. Device was evaluated by post-procedural clinical course, endoscopic exams, post-mortem exam, and histological evaluation. A series of variably sized scaffolds were created. The scaffolds showed structural integrity and successfully expanded the cricoid cartilage in the porcine model study. Post-operative endoscopy and clinical exams demonstrated no signs of implant instability or failure. Gross and histologic exams showed successful mucosalization over the scaffold and cartilage ingrowth by six weeks. This porcine animal pilot study demonstrated early success of a computer-aided designed, 3D printed, bioresorbable PCL posterior graft scaffold. The scaffolds eliminate the need for costal cartilage harvesting and had excellent surgical usability. The scaffolds functioned as designed, offering proof of concept and grounds for further evaluation to expand on this small pilot study with larger animal studies and continued design refinement.

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Osteogenesis Imperfecta and hearing loss in the paediatric population

Judith K. Joseph, Shivesh H. Maharaj

Publication date 10-09-2021


Osteogenesis Imperfecta is a genetic disorder affecting the synthesis of collagen in the body. It is also known as 'Brittle Bone Disease'. It is heterogenous in its clinical presentation. The commonest presentation is a history of frequent fractures, joint deformities and blue sclera. Secondary deformities of the extremities, spine, skull as well short stature observed frequently. Hearing loss has been well documented to occur in Osteogenesis Imperfecta. It is most commonly seen in types I, II and III. Hearing loss forms part of the diagnostic criteria for these types. Depending on the study, the prevalence of hearing loss in children with Osteogenesis imperfecta is between 6.7% and 77.3% The estimated prevalence of Osteogenesis Imperfecta is 1 in 20000. In South Africa, the commonest type of Osteogenesis Imperfecta was found to be Type III. The prevalence of OI Type III has been estimated to be between 1:125000 and 1:200000. Hearing loss is a common feature of OI Type III. This study was a Prospective Cross-sectional study. Ethics Approval was obtained from the University of Witwatersrand Ethics committee (Ethics number M190975) Children with Osteogenesis Imperfecta attending the Metabolic Bone Clinic at Chris Hani Baragwanath Academic Hospital were the target group. The patients and their parents or guardians were recruited at the clinic after a consent and or an assent was obtained. An Otoscopy followed by tympanometry and a hearing screen based on the age of the patient was done. DPEOAEs were also done as a screening test to confirm the pure tone audiogram findings. The results were given to the patients and their parents/guardians immediately. The paediatric patients with Osteogenesis Imperfecta who consented to take part in the study had their hearing screen done at the Audiology Department at Chris Hani Baragwanath Academic Hospital. All of the children were found to have normal hearing. On tympanometry, all except 2 were found to have type A curves in bilaterally. Two patients had a type As curve in one ear with an A curve on the other side. Hearing loss in Osteogenesis Imperfecta forms part of the diagnostic criteria for certain types of this genetic disorder. Hearing loss in the paediatric patients does not seem to be as prevalent as previously thought. All the patients involved in the study were receiving the bisphosphonate therapy (Zoledronic acid) for OI. This may possibly cause a delay in the onset of hearing loss but long term follow-up studies and bigger sample sizes will be required to prove this hypothesis.

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(−)-Epigallocatechin-3-gallate (EGCG) prevents aminoglycosides-induced ototoxicity via anti-oxidative and anti-apoptotic pathways

Yulong Zong, Fang Chen, Shanshan Li, Hui Zhang

Publication date 10-09-2021


Aminoglycoside-induced cochlear ototoxicity causes inner ear hair cells (HCs) loss and leads to hearing impairment in patients, but no treatment completely eliminates the ototoxic effect. This study aims to determine the effectiveness of (-)-Epigallocatechin-3-gallate (EGCG) as a protective agent against aminoglycoside-induced ototoxicity. Zebrafish were exposed to EGCG for 24 h and then co-treated with EGCG and ototoxic agent (amikacin and gentamicin) for 5 h to explore the protective effect of EGCG on zebrafish HCs. Network pharmacology analysis and molecular docking simulation were conducted to explore its potential mechanism, and in vitro cell experiments were used to validate the outcome of the result. EGCG against ototoxicity of aminoglycosides in zebrafish HCs. Network pharmacology analysis and molecular docking showing that molecules related to cellular response regulation to oxidative stress, including AKT1, DHFR, and MET, may be the target proteins of EGCG, which were verified in vitro experiments. Further experiments demonstrated thatEGCG can antagonize the death of HCs caused by amikacin and gentamicin by reducing intracellular reactive oxygen species (ROS) accumulation and anti-apoptosis. EGCG can be an otoprotective drug against aminoglycosides-induced ototoxicity, prevent cellular apoptosis and significantly reduce oxidative stress.

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Endoscopic endonasal management of skull base defects in pediatric patients

Arad Iranmehr, Mehdi Zeinalizadeh, Mohamad Namvar, Ali Fathi, Hesam Azimi, Azin Tabari, Seyed Mousa Sadrehosseini

Publication date 07-09-2021


Skull base defects in children may be the result of congenital anomalies or trauma. They often present as cerebrospinal fluid (CSF) rhinorrhea, meningitis, brain abscess or nasal obstruction. Surgical intervention is predominantly the treatment of choice. Our goal is to assess the efficacy of endoscopic endonasal approach in treating skull base defects in pediatric patients. In this retrospective study we identified 38 patients (mean age 8.7 ± 5.6 years old, ranging 2 months-18 years) who underwent endoscopic endonasal repair of skull base defects, between March 2010 and February 2020. Patients who had skull base reconstruction after tumor resection, those who were lost to follow-up or did not sign the consent forms were excluded from the study. The clinical indications for endoscopic endonasal repair were trauma (n = 24, 63.1%) and congenital defects (n = 14, 36.9%). Congenital skull base defects included basal meningoencephalocele (n = 5, 35.7%) and frontoethmoidal defects (n = 9, 64.3%). Mean follow up time was 32 ± 29.04 months, ranging 2-103 months. Fat graft (alone or in combination) was the most commonly used material to repair the skull base defects. Thirty-seven patients (97%) showed successful results after endoscopic endonasal surgery and were symptom free. The endoscopic endonasal repair of CSF leak and skull base defects proved to be safe and feasible with 97% success rate.

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The effect of nutritional status on post-operative outcomes in pediatric otolaryngology-head and neck surgery

Jordan Luttrell, Matthew Spence, Hiba Al-Zubeidi, Michael J. Herr, Madhu Mamidala, Anthony Sheyn

Publication date 06-09-2021


Nutritional status can affect surgical patients in terms of stress response, healing time, and outcomes. Several abnormalities are known to have a high prevalence in the general population such as vitamin D deficiency (VDD) and subclinical hypothyroidism. We hypothesized that there will be elevated rates of nutritional deficiencies in preoperative patients which may adversely affect postoperative outcomes following pediatric otolaryngology surgery. IRB approval was obtained for a cross-sectional cohort study. Consecutive patients underwent nutritional evaluation when being scheduled for surgery including TSH, albumin and vitamin D. Demographic data, supplementation, and early complication rates were collected. 125 patients were included in the final cohort with adequate demographic distribution. Based on anthropometric data, 12% of our cohort was found to be undernourished, and 40% of our cohort with elevated BMI. However, there was no relationship found between Z-scores and complications. VDD was noted in 83/125 (66.4%) patients. Our cohort had increased rates of VDD in patients with elevated BMI and African American ethnicity. Thyroid hormone abnormalities were present in 12 patients. Mean serum albumin level was 4.29 in our cohort all within normal range. We did find increased risk of postoperative complications in patients with previously diagnosed comorbidities. (p=0.006). There is no current recommendation or consensus for nutritional assessment in preoperative pediatric patients. Our study did not show statistically significant correlation with z-scores, low vitamin D levels with supplementation, albumin, or TSH to postoperative complications. However, our patient cohort had higher than average rates of VDD compared to the many studies of the general pediatric population and significant negative correlation between vitamin D levels and z-scores. By early preoperative identification of VDD and supplementation with calciferol, we found no significant difference in complication rates in patients based on their initial vitamin D status. We suggest screening preoperative patients using z-score calculations and vitamin D levels based on individual patient risk factors including atrisk patient populations such as African American children, and obese children.

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Spontaneous bone bed formation in pediatric cochlear implantation is associated with duration of implantation

Khassan Diab, Olga Pashchinina, Dmitry Kondratchikov, Olga Panina, Lyudmila Balakina, Artyom Korobkin

Publication date 07-09-2021


This study investigated the long-term postoperative spontaneous formation of a bone bed in pediatric cochlear implant patients for whom no bone bed was drilled during the surgery. A cross-sectional observational study of skull thickness under and on the edges of the cochlear implant receiver/stimulator in children with computed tomography (CT scan) ≥6 months after implantation was performed. In total, 37 pediatric patients from a single tertiary center underwent cochlear implantation without bone bed drilling and with screw fixation of the receiver/stimulator. The patients were on average 36.2 ± 20.5 months at implantation (range 8-96 months). At the time of the CT scan, the average duration of implantation was 25.3 ± 17.9 months (range 6-91 months). The average depth of the bone bed that formed spontaneously since implantation was 1.83 ± 0.39 mm (range 0.39-3.04 mm). Linear regression identified that the depth of the bone bed increased significantly with duration of implantation (β = 0.389, p = 0.009), but age at implantation was not associated with bone bed depth. A spontaneously formed temporal bone bed was observed in pediatric CI patients already six months after implantation. A deeper bone bed was measured in children who have had their CI for a longer period. A spontaneously formed bone bed is likely to combine the benefits of a surgically drilled bone bed, whilst limiting the duration of the surgery and thereby associated costs.

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Comparing two different techniques to repair pediatric anterior tympanic membrane perforations

Gabriel Dunya, Geoffrey C. Casazza, Josh Blotter, Erica J. Park, Albert H. Park

Publication date 04-09-2021


Compare outcomes between a microscopic and endoscopic technique for anterior tympanic membrane (TM) perforation. Results of microscopic overlay (MT) and endoscopic tympanoplasty (ET) for management of anterior TM perforations from a single surgeon. There were 28 patients in the MT group and 35 in the ET group. The mean age was 7.1 years and 10.9 years (p < 0.001) MT and ET groups respectively. There was no statistical differences in perforation location (p = 0.1), etiology (p = 0.52) or size (p = 0.1) between both groups. Mean operating time was 119.0 min and 131.0 min in the MT and ET groups respectively (p = 0.23). Follow up was 30.9 months and 9.0 months (p = 0.001) MT and ET respectively. The perforation was successfully closed in 29 patients at 6 weeks in the ET (82.9%) and 25 in the MT (89.3%), p = 0.47. Adjusting for age revealed no significant difference between groups. Long term follow up, resulted in 10 failures (28.6%) and 7 patients (25.0%) in the ET and MT groups respectively, p = 0.75. Adjusting for the follow-up period or age, there was no significant difference between groups. The change in ABG and PTA measures were not statistically different between groups. An anteriorly based ET is a novel technique for management of anterior TM perforations. Results from this pilot study indicate that this ET approach may be an appropriate alternative to MT for difficult to repair anterior perforations. A longer follow-up will be necessary to determine its role in these perforations.

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Protective role of lycopene in experımental allergic rhinitis in rats

Halil Polat, Mustafa Sagıt, Seren Gulsen Gurgen, Mehmet Yasar, Ibrahim Ozcan

Publication date 04-09-2021


We investigate whether lycopene has a protective effect in an experimental rat model of allergic rhinitis. Experimental animals (65 rats) were randomized to 7 groups (Sham-Control, Lycopene 10 mg/kg/day, Lycopene 20 mg/kg/day, Intranasal lycopene drops, Intranasal steroid, Corn oil, Allergic Rhinitis). Rats were sensitized by administering of ovalbumin intraperitoneally and intranasally. In addition to ovalbumin; lycopene, corn oil and steroids were given to the relevant groups. Nasal symptom scores of the rats were recorded throughout the study. At end of the study, after intracardiac blood sample collection, all rats were sacrificed, and nasal tissues were examined histopathologically. Serum total immunoglobulin E (IgE) and ovalbumin (OVA) specific IgE were studied from all rats before and after the study. There was a statistically significant increase (p < 0.05) in OVA specific IgE values measured before and after the study in all groups except the sham group. In serum total IgE values; there was a statistically significant increase after treatment in allergic rhinitis, corn oil, lycopene 10 mg and intranasal lycopene drops group, but other groups did not show any significant change. Histopathological study with hematoxylin-eosin staining and cyclooxygenase-2 (COX-2), matrix metalloproteinase-9 (MMP-9), vasoactive intestinal peptide (VIP) expression found that lycopene suppresses inflammation with both nasal administration and increased dose. Nasal symptom scores were observed to decrease significantly in all lycopene and steroid groups compared to allergic rihinits and corn groups. It was determined that lycopene were effective in the treatment of allergic rhinitis, and this effect was found to be stronger with increasing doses of lycopene.

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Retrospective review of 70 cases of pyriform sinus fistula

Limin Zhao, Le Chen, Wanpeng Li, Kun Ni, Wei Chen, Xiaoyan Li

Publication date 04-09-2021


Pyriform sinus fistula (PSF) is a rare branchial pouch anomaly of the neck that presents a diagnostic and management challenge. The objective of this study is to highlight the value of intraoperative suspension laryngoscope-assisted methylene blue injection through the internal opening as a guide for locating the fistula. A retrospective study of 70 cases of PSF in children from 2009 to 2017 was managed, and an intraoperative suspension laryngoscope-assisted method combined with neck exploration and excision of the tract were performed in all cases. The patients comprised 36 males and 34 females ranging in age from 7 days to 15 years. Sixty-four cases were predominantly left-sided (64/70, 91.4%), and 6 cases (6/70, 8.6%) occurred on the right side. Four cases exhibited temporary postoperative hoarseness (4/70, 5.7%), which disappeared after one week. There were no instances of recurrence during follow-up ranging from two to nine years, and the median follow-up period was four years. The use of our surgical approaches can facilitate the localization of the fistula during dissection in open neck surgery, and reduce recurrence.

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The medium to long-term effects of two-duct ligation for excessive drooling in neurodisabilities, a cross-sectional study

Stijn Bekkers, Sanne de Bock, Karen van Hulst, Saskia E. Kok, Arthur R.T. Scheffer, Frank J.A. van den Hoogen

Publication date 03-09-2021


This study aims to evaluate the medium to long-term (1-12 years) effectiveness of two-duct ligation (2-DL) in patients with nonprogressive neurodisabilities. Main outcomes included a Visual Analogue Scale (VAS), Drooling Severity (DS) and Drooling Frequency (DF), collected at baseline, 32 weeks postintervention and 1-12 years postintervention. Secondary outcomes were adverse events (AEs), and satisfaction. Forty-two patients were analyzed (mean age 17 years, mean baseline VAS 82). VAS decreased significantly from baseline to long-term (n = 30. Mean difference -36.5, CI -47.0 to -26.0, p ≤ 0.001; -26.1, CI -36.2 to -15.9, p ≤ 0.001). However, long-term VAS significantly increased compared to VAS at 32 weeks (+10.4, CI 1.0-19.8, p = 0.031). Out of 42 patients, 64% would recommend 2-DL to peers. There is a significant subjective 2-DL effect on drooling severity in the medium to long-term as reported by patients and caregivers, but there is also a certain degree of recurrence in this time span, and 33% of the patients required subsequent treatment. However, the majority of patients and/or caregivers would recommend 2-DL to peers.

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Clinical and videofluoroscopic evaluation of feeding and swallowing in infants with oropharyngeal dysphagia

Maii Saad, Omayma Afsah, Hemmat Baz, Mohammed Ezz El-regal, Tamer Abou-Elsaad

Publication date 31-08-2021


Dysphagia impacts infants' health and well-being and may result in aspiration pneumonia. This study aimed to evaluate feeding and swallowing functions in infants with dysphagia to determine the possible causes of dysphagia and their relationship with the medical diagnoses. Clinical and videofluoroscopic findings were compared to determine the diagnostic accuracy of clinical evaluation and identify clinical predictors of laryngeal penetration and aspiration. This study was conducted on 60 infants in the age range 2-19 months (median seven months) with suspected aspiration and/or feeding problems. All cases were subjected to both clinical and videofluoroscopic evaluation of swallowing. The two most frequently observed videofluoroscopic findings were aspiration and suck-swallow-breathing incoordination. Infants with structural laryngeal abnormalities were significantly more likely to experience aspiration. A significant association was found between the presence of aspiration and the presence of both recurrent chest infection and gurgly voice combined, which increased the risk of aspiration by 3.57 times. However, the presence of gagging alone and gagging combined with a recurrent chest infection significantly reduced the risk of aspiration. The clinical assessment accuracy presented 56.70%, with 55.60% sensitivity, 58.30% specificity, and a positive predictive value higher than the negative. The study highlights the importance of complementing clinical evaluation, in infants with dysphagia, with an objective evaluation of swallowing such as videofluoroscopy due to the high proportion of false positives noticed in clinical evaluation and the high prevalence of silent aspiration in infants.

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Assessment of event-related evoked potentials and China-Wechsler intelligence scale for cognitive dysfunction in children with obstructive sleep apnea

Yewen Shi, Yani Feng, Yitong Zhang, Haiqin Liu, Huanan Luo, Lei Shang, Liang Xing, Jin Hou, Jing Yan, Xiaohong Liu, Qingqing Zhang, Chao Si, Xiaoyong Ren

Publication date 28-08-2021


To explore the relationship between obstructive sleep apnea (OSA) and cognitive impairment by combining event-related evoked potentials (ERPs) and China-Wechsler Younger Children Scale (C-WISC) in children with sleep-disordered breathing (SDB) with vs. without OSA. This was a retrospective case-control study of all consecutive children (n = 148) with adenoid tonsil hypertrophy between July 2017 and March 2019 at the Hospital. The children were divided into the OSA (n = 102) and non-OSA (n = 46) groups. The apnea-hypopnea index (AHI), obstructive apnea index (OAI), and obstructive apnea-hypopnea index (OAHI) in the OSA group were elevated compared with those of the non-OSA group (all P < 0.001). The mean oxygen saturation (SaO ERPs, as an objective measurement, might help assess cognitive impairment in children with OSA.

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Cochlear implant: More hearing better speech performance

Salman F. Alhabib, Yassin Abdelsamad, Reem S. Badghaish, Farid Alzhrani, Abdulrahman Hagr, Fida Almuhawas

Publication date 29-08-2021


Datalogging feature of the cochlear implant audio processor has been utilized to calculate the average daily wearing hours for cochlear implant devices by patients. To assess the relationship between the time use of cochlear implant audio processor and speech development as well as to identify the lowest acceptable duration of audio processor use to achieve an acceptable language development. A retrospective study design including prelingual thirty-four ears (24 patients) who received the same electrode array of cochlear implant with 2 years follow up. The audiological and speech evaluations were done for all patients postoperatively and the last postoperative follow-up visit was used for analysis in this study. The average daily use of the audio processor was 11.3 ± 2.7 h per day. The pure tone average was 30.55 ± 4.64 dB whereas the speech reception threshold was 30.88 ± 6.12 dB. The average speech discrimination score at 65 dB was 68.59 ± 16.80%. A significant positive correlation (r = 0.54, p value = 0.0009) was found between the daily use of the audio processor and the speech discrimination score. The lowest wearing time needed to have more than 60% of the speech discrimination score was 8.3 h/day. The present study revealed a positive correlation between the daily duration of the audio processor usage and speech performance. Moreover, we found that pediatric patients need to use their cochlear implant device for at least 8.3 h/day to achieve acceptable language development.

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An evaluation of music perception, appreciation, and overall music enjoyment in prelingual paediatric cochlear implant users utilizing simplified techniques: An Indian study

Kranti Bhavana, Sangam, Shamshad, Chandan Kumar

Publication date 28-08-2021


This study was aimed to evaluate the speech abilities, music habits, ability to perceive and enjoy music in prelingual paediatric cochlear implantees between the age group (18-84 months). Testing paediatric CI recipients for their music habits is challenging. This study offers some unique yet simplified tools to test musical parameters in paediatric CI recipients. Twenty-seven paediatric CI recipients who had received at least one year of auditory verbal therapy post-implantation were selected. They were tested for their speech abilities using the CAP (Category of Auditory Performance) and SIR (Speech Intelligibility Ratings) score. Music habits (Musicality Rating Scale/MRS), music perception (Pitch, timbre, melody) and music enjoyment (Subjective Assessment of Music Enjoyment/SAME) were assessed using various tools. All these parameters were compared with age and sex-matched controls who had normal hearing. Simple pitch discrimination, timbre recognition, and melody identification was observed in 29.60%, 37.03%, and 37.03% of implantees, respectively, compared to 88.88%, 81.48% and 88.88%, in normal-hearing children. The mean scores of CAP, SIR and MRS in cochlear implant users who perceived pitch timbre and melody differed significantly from those who did not. The mean SAME score of the normal-hearing group [4.37 ± 0.74] differs significantly from the paediatric cochlear implant user group [2.59 ± 1.47]. (p < .000). This study offers some novel, simplified tools to assess music habits in paediatric cochlear implantees. These can be utilized in low resource settings and can be helpful for rehabilitationists training these children.

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Type I tympanoplasty in pediatric age – The results of a tertiary hospital

Ana Isabel Gonçalves, Catarina Rato, Delfim Duarte, Ditza de Vilhena

Publication date 28-08-2021


The performance of pediatric tympanoplasty is a matter of controversy in the literature, varying from 35 to 94%. Several authors argue that the performance of tympanoplasty should be delayed until 6-8 years old or even after 10 years old. To analyze the results of type I tympanoplasty in pediatric age and to identify possible prognostic factors. Retrospective study of children undergoing type I tympanoplasty (Portmann's classification) between January 2012 and December 2018 in our hospital.
The following variables were analyzed: age, gender, etiology, size and location of the perforation, operated ear, season of the surgery, experience of the surgeon, condition of the contralateral ear, previous otologic surgery, previous adenoidectomy, presence of tympanosclerosis, surgical approach, type of graft, tympanoplasty technique, pre and postoperative audiometric results and follow-up time. The integrity of tympanic membrane (TM) was defined as anatomical success at 6 months postoperatively and as functional success we defined a pure tone average < 20 dB (mean of 0.5-4 KHz) in postoperative tonal audiometry, performed between 3 and 6 months after surgery. A total of 48 ears operated on 38 patients, aged between 8 and 17 years. Anatomical and functional success rates of 81.3% and 87.5%, respectively, were obtained. The only statistically significant poor prognostic factor was the presence of tympanosclerosis plaques in the middle ear, negatively affecting anatomical success (p = 0.007) and functional success (p = 0.008). There was an anatomical failure rate of 25% in the anterior and lower TM perforations, 14.3% in central and 7.7% in posterior perforations (p = 0.603). Perforations >50% of the TM surface showed a functional failure rate of 25% vs. 10% in perforations <50% of the TM (p = 0.242) and anatomical failure rates of 12.5% vs. 20%, respectively (p = 0.620). Regarding age, the group <12 years had an anatomical success rate of 85.7%, while the group ≥12 years had a rate of 79.4% (p = 0.611). As for the functional success rates, this was 92.9% and 85.3%, respectively (p = 0.471). Apart from the presence of tympanosclerosis, no other variable was statistically significantly associated with surgical success. Our study shows that type I tympanoplasty in pediatric age is a procedure with a high rate of anatomical and functional success. The presence of tympanosclerosis plaques in the middle ear was the only factor associated with poor anatomical and functional prognosis. Contrary to what has been described in some articles in the literature, in this study, the functional and anatomical success rates did not vary according to the age group.

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Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients

Cameron Heilbronn, Theodore W. Heyming, Chloe Knudsen-Robbins, John Schomberg, Dina Simon, Kellie Bacon, Kevin Huoh

Publication date 27-08-2021


Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.

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Contralateral hearing loss in children with a unilateral enlarged vestibular aqueduct

E.A. van Beeck Calkoen, R.J.E. Pennings, J. Smits, S. Pegge, L.J.C. Rotteveel, P. Merkus, B.M. Verbist, E. Sanchez, E.F. Hensen

Publication date 24-08-2021


To evaluate the long-term ipsi- and contralateral hearing of patients with a unilateral enlarged vestibular aqueduct (EVA). Multicenter retrospective cohort study. Three tertiary otology and audiology referral centers. A total of 34 children with a unilateral enlarged vestibular aqueduct as identified on CT and/or MR imaging were evaluated with pure tone and speech perception audiometry. Radiologic measurements of the vestibular aqueduct, ipsi- and contralateral hearing loss, ipsi- and contralateral hearing loss progression over time and DNA test results. All patients in this cohort with unilateral EVA presented with hearing loss. Hearing loss was progressive in 38% of the ipsilateral ears. In 29% of the children, hearing loss was also found in the contralateral ear without EVA. In 90%, the contralateral hearing was stable, with a mean follow up of 4.2 years. We found a significant correlation between the severity of the hearing loss and the size of the EVA. A genetic diagnosis associated with EVA and/or SNHL was found in only 7%. About a third of the children with unilateral EVA are at risk of developing hearing loss in the contralateral ear. This indicates that at least in some patients with a unilateral EVA, a bilateral pathogenic process underlies the hearing loss, in contrary to what the imaging results suggest. These findings are important for counseling of EVA patients and their parents and have implications for follow up.

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Long term outcomes of canal wall up and canal wall down tympanomastoidectomies in pediatric cholesteatoma

Gianluca Piras, Vittoria Sykopetrites, Abdelkader Taibah, Alessandra Russo, Antonio Caruso, Golda Grinblat, Mario Sanna

Publication date 24-08-2021


Cholesteatomas in children have a more aggressive growth pattern compared to adults, which leads to a higher incidence of both residual and recurrent disease. A staged canal wall-up or a canal wall-down tympanomastoidectomy (CWUT and CWDT, respectively) is selected depending on the extent of the disease and condition of the middle ear (ME) cleft and mastoid. Endoscopic ear surgery (EES) has been recently introduced as an adjuvant tool for the treatment of this pathology even in the pediatric population. To analyze long term outcomes of CWUT and CWDT in the pediatric population, focusing on residual and recurrence rates of cholesteatoma and hearing results. A literature review including cases treated with EES were discussed. Pediatric patients treated for cholesteatoma involving both the ME and mastoid with a follow-up (FU) of at least 4 years were retrospectively analyzed in a quaternary referral center for otology and lateral skull base surgery. Patients were grouped according to the surgical technique (CWUT versus CWDT). Rates of residual and recurrent cholesteatoma after each surgical technique were reported and compared. Mean Air-Bone Gap (ABG) of 0.5-1-2-4 KHz was measured and reported before the first surgery and at the last post-operative FU. Two-hundred and thirty-six cases fulfilled our inclusion criteria. The mean FU was 100.4 ± 44.2 months (median 89 months). One-hundred and five (44.5%) cases underwent a CWUT, whereas 131 (55.5%) a CWDT. A second stage surgery was performed in 73.5% of CWUT and 58.7% of CWDT. Among the CWUT group, residual cholesteatoma occurred in 22 (21%) ears and recurrence in 24 (22.9%). Patients undergoing CWDT showed lower rates of both residual and recurrent cholesteatoma (7.6% and 2.3%, respectively). ABG improvement was noted for both groups, even though CWUT showed better post-operative hearing results. The CWDT technique offers a definite surgical therapy, with minimal residual and recurrence rates and audiological results comparable to the CWUT technique. EES must still prove its added benefit or equivalence to pure microscopic approaches.

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Treatment failure in pediatric acute otitis media: How do you define?

Tal Marom, Ofer Gluck, Sharon Ovnat Tamir

Publication date 21-08-2021


Reaching the point of treatment failure in the management of pediatric acute otitis media (AOM) is decision-changing, and is often associated with switching to a broader coverage antibiotic with/without middle ear surgical drainage. Yet, still there is no consensus on the definition of what is treatment failure, which may lead to confusion for clinical decision-making purposes. We sought to review the heterogeneity of treatment failure definitions in AOM. We searched for relevant English language manuscripts using the following key-words: ['otitis media' (OM) or (AOM)] AND ['treatment failure' or 'failure' or 'response failure' or 'response'] AND 'human' in various electronic databases from 1/1/2005 through 10/31/2020. In the 60 retrieved papers, treatment failure was considered only when antibiotics had been prescribed beforehand, but not when watchful waiting had been adopted. We categorized the manuscripts into 5 major treatment failure definition subgroups, which occasionally overlapped: unimprovement or worsening of symptoms or signs of failure in otoscopy (n = 36), specialist(s) referral or hospital admission (n = 12), changing or adding antibiotic treatment (n = 22), failure to eradicate causative bacteria (n = 7) and failure as perceived by parents (n = 4). We suggest a broader definition of AOM treatment failure including physical examination findings and degree of initial treatment response, which will enable an unbiased, uniform comparison of treatments for pediatric AOM.

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Genetic testing hearing loss: The challenge of non syndromic mimics

Catherine Gooch, Natasha Rudy, Richard JH. Smith, Nathaniel H. Robin

Publication date 26-08-2021


Congenital hearing loss is a common cause of morbidity in early childhood. There are multiple reasons for congenital hearing impairment, with genetic contribution becoming increasingly recognized. Sensorineural hearing loss has classically been viewed as either syndromic or non-syndromic. With the advent of DNA sequencing technology such as Next Gen sequencing, a subcategory has arisen, that of non-syndromic mimics (NSM)s. NSMs present initially as isolated hearing loss but as the patient ages other phenotypes become evident. Early diagnosis of these conditions is imperative as patients may suffer significant morbidity and mortality from complications from their hearing loss syndrome. An example is QT prolongation in Jervell and Lange-Nielsen Syndrome. The need for genetic testing and proper genetic counseling is necessary for patients with hearing loss and testing should be done as early in life as possible.

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Correlation of quality of life with speech and hearing performance after pediatric cochlear implantation

Bshair Aldriweesh, Mashael Alharbi, Musaed Alzahrani

Publication date 24-08-2021


This study aimed to determine the correlation of the quality of life (QOL) with the Categories of Auditory Performance (CAP) and the Speech Intelligibility Rating (SIR) scales in children after cochlear implantation. This cross-sectional study was conducted from November 2018 to February 2020 at the otolaryngology department at a tertiary referral center. Patients aged ≤16 years who had received cochlear implants (CIs) at our center were consecutively included in this study. Parents were asked to complete the Glasgow Children's Benefit Inventory questionnaire, and auditory and speech assessments were performed by the speech therapists at our center. The correlations of Glasgow Children's Benefit Inventory results with the objective data from the CAP and SIR assessment tools were analyzed. Seventy patients were included in this study. The mean age at implantation was 3 years and 9 months. The mean Glasgow Children's Benefit Inventory score was 52.23 (standard deviation = 23.99), indicating a positive benefit in QOL. There was a statistically significant correlation of the QOL questionnaire score with the CAP score (r = 0.40, p = 0.008), but no correlation was found between the QOL questionnaire score and the SIR score. We recommend that cochlear implant patients should undergo an evaluation that incorporates auditory, language, and QOL assessment tools to gain a more comprehensive understanding of their progress.

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Coblation intra-capsular tonsillectomy: A prospective tertiary center trial

Nadim Khoueir, Joe Rassi, Tony Richa, Diane Helou, Michel G. Khalaf, Simon Rassi

Publication date 20-08-2021


There is a growing interest in intra-capsular coblation tonsillectomy (ICT) for the treatment of obstructive sleep apnea (OSA) in children. Literature remains controversial regarding which intra-capsular tonsillectomy (IT) technique is most effective and with least morbidity. Therefore, the aims of this study are to objectively measure the post-operative morbidity and the effectiveness of the ICT technique. 107 children undergoing ICT (with or without adenoidectomy) for upper airway obstruction due to tonsillar hypertrophy at a tertiary center university hospital were prospectively enrolled from March 2016 to March 2018. Efficacy of the surgery was assessed by a pre-and post-operative Obstructive Sleep Apnea score (OSA-18). Post-operative morbidity was measured based on the Parent's Post-operative Pain Measure questionnaire (PPPM), type and duration of administered pain medication, time before resuming a full diet and a normal activity, readmission for dehydration and post-operative bleeding incidence. After a mean follow-up of 21.6 months, OSA-18 mean total score was 78.77 (SD = 15.74) before ICT and 23.7 (SD = 9.25) after surgery, with a significant difference between pre-operative and post-operative scores (p < 0.001). Mean PPPM scores were low at all evaluation points (5.89, 2.42 and 0.83 at days 2, 5 and 10 respectively). Analgesic use was restricted to acetaminophen in nearly all children for a mean duration of 1.93 days. They resumed a normal diet after 2.42 days and a normal activity (including return to school) after 2.7 days. No hospital readmission nor post-operative hemorrhage were reported. Intra-capsular tonsillectomy by coblation is an effective and safe procedure that provides rapid post-operative recovery with minimal analgesic requirements, thus deserving a wider application in treating upper airway obstruction due to tonsillar hypertrophy in children.

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Middle ear disease requiring myringotomy in the first two years after tracheotomy in the pediatric population

Nicole Kloosterman, Nathaniel Donnell, Evan Somers, Heidi Chen, Daniel Kirse, Amy S. Whigham

Publication date 20-08-2021


Risk factors for middle ear disease necessitating myringotomy with tympanostomy tube placement after a tracheostomy have not been thoroughly explored. This study investigates the incidence and risk factors for ear tube placement in pediatric patients with a tracheostomy. Pediatric patients under age 18 who underwent tracheotomy between 2002 and 2010 at two institutions were identified. Patients were excluded if they had undergone myringotomy prior to, or at the same time as, the tracheotomy, or did not have at least two years of follow-up clinic visits. The presence of other comorbidities was recorded. Descriptive statistics and logistic regression models were used to assess the impact of clinical characteristics on outcomes. A total of 214 patients met inclusion criteria. Median patient age at time of tracheotomy was 6 months (IQR 2-17), median patient age at time of myringotomy with tubes was 12 months (IQR8-17), and median time between tracheotomy and myringotomy with tube placement was 8 months (IQR 5-11). Sixty-seven (31%) patients required myringotomy with tympanostomy tube placement within the first two years after tracheotomy. Fifty-eight (87%) patients who underwent myringotomy with tympanostomy tubes were younger than 2 years at the time of the procedure. Logistical regression found younger age at time of tracheotomy to be a risk factor (OR: 0.71, 95% CI: 0.5-0.9, p < 0.006). The combination of tracheostomy with gastric tube increased the risk of requiring myringotomy with tubes 2.79 fold (p < 0.009). Craniofacial abnormalities (p < 0.001), known genetic syndrome (p = 0.009), cleft palate (p < 0.001), age at time of tracheotomy (p < 0.001) and gastric tubes (p = 0.002) were all independently found to increase risk of myringotomy with tubes. Patients' gestational age (p = 0.411), ventilator dependence (p = 0.33), and airway structural abnormalities (p = 0.632) did not increase this risk. This study reports a high incidence of myringotomy with tubes in children with tracheostomy relative to the general pediatric population. Many comorbid conditions that often accompany the need for tracheotomy place these patients at a higher risk for ear disease requiring surgical intervention. Risk factors for operative middle ear disease in this population included age at time of tracheostomy, craniofacial abnormalities, and presence of a G-tube.

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A Swedish population-based study of complications due to acute rhinosinusitis in children 5–18 years old

S. Hultman Dennison, Olof Hertting, Rutger Bennet, Margareta Eriksson, Mats Holmström, Lina Schollin Ask, Ann Lindstrand, Praxitelis Dimitriou, Pär Stjärne, Anna Granath

Publication date 21-08-2021


There are few population-based studies of complications due to acute rhinosinusitis in children. The aim was to clarify the admission and complication rate and analyze bacterial cultures in children five to 18 years old in Stockholm, Sweden. This was a population-based observational cohort study with retrospectively collected data from individual medical records, from 1 July 2003 to 30 June 2016 in Stockholm, Sweden. Hospital admissions of children with a discharge diagnosis of rhinosinusitis and related complications were reviewed. Incidence of admission due to acute rhinosinusitis was 7.8 per 100 000 children per year (boys 9.2, girls 6.2) and 61% of the admitted children were boys. A severe - postseptal orbital, intracranial or osseous - complication, was present in 34% of admissions (postseptal orbital 28%, intracranial 6%, osseous 4%), resulting in an incidence of 2.6 severe complications per 100 000 children per year (boys 3.6, girls 1.6). Orbital preseptal cellulitis was present in 88% of admissions. Incidence of surgery was 1.3 per 100 000 per year (boys 1.8, girls 0.8) and the percentage of admitted children that had surgery increased with age. S. pyogenes was the most common pathogen found in the whole cohort (29 admissions), while S. milleri was the most common pathogen found among the children with severe complication and surgery. There is a relative high risk of severe complications in children between five to 18 years that are admitted due to acute rhinosinusitis. There is a need for prospective studies to further analyze the pathogens involved in complications due to acute rhinosinusitis.

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Risk factors for return visits in children discharged with tracheostomy

Brian Pettitt-Schieber, Geetha Mahendran, Ching Siong Tey, Kara K. Prickett

Publication date 18-08-2021


To determine associations between demographic and clinical characteristics and rate of unplanned returns to system (RTS) in pediatric patients discharged with tracheostomy. Medical records were examined for pediatric patients discharged after tracheostomy placement between January 1, 2011 and December 31, 2015. Exclusion criteria included death or decannulation prior to discharge and lack of follow-up through 180 days post-discharge. Readmissions were grouped by time interval after discharge (within 30 days or within 31-180 days). Chi-squared analysis and Fisher's Exact Test were utilized to determine associations between patient characteristics, rate and frequency of RTS, and type of admission (Emergency Department [ED] or inpatient [IP]). One hundred twenty-one patients were eligible for the study, and 80 (66.1 %) had an unanticipated RTS during the follow-up period. Patients with early RTS had a higher total number of RTS. Patients with two or more RTS were more likely to be younger, while patients with five or more RTS were more likely to have greater organ system involvement and cardiovascular (CV) disease in particular. Patients presenting with GI diagnoses were more likely to be discharged from the ED. The rate of RTS remained constant throughout the time period examined. Pediatric patients discharged with tracheostomy are medically complex and at high risk of RTS, especially for respiratory and GI problems. This risk does not decrease after the initial post-discharge period and long-term follow-up is warranted. Younger patients and patients with history of early RTS are at highest risk for repeat RTS and should be identified for closer outpatient care.

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Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

R.E. Wineski, E. Panico, A. Karas, P. Rosen, B. Van Diver, T.G. Norwood, J.W. Grayson, G. Beltran-Ale, R. Dimmitt, R. Kassel, A. Rogers, M. Leonard, A. Chapman, L. Boehm, B. Wiatrak, W.T. Harris, N. Smith

Publication date 16-08-2021


The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients. A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed.
Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05. 449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05). In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

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Childhood head and neck cancer in France: Incidence, survival and trends from 2000 to 2015

Luc Person, Brigitte Lacour, Laure Faure, Sandra Guissou, Claire Poulalhon, Daniel Orbach, Stéphanie Goujon, Claire Berger, Jacqueline Clavel, Emmanuel Desandes

Publication date 14-08-2021


Childhood head and neck cancers (HNC) are rare and represent a complex group of anatomical topographies. The aim of this study is to describe the distribution, the incidence and survival rates of children with malignant HNC in France. A population-based study was conducted between 2000 and 2015 in children less than 15 years with a diagnosis of HNC using the French National Registry of Childhood Cancers database (RNCE). Age-standardized incidence rates (ASR) and survival analysis were performed. The 1623 included HNC represented 5.6% of all cancers included in the RNCE. The thyroid was the leading tumor site category (26.6%), followed by head and neck soft tissue location (15.4%) and the nasopharynx (10.8%). The most common cancers were thyroid gland carcinomas (26.1%), rhabdomyosarcomas (23.9%) and Burkitt Lymphomas (8.6%). Nasopharynx cancers and soft-tissue sarcomas were statistically more frequent in boys, while thyroid carcinomas were significantly more frequent in girls. The annual ASR was 8.6 new cancer cases per million children. For all HNC combined, the 5-year overall survival (OS) was 87.7% [95%CI: 85.9-89.2]. There was no statistically significant variation in 5-year OS between 2000-2007 and 2008-2015. Epidemiological data on HNC distribution, incidence and survival contributes to better understand these tumors by quantifying their impact on the French population and assessing their burden. Regarding the exclusion of topographies and some histological origins performed by some authors, this report proposes new recommendations to study HNC in a pediatric population.

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Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic

F.G. Kavanagh, D.L. James, D. Brinkman, S. Cornyn, C. Murphy, S. ONeill, R. OShea, A. Affendi, B. Lang, A. OConnor, I. Keogh, E. Lang, J. Russell, D. OBrien, P. Sheahan, So Jeong Kang, Ryan OSullivan, Brian Kennedy, Conor Tiernan, Oisín ó Murchú

Publication date 29-09-2021


Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications. Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19. 302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period. The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

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Therapeutic approaches to early intervention in audiology: A systematic review

A. Casoojee, A. Kanji, K. Khoza-Shangase

Publication date 10-09-2021


Babies born with a congenital sensorineural hearing impairment or acquire early-onset permanent bilateral hearing impairment are at risk for delayed speech and language development and poor scholastic outcomes. Auditory Verbal Therapy (AVT) has become the primary intervention approach for developing spoken language in children with hearing impairment, and South Africa also has adopted this approach. The outcomes of AVT within the South African context have not been thoroughly investigated. As part of a larger study, the objective of this systematic review was to describe the speech, language and scholastic outcomes of hearing-impaired children enrolled in AVT as a therapeutic approach to early intervention. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Electronic databases searched included Google Scholar, Science Direct and Pub Med. Selected studies were published in English and focused on the outcomes of early intervention for children with hearing impairment. The selected date range of the included articles ensured that the latest research was reviewed. Due to the limited evidence base, the review cannot conclude definitively that AVT yields positive speech, language, and scholastic outcomes in children with hearing impairment. Of the reviewed articles, only one study compares the outcomes of therapeutic intervention approaches, an important consideration, particularly in Low- and Middle-Income countries (LMICs). Current findings provide a strong rationale for the larger study by highlighting that further research comparing AVT to standard speech-language habilitation is required. Research in contexts with linguistic and cultural diversity in countries such as South Africa is required.

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"Charles F. Ferguson, MD: Americas first full time pediatric otolaryngologist"

Michael J. Cunningham

Publication date 11-08-2021


Each year the Program Committee of the American Society of Pediatric Otolaryngology bestows three Charles Ferguson Clinical Science Awards. Who was Dr. Charles Ferguson, and why do these prestigious awards carry his name? Historical review. Dr. Charles Ferguson officially joined the Boston Children's Hospital surgical staff in 1940. He was hired by the surgeon-in-chief William Ladd to devote his otolaryngology practice solely to children. His career at Boston Children's Hospital spanned 38 years. Disorders of the larynx, trachea and bronchi were his principal professional focus. He was the guest editor of a 1962 Pediatric Clinics of North America Symposium on Ear, Nose and Throat Problems, and subsequently edited the first Pediatric Otolaryngology textbook in 1972. His pioneering work in pediatric airway endoscopy and the development of techniques to diagnose congenital airway malformations led to his receipt of the Chevalier Jackson Award from the American Bronchoesophagological Association in 1974, and the James Newcomb Award from the American Laryngological Society in 1979. Together with contemporaries Seymour Cohen in Los Angeles and Blair Fearon in Toronto, he set the foundation for the creation of the American Society of Pediatric Otolaryngology in 1984, six years following his retirement. Recognizing his contributions as truly the "father of pediatric otolaryngology", the Society granted Dr. Ferguson honorary membership in 1987, and established the Charles Ferguson Clinical Science Awards to sustain his legacy.

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"Authors response to a letter to the editor IJPORL-D-20-01778: Response to a Letter to the Editor"

Ana Concheiro-Guisan, Isabel González-Guijarro

Publication date 08-02-2021


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