International Journal of Pediatric Otorhinolaryngology 2021-04-11

Multisystem inflammatory syndrome in children (MIS-C) and retropharyngeal edema: A case series

Ariel Daube, Scott Rickert, Rebecca Pellett Madan, Philip Kahn, Joanne Rispoli, Heda Dapul

Publication date 23-03-2021


Multisystem inflammatory syndrome in children (MIS-C) is thought to follow SARS-CoV-2 infection and presents with fever and multisystem dysfunction. We report three children with suspected MIS-C found to have retropharyngeal edema without evidence of a bacterial etiology. We raise the possibility that an association between MIS-C and retropharyngeal edema exists.

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Short lingual frenulum and head-forward posture in children with the risk of obstructive sleep apnea

Eliza Brożek-Mądry, Zofia Burska, Zuzanna Steć, Marcin Burghard, Antoni Krzeski

Publication date 07-04-2021


Recent studies have shown that a short lingual frenulum is a potential risk factor for obstructive sleep apnea syndrome (OSAS) in children. A short frenulum leads to abnormal orofacial development and may consequently contribute to sleep-disordered breathing by narrowing the upper airways and increasing the risk of upper-airway collapsibility. The aim of this study was to assess the impact of a short lingual frenulum on the risk of OSAS in children. Children from pre-, primary, secondary, and high school, aged 3-17 years, were included in the study. Parents/guardians were asked to fill in the Pediatric Sleep Questionnaire (PSQ), and then, children at risk of OSAS were enrolled in the study group. A control group was established randomly from patients with negative PSQ results. A physical examination, including measurements of head-forward posture (HFP) and length of the free tongue, inter-incisor distance and subjective high-arched palate evaluation was performed in children from both groups. A total of 1,500 PSQ questionnaires were distributed, and less than half (713) were returned correctly filled in. In the second part of the study, 135 children were evaluated: 67 in the study group and 68 in the control group. The mean ages were 9.4 ± 3.0 and 9.5 ± 3.1 years, respectively. Children in the study group had significantly shorter lingual frenula, higher HFP measures, and had a higher prevalence of a high-arched palate. Based on statistical analysis, a short lingual frenulum (OR 5.02 [1.58-15.94]). The study identified a relationship between a short lingual frenulum and the risk of OSAS in children. Detecting and addressing ankyloglossia in children is necessary before it leads to orofacial changes, malocclusion, and consequently, sleep apnea. Furthermore, OSAS was associated with higher HFP, but no relationship was found between the two parameters.

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Satellite habilitation centres following cochlear implantation – Are they the way ahead in improving outcomes in developing countries?

Senthil Vadivu Arumugam, Sarankumar Thirugnanam, Vijaya Krishnan Paramasivan, Rabindra Bhakta Pradananga, Nithya, Mohan Kameswaran

Publication date 07-04-2021


Cochlear implantation is a safe surgery for restoration of hearing in profoundly deaf children. Following cochlear implantation, children undergo rehabilitation (or 'habilitation' for those without previous hearing). The device is programmed after the surgery, so that the user can hear sounds through it and through rehabilitation training, the heard sounds are made to understand. Our study was aimed at analysing the role of satellite habilitation centres following cochlear implantation by analysing the outcomes following habilitation and comparing it with the outcomes of the main centre and correlating it with the percentage of attendance of classes. Our study also aims to compare the attendance of implant patients from outside the geographical area of the main centre before and after starting the satellite centre. 1004 profoundly deaf children (6 years and below) who had undergone cochlear implantation and completed 12months of habilitation in our institution from July 2013 to December 2019 were retrospectively analysed. The outcomes of all the centres were assessed by comparing the baseline CAP with CAP scores at 12 months and baseline SIR with SIR scores at 12 months. The outcomes of the main centre and satellite centres were also compared. The outcomes were correlated with percentage of attendance of classes. The overall attendance in all the centres was between 75 and 80%. Both main and satellite centres showed statistically significant good outcomes and this correlates with percentage of attendance. Satellite centres for habilitation across the state has greatly helped to improve the attendance of these patients and outcomes. Reduced drop-out rates and improved speech language outcomes can be achieved by starting satellite centres for habilitation post cochlear implantation in developing countries like India.

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Extended high frequency audiometry thresholds in healthy school children

Dagny Hemmingsen, Niels Christian Stenklev, Claus Klingenberg

Publication date 11-04-2021


Extended high frequency (EHF) audiometry is the recommended method for monitoring oxotoxic hearing loss in children. This study aims to provide high quality reference audiological data for the EHF range in healthy children. Participants were 126 healthy schoolchildren between 6 and 14 years of age. All participants were term born with normal birthweight, had not suffered severe neonatal illness and had no history of middle ear disease. The averaged mean (SD) hearing threshold for the EHF 9, 10, 11.2, 12.5, 14 and 16 k Hz was -0.4 (6.0) dB HL. The lowest mean hearing thresholds were observed at 14 k Hz with -4.2 (8.7) dB and at 16 k Hz with -6.4 (12.1) dB HL. We found significantly lower thresholds at 16 k Hz for children aged 6-9 years (-8.7 dB HL) compared to age 10-14 years (-3.9 db HL), p 0.042. For both age groups the inter-subject variability increased in the highest frequencies. We found no significant differences in mean hearing thresholds between right and left ears at any frequency, and no gender differences in the EHF range. Our findings support that decreased hearing sensitivity in the EHF's may start around or even before the age of 10 years. In order to use EHF audiometry for ototoxic monitoring in children, we suggest to establish an international reference standard for hearing levels in children under the age of 18. Specific references for different age groups are needed as hearing in the EHF range appears to gradually deteriorate from an early age. NCT03253614.

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Persistence of choking injuries in children

David T. Chang, Kaitlyn Abdo, Jay M. Bhatt, Kevin C. Huoh, Nguyen S. Pham, Gurpreet S. Ahuja

Publication date 06-04-2021


Choking injuries are a significant cause of morbidity and mortality in children and represent a significant public health concern. Evaluating trends and the impact of interventions are essential to highlight whether progress has been made and to target public health efforts. To investigate how rates of nonfatal and fatal choking injuries have changed before and after 2010 when policy recommendations were made by the American Academy of Pediatrics. A descriptive study investigating unintentional nonfatal and fatal choking injuries in children aged 0-19 years using national data from 2001 to 2016 through the Centers for Disease Control and Prevention's WISQARS™ and WONDER databases, focusing on the 6 years prior and 6 years after release of the AAP's recommendations. The data was categorized by age, gender, year, and race/ethnicity for descriptive and statistical analyses. From 2001 to 2016, there were a total of 305,814 nonfatal injuries and 2347 choking deaths in children from 0 to 19 years. Children under five years of age accounted for 73% of nonfatal injuries and 75% of choking fatalities. There was a statistically significant increase in the nonfatal injuries rate when comparing 2005-2010 and 2011-2016 (19/100,000 versus 26/100,000, respectively). There was a decrease in the choking fatalities rate in all children (0.18/100,000 versus 0.16/100,000, respectively) but no change in fatalities rate for children under five. White and Black children experience nonfatal choking injuries at a higher rate than Hispanics. Black children had highest rates of choking fatalities over Hispanic, White, Asian, and Alaskan or American Indian ethnicities. The lowest rates of death occurred in Asians. Overall rate of nonfatal choking injuries increased, while rate of choking fatalities in children decreased after 2010. However, the choking fatalities rate in 0-4 years olds, the highest risk group, did not change. Racial gaps exist with highest rates of injury in Black children. We must continue to educate and raise awareness of choking injuries, with targeted efforts to address racial disparities.

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Pediatric subperiosteal orbital abscess characterization and prediction of size, location, and management

Jennifer L. McCoy, Ronak Dixit, Joseph E. Dohar, Allison B.J. Tobey

Publication date 05-04-2021


Subperiosteal orbital abscess (SPOA) is a serious suppurative complication of pediatric sinusitis. The objective of this study is to stratify patient selection into those best treated medically versus surgically based on clinical outcomes. This is a retrospective review of patients diagnosed with SPOA complicating sinusitis treated at a tertiary care pediatric hospital from 2002 through 2016. SPOA was diagnosed by CT scan. Characteristics evaluated include demographics, abscess size, location, and measurements, length of hospital stay, medical and surgical interventions, presenting symptoms, and complications. A total of 108 total SPOA secondary to sinusitis patients were included. A majority, 72.2%, were male with an average age at presentation of 6.8 years. The mean ± standard deviation abscess cubic volume was 0.98 ± 1.27 cm In the pediatric population, SPOA is a serious consequence of sinusitis. This study provides evidence supporting that larger abscess size is a significant risk factor for requiring surgery. The appeal of our study is that it provides evidence and support that employ clinical parameters already assessed as standard practice in evaluating these patients. In summarizing the clinical translational relevance of our study, when determining whether to treat a patient with surgery and antimicrobial/medical therapy vs. non-surgical medical therapy alone, the clinician should focus on size of 0.510 cm

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Middle ear risk index (MERI) as a prognostic factor for tympanoplasty success in children

de la Torre Carlos, Vasquez Carolina, Villamor Perla

Publication date 05-04-2021


Tympanoplasty performed in childhood has been controversial over the years because there is no clarity in determining what prognostic factors lead to surgical success. The objective of this study was to evaluate the effect of the Middle Ear Risk Index (MERI) score on the success of pediatric tympanoplasty. A retrospective case-control study was performed at a tertiary pediatric referral center. A database was created with surgical and clinical records of pediatric patients (<18 years of age) with tympanic membrane perforation, assessed and surgically managed by the same surgical team from January 2012 through March 2018. Mild MERI before tympanoplasty was found to be a protective factor against surgical failure, with an odds ratio of 0.24 (p: 0.002). The odds ratio for severe MERI in unsuccessful tympanoplasty was 5.87, with a p: 0.003, standing out as a risk factor for surgical failure. Presurgical MERI in children may be a useful tool to determine if patients are candidates for tympanoplasty, more aggressive interventions, or if medical treatment before tympanoplasty is necessary to improve prognosis. When facing a high MERI score, parents and family should be advised before surgery about the possibility of tympanoplasty failure.

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Development and validation of an automated dichotic double word test in Indian English using MATLAB

Mayur Bhat, Hari Prakash Palaniswamy, U. Varsha, Y. Krishna

Publication date 03-04-2021


Dichotic listening is an experimental paradigm where two different stimuli are presented to the right and left ear simultaneously. Currently, there are no clinically validated full version (Forced recall condition) of dichotic word test in Indian language with established normative. Hence the study involves the development of a MATLAB based Dichotic listening test in Indian English including free recall and forced recall conditions. This study was carried out in two phases. Phase 1 involved development and validation of an automated dichotic listening test using MATLAB software. Phase 2 involved data collection and constructing a normative data on 70 healthy adults (18-50 yrs) and 70 children (10-15 yrs) also establishing test retest reliability on 25 participants for the newly developed test. Right ear advantage was observed for free recall condition similar to that of classical dichotic effect. Also, there was no significant difference between the right and left ear scores in the two forced recall condition. The test showed moderate to good test-retest reliability for both the conditions. The results showed ideal retention of original dichotic effects for both free recall and forced recall conditions and hence can be used in clinical set to tests disordered population like Central auditory population disorder and Learning disability.

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Characteristics and overall survival in pediatric versus adult esthesioneuroblastoma: A population-based study

Michael H. Berger, Brandon M. Lehrich, Tyler M. Yasaka, Brendan M. Fong, Frank P.K. Hsu, Edward C. Kuan

Publication date 04-04-2021


Esthesioneuroblastoma (ENB) is an uncommon sinonasal malignancy and is even less common in the pediatric population. The purpose of this study is to compare characteristics and outcomes of ENB between adult and pediatric patients. The National Cancer Database was queried for patients with histologically proven ENB of the nasal cavity and paranasal sinuses, and then baseline characteristics, treatment, and survival data compared between the pediatric (age < 18 years) and adult (age ≥ 18 years) populations. 1411 patients were identified, with 45 in the pediatric cohort and 1366 in the adult cohort. Ten-year overall survival (OS) in the pediatric cohort was improved compared to the adult cohort, 87% and 66%, respectively (p < 0.05). Adjuvant chemotherapy was more commonly utilized in the pediatric cohort (p < 0.001). Race was associated with decreased OS in the pediatric cohort (p = 0.013). Pediatric patients had shorter length of stay (p = 0.009) and lived closer to their provider (p = 0.044) than adult ENB patients. Treatment of ENB in pediatric patients more commonly includes chemotherapy and more commonly occurs at academic medical centers. OS is improved in pediatric ENB compared to adults as well, but larger studies are necessary.

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Early surgical intervention enhances recovery of severe pediatric deep neck infection patients

Jarno Velhonoja, Meira Lääveri, Tero Soukka, Jussi Hirvonen, Ilpo Kinnunen, Heikki Irjala

Publication date 03-04-2021


Pediatric deep neck space infection (DNI) is a relatively rare but potentially life-threatening condition and requires prompt and accurate management. This study retrospectively reviews our experience in a tertiary referral hospital from 2004 to 2019. Systematic data collection from medical records using ICD10 codes between 2004 and 2019. age ≤16 years, DNI requiring hospitalization and/or surgery.
EXCLUSION: peritonsillar abscess without complications. We identified 42 patients, 21 boys and 21 girls, with a median age of 4.9 years. Most of the patients had severe symptoms, the most common of which were neck swelling (n = 39; 92.9%), neck pain (n = 39; 92.9%) and fever (n = 32; 76.2%). Twenty-two (52.4%) had torticollis, and the mean duration of symptoms before hospitalization was 4.95 days. Diagnosis was confirmed by MRI (n = 24), contrast-enhanced CT (n = 11) or ultrasonography (n = 6), except in one case. Twenty-three (54.8%) required an open neck incision, ten (23.8%) patients had intraoral surgery and nine were treated conservatively. Twelve (28.6%) patients were admitted to the pediatric ICU. Median hospitalization duration was six days. The infection most commonly had tonsillopharyngeal etiology (n = 18) and a retropharyngeal location (n = 17). Staphylococcus Aureus (n = 7) and Streptococcus pyogenes (n = 7) were the most frequent pathogens. We compared the early surgical intervention group (<2 days of intravenous antibiotics; n = 18; 42.9%) to the late surgery group (n = 15; 35.7%) and the conservatively treated groups (n = 9; 21.4%). The overall length of stay (LOS) was lower in the shorter preoperative medication group (mean 4.4 vs. 7.2; p = 0.009). The size of the abscess did not differ between the groups (mean 28 mm; 30 mm; 21 mm; p = 0.075) and the neck incision rate was similar in the operated groups. Early surgical intervention is associated with decreased LOS among severe pediatric DNI patients.

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Foreign body aspiration in children: Treatment timing and related complications

Juan L. Antón-Pacheco, Rubén Martín-Alelú, María López, Rocío Morante, Lara Merino-Mateo, Sergio Barrero, Rubén Castilla, Indalecio Cano, Araceli García, Andrés Gómez, M

Publication date 03-04-2021


The aims of this study were to describe our experience in the management of FB aspiration in children, focusing on the eventual association between delay in treatment and the development of complications, and to determine if the incidence of this emergency had decreased in the last 10 years. Retrospective study of children with a diagnosis of FB aspiration managed between 1999 and 2019 at a tertiary care referral hospital.
The following data were collected: demographics, clinical presentation, radiological findings, endoscopic technique, type of FB, time elapsed between the aspiration episode and treatment, and complications. Main outcome measures were the rate of complications (intraoperative and long-term) in the cohort of patients with delay in treatment (>72 h), and the incidence of FB aspiration in each of the two historical subgroups of the study. The study included 130 patients, 66.2% male, with a median age of 24 months. Cough was the most frequent symptom (76.1%) and unilateral air trapping was the most common radiological finding (48.8%). Removal of FB was performed with rigid bronchoscopy in every case. The most common type of FB was organic (73%) and located in the right bronchial system (47.7%). The global rate of complications was 16.1%. Patients with a delay in treatment beyond 72 h from the aspiration episode showed a statistically significant risk of developing both intraoperative and postoperative complications. Additionally, we have stated that the incidence of FB aspiration in our community has decreased by 44.4% in the last 10 years. The incidence of FB aspiration has remarkably decreased in our environment in the last decade. Delay in treatment placed our patients at a significant higher risk of developing complications both during the bronchoscopic procedure and in the long-term.

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Cry features of healthy neonates who passed their newborn hearing screening vs. those who did not

Kathleen Wermke, Mario Cebulla, Vivien Salinger, Veronique Ross, Johannes Wirbelauer, Wafaa Shehata-Dieler

Publication date 03-04-2021


Temporal and fundamental frequency (fo) variations in infant cries provide critical insights into the maturity of vocal control and hearing performances. Earlier research has examined the use of vocalisation properties (in addition to hearing tests) to identify infants at risk of hearing impairment. The aim of this study was to determine whether such an approach could be suitable for neonates. To investigate this, we recruited 74 healthy neonates within their first week of life as our participants, assigning them to either a group that passed the ABR-based NHS (PG, N = 36) or a group that did not, but were diagnosed as normally hearing in follow-up check at 3 months of life, a so-called false-positive group (NPG, N = 36). Spontaneously uttered cries (N = 2330) were recorded and analysed quantitatively. The duration, minimum, maximum and mean fo, as well as two variability measures (fo range, fo sigma), were calculated for each cry utterance, averaged for individual neonates, and compared between the groups. A multiple analysis of variance (MANOVA) revealed no significant effects. This confirms that cry features reflecting vocal control do not differ between healthy neonates with normal hearing, irrespective of the outcome of their initial NHS. Healthy neonates who do not pass the NHS but are normal hearing in the follow-up (false positive cases) have the same cry properties as those with normal hearing who do. This is an essential prerequisite to justify the research strategy of incorporating vocal analysis into NHS to complement ABR measures in identifying hearing-impaired newborns.

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The use of laryngeal mask airway for tonsillectomy and adenoidectomy

Nathaniel Webb, Michelle S. Kars, Alan L. Butler, Monika Malesinska, Lee P. Smith

Publication date 28-03-2021


Patients undergoing tonsillectomy and adenoidectomy traditionally receive anesthesia with endotracheal intubation (ETT) for airway management. The laryngeal mask airway (LMA) may be used instead and may be associated with less airway stimulation and shorter operating room times. The purpose of this study was to report on a large cohort of patients undergoing tonsillectomy and/or adenoidectomy while using the LMA for airway maintenance during anesthesia. Patients undergoing tonsillectomy and adenoidectomy between January 6, 2017 and January 6, 2020 with a LMA were reviewed for safety outcomes. We compared two cohorts of patients with LMA and ETT to analyze the effect on operating room times. Our study identified 1042 patients who met criteria for review. The incidence of cases requiring conversion to ETT (1.2%) and laryngospasm (0.3%) in our cohort is lower than previously suggested by the literature. The patients who underwent surgery with the LMA spent less time in the operating room (p = 0.004) compared to the ETT group. The use of the LMA may be a safe and effective option for airway management during tonsillectomy and adenoidectomy. There may be a benefit of OR time reduction in patients undergoing anesthesia with an LMA compared to ETT.

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Propranolol versus nadolol for treatment of pediatric subglottic hemangioma

Weining Yang, Nikolaus E. Wolter, Sharon L. Cushing, Elena Pope, Jennifer K. Wolter, Evan J. Propst

Publication date 28-03-2021


The beta-blocker propranolol is the standard medical therapy for subglottic hemangioma (SGH), but side effects and incomplete response rates require close monitoring. Nadolol has been identified as a potential alternative but its use has not been examined for SGH. Single institution retrospective cohort study of pediatric SGH treated with propranolol or nadolol. Thirteen children (1 male, 12 female) with SGH were included: 6 were treated with propranolol (2.0-3.5 mg/kg/d) and 7 with nadolol (2.0-4.0 mg/kg/d). The most common presenting symptom was stridor (85%) and mean (SD) symptom duration prior to diagnosis was 4.6 (3.8) weeks. Cutaneous vascular lesions were present in 54%. There were 7 right-sided, 5 left-sided and 1 bilateral SGH. The mean (SD) percentage of airway obstruction was 60.6% (27.4). The response rate was 100% (6/6) for propranolol and 85.7% (6/7) for nadolol (p = 0.36). Mean (SD) time to symptomatic improvement was 2.6 (2.2) days with no difference across groups (p = 0.71). There was no hypotension, hypoglycemia, weight loss, or sleep disturbances in either group. One patient in the propranolol group experienced vomiting. Two patients in the nadolol group required dosage reduction due to asymptomatic bradycardia. The mean (SD) duration of admission was 14.4 (12.6) days and duration of treatment was 13.8 (11.2) days with no difference across groups (p = 0.23; p = 0.31, respectively). All patients had treatment initiated as inpatients and completed as outpatients. Children with SGH treated with propranolol or nadolol had similar response rates and side effect profiles.

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Comparison between MB11 BERAphone® and ALGO2e color for hearing screening in Japanese healthy newborns

Akihiro Kishino, Takeshi Masuda, Yasuyuki Nomura, Shuntaro Shigihara, Takeshi Oshima

Publication date 24-03-2021


Since 2001, newborn hearing screening has been performed in Japan. This study compared newborn hearing screening results between the MAICO MB11 BERAphone (MB11) and the Natus ALGO2e color (ALGO) Automated Auditory Brainstem Response (AABR) devices among healthy Japanese newborns. From December 2014 to April 2018, 1477 healthy newborns were screened by MB11 and 267 by ALGO. Data from at-risk newborns were not included. Outcomes were 'Pass' and 'Refer' rates, specificity, false-positive rates, and assessment duration. Infants with a Refer result were examined using Interacoustics Eclipse. MB11 identified 1425 (96.5%) as Pass and 52 (3.5%) as Refer. ALGO identified 263 (98.5%) as Pass and four (1.5%) as Refer. Specificity and false-positive rates were 97.7% and 2.3% for MB11 and 98.5% and 1.5% for ALGO, respectively. Using MB11, the total mean assessment time was 320.2 ± 220.7 s, with 315.6 ± 214.2 s for Pass and 628.6 ± 288.8 s for Refer. MB11 is useful for hearing screening in healthy Japanese newborns and is fast and easy to operate. MB11 showed high specificity equivalent to ALGO.

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The expression of VEGF and VEGFR in endotoxin induced otitis media with effusion in rats

Xiping Li, Mengxiao Ye

Publication date 25-03-2021


To investigate the expression and correlation of vascular endothelial growth factor (VEGF) and its receptor with hypoxia-inducible factor-1 α (HIF-1 α) in otitis media with effusion (OME). A rat model of OME was induced by injection of lipopolysaccharide (LPS) into the middle ear. Hematoxylin and eosin (HE) staining was used to observe the pathomorphological changes of the tympanic cavity in the middle ear of rats. Immunohistochemistry (IHC), western blotting and RT-qPCR were used to determine the mRNA and protein expression of VEGF, VEGFR-1, VEGFR-2 and HIF-1α in mucosa of tympanic cavity mucosa, respectively. In the OME group, the epithelial space of the middle ear mucosa was significantly thickened and infiltration of a large number of inflammatory cells was found on postoperative day (POD), and the otitis media basically subsided 2 weeks after operation. VEGF mRNA expression was significantly increased on POD 1, and its protein expression peaked on POD 3. HIF-1α mRNA expression was significantly increased and peaked on POD 1, while its protein expression began to increase on POD 3 and was significantly expressed in the middle ear mucosal epithelium. HIF-1α mRNA showed a positive correlation with VEGF mRNA and VEGFR-1 mRNA expression. VEGF mainly plays a role in the acute phase of OME, and it is abundantly expressed mediated by HIF-1α. And then it play a role in vasodilatation and increase of vascular permeability, thus promoting the generation of middle ear effusion.

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Process improvement strategy to implement an outpatient surgery center efficiency model in an academic inpatient setting

Michael Kubala, J. Reed Gardner, Justin Criddle, Abby R. Nolder, Gresham T. Richter

Publication date 24-03-2021


By utilizing process improvement methodology, we aim to: 1) create an ambulatory surgical efficiency model (SEM) confined to an inpatient setting, and 2) reduce patient wait time and improve patient flow within the operating room. A prospective cohort of all otolaryngology cases performed from May 2016 to October 2017 at a tertiary, academic, pediatric hospital. Intraoperative timestamps were collected to determine turnover times. Time to procedure was collected from clinic visit to the day of operation. A total of 5955 patients were enrolled. 3393 cases were performed prior to the implementation of SEM and 2562 after. Of the 2562 cases, 819 were deemed appropriate for the SEM. Prior to the SEM, the average number of working days between the clinic visit and operating room (WD) was 31.1 days (95% CI 30.7-31.4). After the SEM, the WD for non-SEM cases was 30.0 days (95% CI 29.7-30.2), and the WD for SEM cases was 14.4 days (95% CI 14.2-14.6). The average turnover time was significantly less for SEM cases at 11.4 min (95% CI 10.7-12.2) vs. non-SEM cases at 24.4 min (95% CI 23.9-25.0) (p < 0.0001). Process improvement methodology is effective in improving perioperative patient flow. This quality improvement project decreased the average time from diagnosis to surgical procedure, as well as decreased the average turnover time between cases. Patient flow can improve with a high-volume SEM within an inpatient hospital operating room setting. This strategy can be instrumental in improving patient care by providing increased access to the operating room.

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A SEER database study of malignant teratomas in the head and neck region

Tam Ramsey, Kent Curran, Jason Mouzakes, Neil Gildener-Leapman, Lisa Galati

Publication date 20-03-2021


To review tumor and patient characteristics as well as survival of pediatric head and neck malignant teratomas (HNMT) in comparison to the adult population. This investigation was a retrospective cohort study. The Surveillance, Epidemiology, and End Results (SEER) database (SEER-18 Regs Custom registry, November 2018) was reviewed for all cases of head and neck malignant teratomas from 1975 to 2016. A log rank test was used to compare survival between infant, pediatric, and adult HNMT, and between head and neck and non-head and neck malignant teratomas. Infant, pediatric, and adult patients were defined as younger than one year old, younger than 18 years old, and older than 18 years old, respectively. Sixty-three malignant teratoma cases (1.96%) occurred in the head and neck region from 1975 to 2016, including 11 adult (17.46%) and 52 (82.54%) pediatric patients. 79.37% (50 patients) were diagnosed during infancy. The most common location was the soft tissue of the head and neck in pediatric patients (65.38%) and the thyroid gland in adults (54.54%). The 5-year survival was 45.83% (±7.19%) in infants and 46.00% (±7.05%) in pediatric patients. There were differences in 1-year and 5-year survival between pediatric HNMT and non-head and neck malignant teratomas, (76.01% versus 86.20%) (p = 0.022) and (46.00% versus 67.10%) (p < 0.001), respectively. There was no difference in 1-year and 5-year survival between pediatric patients and adults with HNMT, (76.01% versus 81.81%) (p = 0.618) and (46.00% versus 54.54%) (p = 0.560), respectively. HNMT occurred most frequently in patients under the age of 1. Prognosis of pediatric HNMT is poor in comparison to pediatric non-head and neck malignant teratomas. Repeat studies after accumulating more patients in the database would be beneficial to confirm our findings.

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Predictive clinical exam findings in post-tonsillectomy hemorrhage

Harleen K. Sethi, David Lafferty, Jane Y. Tong, David Zwillenberg

Publication date 18-03-2021


Post tonsillectomy hemorrhage (PTH) is a common complication of tonsillectomy.
Our objectives were to: 1) Examine the postoperative course of patients presenting to St. Christopher's Hospital for Children (SCHC) with PTH; 2) Compare patients with and without a blood clot visualized in the tonsillar fossa at time of presentation to determine if outcomes regarding return to the operating room (OR) differ. This was a retrospective chart review conducted at an academic, tertiary, pediatric hospital in an urban setting. Pediatric patients who underwent a tonsillectomy with concurrent adenoidectomy and were admitted for observation following secondary post tonsillectomy hemorrhage were reviewed. The effects of age, gender, indication, and clinical exam findings on admission on the rate of eventual return to the OR for control of hemorrhage were also analyzed. Chi-square analysis and Fisher's exact test were used to compare the significance of categorical frequencies. The rate of blood clot presence in our cohort was 50.9% (28/55). Return to OR rates were defined as patients who began actively hemorrhaging following admission for observation, further stratified by presence or absence of clot on admission physical exam. There was a statistically significant higher rate of return to OR in patients who presented with a clot (46.6%) on clinical exam versus no clot (18.5%) after resolved post tonsillectomy hemorrhage (p < .027). Furthermore, patients with a blood clot present were significantly more likely to require OR sooner (21.31 h from admission) than those without a clot (100.75 h from admission) (p < .012). There was no statistically significant higher rate of blood clot presence or rate of return to OR in groups based on age, gender, or indication. Pediatric patients presenting after resolved secondary PTH with a blood clot visualized in the tonsillar fossa are more likely to require return to the OR for hemostasis and cautery than are those without a blood clot, and this is more likely to occur within 24 h of admission. Thus, patients with a blood clot on initial presentation may benefit from admission for a 24-h observation period, while a similar observation period may be unproductive for patients without a blood clot. Patients who present with a resolved secondary PTH and a blood clot present on clinical exam require return to the OR more often than patients presenting without a blood clot. While previously controversial, we feel that this demonstrates that a 24-h observation of a patient with a clot on exam is reasonable.

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Altered tonsillar toll-like receptor (TLR)-1 and TLR-2 expression levels between periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), and group A beta-hemolytic streptococcal (GAβHS) recurrent tonsillitis patients

Umut Gazi, Hanife Ozkayalar, Monjed I.M. Mujahed, Ozgur Tosun, Ceyhun Dalkan, Burcin Sanlidag, Mustafa Asım Safak, Gamze Mocan, Nerin Onder Bahceciler

Publication date 17-03-2021


Tonsillar microenvironment is thought to contribute to innate immune dysregulation responsible for the periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) because of beneficial effects of tonsillectomy on treatment of the syndrome. Accordingly previous studies reported altered lymphocyte frequency, cytokine level and microbial composition in PFAPA tonsils. The aim of our study is to monitor expression levels of pro-inflammatory cell surface Toll-like receptors (TLRs) which have important role in induction of inflammation and maintaining tissue haemostasis. Seven patients with PFAPA syndrome, and eight patients with group A beta-hemolytic streptococcal (GAβHS) recurrent tonsillitis were included in our study. Tonsillar expression levels of TLR-1, -2, -4, -5, and -6 were monitored by immunohistochemistry (IHC). Expression levels were scored using semi-quantitative analysis method and were statistically analyzed by Two-Way Repeated Measures Analysis of Variance test. IHC analysis demonstrated expression of all TLRs in tonsillar surface epithelium (SE) and lymphoid interior (LI) except for TLR-6 which was not present in the former. There has not been any statistically significant difference in TLR expression levels between PFAPA and GAβHS tonsils, except for TLR-1 and TLR-2 which were higher on LI and lower on SE of PFAPA tonsils, respectively, than that of the GAβHS samples. Altered TLR expression levels may be involved in PFAPA pathogenesis. Future studies with higher patient number, uninflamed tonsils and cellular markers are required to further enlighten the role of TLRs in the development of syndrome.

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Congenital bony nasal cavity stenosis: A review of current trends in diagnosis and treatment

Francesca Galluzzi, Werner Garavello, Gianluca Dalfino, Paolo Castelnuovo, Mario Turri-Zanoni

Publication date 12-03-2021


Congenital bony nasal cavity stenosis is caused by alterations of the normal embryological development of the nasal cavity. Depending on the site of the obstruction, the most important types of stenosis are: choanal atresia and stenosis, congenital nasal pyriform aperture stenosis, congenital midnasal stenosis, arhinia and nasal septum deviation. Although they are uncommon, they could be potentially life-threatening conditions that require early diagnosis and proper treatment. In case of neonatal nasal obstruction, appropriate differential diagnosis with other causes, such as rhinitis and sinonasal masses, are performed by nasal endoscopy and radiological exams. Treatment strategy consisting of medical nasal therapies and endoscopic or open nasal surgery should be tailored according to the types and the degree of the stenosis. When indicated, endoscopic endonasal approach is considered the most effective technique in neonates warranting minimal surgical invasiveness and maximum effect. In order to promote the management of these rare yet clinically relevant neonatal nasal breath disorders, we review the current trends in diagnosis and treatment of congenital bony nasal cavity stenosis.

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Anesthesia for extraction of a fractured COVID-19 nasopharyngeal swab

Varun Suresh

Publication date 17-01-2021


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Complicated acute frontal sinusitis in a child presenting with acute ischemic stroke

Wesley L. Davison, David A. Gudis

Publication date 29-01-2021


Acute stroke as a complication of sinusitis is exceedingly rare, and even more so in children. Here we present the case of a healthy 9-year-old male who had an acute stroke in the setting of severe acute pansinusitis. The patient was started on parenteral antibiotics and underwent urgent endoscopic sinus surgery and adenoidectomy, ultimately making a full neurologic recovery. Of the previously reported cases of stroke as a complication of sinusitis, all showed evidence of carotid artery pathology. This is the first report to our knowledge of acute sinusitis presenting as stroke with normal arterial anatomy and function.

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Risk factors for the development of hypocalcemia in pediatric patients after total thyroidectomy – A systematic review

Kung-Ting Kao, Elspeth C. Ferguson, Geoff Blair, Neil K. Chadha, Jean-Pierre Chanoine

Publication date 12-03-2021


Post-thyroidectomy hypocalcemia is a common complication that causes increased morbidity. This review aims to identify the factors that predict occurrence of hypocalcemia after total thyroidectomy in children and adolescents. Comprehensive searches of English language pediatric (≤18 years of age) articles were performed in Medline, CINAHL, EMBASE, Web of Science and the Cochrane Library. Studies published between January 1, 1970 to August 20, 2020 regarding risk factors and strategies to prevent hypocalcemia were included if the study: 1. included only pediatric patients who were ≤18 years of age, 2. included only patients who had total, subtotal or completion thyroidectomy, 3. defined hypocalcemia as serum total calcium of <2.0 mmol/L (8 mg/dL) or ionized calcium of <1.0 mmol/L. The quality of included papers was assessed using the Newcastle-Ottawa scale. Results of all included studies were summarised. Meta-analyses were performed if appropriate. Five studies with a total of 477 patients between 0 and 18 years, who had total/subtotal/completion thyroidectomy, were included. Overall rates of transient hypocalcemia were higher than permanent hypocalcemia (transient n = 104, 22%; permanent n = 48, 10%). Two studies found intraoperative parathyroid hormone (PTH) useful in predicting hypocalcemia. While two single institution cohort studies reported that neck dissection, male sex and a lower Parathyroid Gland Remaining In Situ score were associated with hypocalcemia, two other studies, including one population-based cohort study, reported that age at surgery, patient sex, hospital volume, type of thyroid disease, number of identified parathyroid glands, parathyroid auto-transplantation, operation time, thyroid specimen weight, and lymph node dissection were not risk factors for hypocalcemia. Intraoperative PTH may be useful in predicting hypocalcemia in children after total thyroidectomy. No consistent clinical risk factors or preventative methods were identified in the pediatric literature. High-quality pediatric research is urgently required to address this knowledge gap.

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The effect of nebulized antibiotics in children with tracheostomy

Emine Atag, Fusun Unal, Huseyin Arslan, Burcu Gizem Teber, Leyla Telhan, Refika Ersu, Fazilet Karakoc, Sedat Oktem

Publication date 14-03-2021


Children with tracheostomy have an increased risk of bacterial colonization and infection of the lower respiratory tracts. This study aimed to investigate the effects of nebulized antibiotics on the bacterial load, the need for oral antibiotics, the number of hospitalizations, and the length of stay in the intensive care unit in tracheotomised children with persistent colonization. Children with tracheostomy and persistent bacterial colonization who were started on nebulized antibiotic therapy after a lower respiratory tract infection were included in the study. Nebulized gentamicin or colistin were used according to the results of the tracheal aspirate cultures. Demographic and clinic characteristics were recorded from one year prior until one year after initiation of nebulized antibiotic treatment. Nebulized antibiotic treatment was initiated in 22 patients. Nebulized gentamicin was administered to 14 patients (63.6%) and colistin to 8 patients (36.4%). The median duration of treatment was 3 months (range 2-5 months). Following nebulized antibiotic treatment, median number of hospitalizations decreased from 2 (range 1.0-3.5) to 1 (range 0.0-1.5) (p = 0.04). The median length of stay in the intensive care unit reduced significantly from 89.5 days (range 43.0-82.5) to 25 days (range 7.75-62.75) after starting nebulized antibiotics (p = 0.028). Following nebulized antibiotic treatment median bacterial colony count also decreased (from 10 The use of nebulized antibiotics reduced the number of hospitalizations, length of stay in the intensive care unit, and bacterial load in tracheotomised children with persistent airway colonization without significant side effects. The use of nebulized antibiotics showed a statistically significant decrease in the measures studied. Use of nebulized antibiotics may help to decrease the health care burden of these children, families and health care system. Further studies are needed to determine the indications and optimal duration of long-term nebulized antibiotic treatment in children with tracheostomy.

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Risk of dental malocclusion in children with upper respiratory tract disorders: A case-control study of a nationwide, population-based health claim database

Shi-Wei Lin, Chai-Hong Jheng, Chun-Lung Wang, Chia-Wen Hsu, Ming-Chi Lu, Malcolm Koo

Publication date 11-03-2021


The aim of this study was to evaluate the association between different upper respiratory tract disorders and severe dental malocclusion in pediatric patients. Newly diagnosed patients (N = 773) with dental malocclusion aged 8-18 years and controls (N = 3865) were identified from the health claim records of the Longitudinal Health Insurance Database 2000 of Taiwan's National Health Insurance Research Database. Controls were frequency matched to the cases by sex, age group, and index year. Univariate and multiple logistic regression analyses were used to evaluate the association between severe dental malocclusion and six common upper respiratory tract disorders, including acute sinusitis, allergic rhinitis, chronic sinusitis, nasal septum deviation, nasal polyps, and hypertrophy of tonsil and adenoids. The risk of severe dental malocclusion was significantly elevated in pediatric patients with three upper respiratory tract disorders, including acute sinusitis (adjusted odds ratio [aOR] = 1.66, 95% confidence interval [95% CI] 1.39-1.99), allergic rhinitis (aOR = 1.64, 95% CI 1.34-2.02), and chronic sinusitis (aOR = 2.01, 95% CI 1.27-3.19). When all the six upper respiratory tract disorders were simultaneously included in the multiple logistic regression analysis, acute sinusitis (aOR = 1.48, p < 0.001) and allergic rhinitis (aOR = 1.34, p < 0.010) were significantly and independently associated with an increased risk of severe dental malocclusion. Findings from this nationwide, population-based case-control study indicated that acute sinusitis and allergic rhinitis were independently and significantly associated with an increased risk of severe dental malocclusion in pediatric patients. Pediatricians should remain vigilant for the risk of dental malocclusion in their patients with these disorders.

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Odor identification performance in children using the “U-Sniff” test – Administered by an untrained person

Janine Gellrich, Liesa Zscheile, Claudia Zickmüller, Valentin A. Schriever

Publication date 14-03-2021


The examination of olfactory function of patients with psychophysical olfactory tests such as the "Sniffin' Stick" test is a central component of any olfactory clinical diagnostics and clinical trials. Because olfactory disorders can also occur in childhood, reliable, valid and time-efficient olfactory tests are important. With the "U-Sniff", a child-friendly odor identification test that has already been sufficiently validated is available The aim of this study was to investigate whether untrained persons (e.g. parents with their children) are able to administer the "U-Sniff" odor identification test with appropriate guidance. A total of 80 kindergarten children, aged 6 years, underwent an odor identification test. Half of the children were tested by their parents and the other half by a trained examiner. In addition, the examiner performed a concentration test (Kaseler Konzentrationsaufgaben). The results of the two groups were compared. All children completed the rapid testing protocol. No significant differences between the results of the two testing procedures occurred. On average an odor identification score of 9.68 ± 2.02 points (mean ± SD) was reached in the examiner's group while 9.65 ± 2.38 points were observed in the parents' group. It can be concluded that this study presents a new testing procedure using the "U-Sniff" odor identification test for children by untrained persons. Further validation of this test procedure examining olfactory impaired children should follow.

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Genetic variations at 10q26 regions near FGFR2 gene and its association with non-syndromic cleft lip with or without cleft palate

Ginila T. Raju, Bhaskar L.V.K.S, Venkatesh Babu Gurramkonda, Syed Altaf Hussain, Solomon F.D. Paul

Publication date 09-03-2021


In our study, we focussed on three SNPs in the non-coding regions near FGFR2 gene, as studies on non-coding variants in the genome are the novel trends to identify the susceptible loci for nonsyndromic cleft lip with or without cleft palate (NSCL/P). FGFR2 gene is selected as a candidate gene based on knock out animal models and the role played in syndromic forms of clefting. FGFR2 gene also plays an important role in FGF signaling pathway during craniofacial development. In the present study 148 case-parent triads were assessed for three SNPs rs10749408, rs11199874 and rs10788165 near FGFR2 gene by using Taq Man allelic discrimination method. Transmission disequilibrium test (TDT) was used to find the allelic association. Linkage disequilibrium (LD) between the markers was analysed using Haploview program 4.2. Haplotype transmission effects were estimated using FAMHAP package. The possible parent-of-origin effects were assessed by likelihood based approach. TDT analysis of three SNPs failed to show significant transmission disortion from heterozygous parents to the affected child and are not associated with NSCL/P. Linkage disequilibrium analysis showed strong LD between rs11199874 and rs10788165 SNPs. In the haplotype TDT analysis, GG haplotype of rs11199874-rs10788165 showed significant undertransmission to affected child. No significant parent-of-origin effects were observed. The present study on noncoding variants near FGFR2 gene is not associated with NSCL/P. As the numbers of triads included in the study are less, further studies are needed including large sample size to find association with NSCL/P.

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Is bib count an accurate quantitative measure of drooling?

Tanya Chen, Sam J. Daniel

Publication date 08-03-2021


Bib count is a frequently used measure amongst pediatric otolaryngologists to quantify drooling status. The plethora of bibs used, including important differences in material, size, and shape, makes one question the validity of bib count as an accurate surrogate measure of drooling frequency or severity. To date, no study has addressed this question in the literature. We evaluated the correlation between drooling frequency, drooling severity, and number of bibs changed to better guide clinical practice in saliva management in a large pediatric patient population. This was a retrospective cohort study comprising 414 pediatric patients from 2014 to 2019. Patients were included if there was presence of drooling and completed the Daniel Drooling Impact Score Questionnaire. The primary outcome was the severity of drooling, frequency of drooling, and number of bibs changed. Age, sex, feeding type and diagnosis were also data points collected. Pearson's coefficient of correlation and multiple regression analysis were used to analyze association between variables. Bib count, frequency of drooling, and severity of drooling were all positively correlated. The strongest positive correlation was between drooling frequency and drooling severity (r = 0.659; p < 0.01), followed by bib count and drooling severity (r = 0.541; p < 0.01), then bib count and drooling frequency (r = 0.416; p < 0.01). In multivariate regression analysis, only bib count was a statistically significant positive predictor of drooling severity (β=1.14, p < 0.01). Feeding type and underlying diagnosis also influenced bib count. The number of bibs changed per day is an accurate predictor of sialorrhea that correlates positively with drooling severity and frequency despite the variability and lack of standardization in bibs. Consistent definitions of what constitutes a bib and its characteristics should be collected during drooling evaluation.

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Pediatric penetrating cervical trauma in HCUP: Associations with hospital length of stay and cost

Sam DeVictor, Jason DeGiovanni, Michele M. Carr

Publication date 06-03-2021


To describe pediatric penetrating cervical trauma (PCT) and determine factors associated with increased length of stay (LOS) and total hospital charges. Retrospective review of Healthcare Cost and Utilization Project (HCUP) from the Kids' Inpatient Database (KID) for 2016. Public database. A retrospective analysis of the HCUP from the KID for 2016 for inpatients ≤18 years of age. Comparisons between PCT and non-PCT patients were made, including hospital LOS and total charges. There were 1279 patients with neck trauma of which 686 (53.6%) were identified as sustaining PCT. Patients with PCT were older (13.2 vs 11.8 yr, p = .001), and were more likely to be male (65.9% vs 54.8%, p < .001) and African-American (21.9% vs 15.9, p = .01). PCT patients were less likely to have a vascular injury (6.1% vs 20.1%, p < .001) and they were more likely to undergo airway evaluation (8.3% vs 2.2%, p < .001). Within the PCT group, 11.5% had open pharyngeal/esophageal lacerations, 6.1% had open tracheal injuries, 2.0% had open thyroid injuries, and 1.6% had open laryngeal injuries. LOS and total charges were not different between children with and without PCT (mean LOS 6.5 days, mean total charges US$106,000). Linear regression analysis showed significant associations with LOS for age, tracheal open injuries, cervical or vascular injury, and undergoing airway evaluation and/or esophagoscopy. Total charges associations were similar. LOS and total charges were not different in children with PCT and non-PCT, but both were increased when there were more cervical injuries and more related procedures done.

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Normative vocal acoustic parameters for preschool and elementary school Egyptian children

Reham Abdelwakil Ibrahim, Elham Magdy Hassan

Publication date 06-03-2021


A reliable acoustic analysis necessitates the availability of standard normative values at different ages. Normative values of vocal acoustic parameters are readily available for the adult population but not much data are available for the pediatric population. Providing a database for the normative vocal acoustic parameters in preschool and elementary school Egyptian children to lay out an objective model for the diagnosis and optimal treatment of childhood voice disorders. A total of 237 Egyptian children between the ages of 4 and 9 years from both genders were enrolled in the study. A Computer-assisted acoustic vocal analysis was done for all children. Fundamental frequency values differed significantly according to gender with higher measures in girls. Mean values of the fundamental frequency were 258.57 Hz ± 39.69, jitter percentage 0.85% ± 0.67, shimmer percentage 1.59% ± 1.03, fundamental tremors 1.64HZ ± 0.421, maximum phonation time 4.81sec. ± 1.73 and harmonic/noise ratio were 15.34 dB ± 10.65. A decline of measures of the fundamental frequency and jitter percentage with increasing age and an increase of values of harmonic/noise ratio and shimmer percentage in children residing in rural areas are observed. This study provides an insight into the normative values of vocal acoustic parameters in preschool and elementary school Egyptian children. Comparable to other studies, both fundamental frequency and jitter percentage values show a decline with increasing age. Also, fundamental frequency values differ significantly among genders. The difference in socioeconomic environment seems to influence some of the vocal acoustic parameters in children.

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Study on the role of methylation in nonsyndromic cleft lip with or without cleft palate using a monozygotic twin model

Xuheng Shi, Qi Wang, Changsheng Sun, Qiang Guo, Tao Song

Publication date 06-03-2021


The research on the etiology of nonsyndromic cleft lip with or without cleft palate(NSCL/P) is challenging, and DNA methylation has an impact on the formation of cleft lip and palate. In this study, one of a pair of monozygotic twins (T1) had nonsyndromic cleft lip (NSCL), and one of a pair of monozygotic twins (T2) had nonsyndromic cleft lip and palate (NSCLP). We determined the methylation profiles of more than 850,000 Cp Gs in the DNA of the blood samples from the two pairs of monozygotic twins. Methylation data indicated that 1184 differentially methylated CpG sites were found in the T1 group (651 hypermethylated and 533 hypomethylated) and 8099 differentially methylated CpG sites in the T2 group (1713 hypermethylated and 6386 hypomethylated) compared with the healthy twin.
The common difference was 107 methylation sites.
GO enrichment analysis showed that regulation of smooth muscle cell migration and actin cytoskeleton reorganization were the most prominent classes.
KEGG pathway enrichment analysis showed that the TGF-β signaling pathway, Notch signaling pathway and Wnt signaling pathway are relevant to the formation of NSCL/P.
Two selected genes (NTN1 and PLEKHA7) are involved in the formation of NSCL/P. These findings provide some support for the hypothesis that abnormal DNA methylation may influence the formation of clefts.

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Challenges faced by parents when seeking diagnosis for children with sensorineural hearing loss

Nur Fatihah Ainun Hamzah, Cila Umat, Deepashini Harithasan, Bee See Goh

Publication date 05-03-2021


The Joint Committee of Infant Hearing (JCIH) recommended hearing screening by one month of age, diagnosis of hearing loss by three months of age, and intervention initiated by six months of age. In Malaysia however, the age of diagnosis of hearing loss in children is relatively late. This study aimed to identify the challenges faced by parents in seeking a diagnosis of hearing loss for their children. The study utilized a semi-structured interview with open-ended questions to obtain information about parents' experiences during the diagnosis period and their challenges when going through that process. In this study, a total of 16 parents of children who were diagnosed with moderate to profound sensorineural hearing loss and received intervention within three years at the time of the study participated. Ten of the children were cochlear implant users, and six were hearing aid users. Thematic analysis was used to analyse themes generated from the data according to the study objective. Four main themes and 17 subthemes were identified from this study. The four main themes were 1) Parents' emotion; 2) Parental knowledge; 3) Others; 4) Profesional services. Challenges that parents faced often include emotional behaviours such as feeling guilty and devastated during the diagnosis, lack of information-sharing from healthcare givers, lack of knowledge on childhood hearing loss among parents, support from families, seek for a second opinion, worry about others' acceptance, longer time for diagnosis to confirm, late referral to other related profesionals and no priority for the appointment. Emotion is identified as the biggest challenge faced by parents in the process of diagnosis for their children with hearing loss. Hence, management of parental emotion needs to be emphasized by health profesionals as it influences the acceptance of parents towards their child's diagnosis.

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Monopolar electrocautery tip vs plasma ablation in tonsillotomy: A randomized case-control study comparing outcomes in pediatric population

Elie Bou Sanayeh, Samar Idriss, Youssef Farchakh, Charlie Hanna, Souheil Hallit, Bassam Romanos

Publication date 28-02-2021


The objective of this study was to compare the low-priced monopolar electrocautery to the high-priced, worldwide used, plasma ablation in tonsillotomy among children aged between three and twelve years, suffering from obstructive breathing disorders (OBD), with respect to post-operative pain, bleeding and related morbidities. A randomized case-control study was conducted in the Eye and Ear Hospital International- Lebanon. 103 children aged between three and twelve years suffering from OBD secondary to tonsillar hypertrophy were randomly assigned into two groups. Post-operative pain was evaluated using age-adequate validated scales: "FLACC-R" (Face, Legs, Activity, Cry, Consolability-Revised) for children aged less than five years, and "Wong Baker faces" for older children. Additional post-operative outcomes were evaluated using Pain-PROM (Patient reported Pain-Related Outcome Measures) and TAHSI (Tonsil and Adenoid Health Status Instrument) scales. Significantly, higher rates of patients who underwent tonsillotomy via plasma ablation technique used analgesics and had severe pain compared to the monopolar electrocautery group. A longer operative duration was significantly associated with higher pain scores, and the plasma ablation technique yielded significantly higher operative mean durations. 10 days post-operatively, a significantly higher percentage of children reported an overall high pain severity and more than expected overall pain when using the plasma ablation technique compared to the monopolar electrocautery one. Overall bleeding rates were similar. No difference was reported one month post-operatively. When compared to plasma ablation, monopolar electrocautery, can provide the same efficiency in relieving OBD in healthy children, with equal overall bleeding rates, but significantly lower cost, operating time, pain scores and need for analgesics.

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Prevalence of hearing loss in school aged Nepalese children

Milan Maharjan, Samjhana Phuyal, Mana Shrestha

Publication date 27-02-2021


The main objective of this study is to identify the prevalence of hearing loss in school aged children of Nepal. This cross-sectional study was carried out on school aged children attending the government run schools of Nepal. A total of 79,340 children from grades 1 through 10 were included in the study. After taking brief history about ear diseases and hearing loss, children were screened for ear diseases in their respective classroom by otoscope. Hearing evaluation was carried out by pure tone audiometer and hearing threshold was obtained at 0.5-4 k Hz. The results were then documented and analyzed. The prevalence of hearing impairment in school aged children in Nepal is found to be 5.73% (4551 of 79,340). Conductive hearing loss was the most common type of hearing loss and was observed in 70.47% (n = 3207) of the children. This study shows that hearing loss is a common problem in children of Nepal. With the main cause of hearing loss due to preventable conditions such as chronic otitis media, it is believed that early standardized screening, detection and timely management of chronic otitis media in these children can prevent hearing loss and its impact on their educational, social and language development. School based ear health programs are a useful community-oriented solution for prevention of deafness. It shows how important it is to introduce hearing screening for primary school aged children to prevent hearing loss.

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Improving community-based care for children with a rare condition: The example of long-segment congenital tracheal stenosis and perceptions of health professionals, parents and teachers

Jo Wray, Hannah Sugarman, Laura Davis, Colin Butler, Denise McIntyre, Richard Hewitt

Publication date 05-03-2021


Long segment congenital tracheal stenosis (LSCTS) is a rare, complex condition which is often poorly understood by community-based health professionals (HPs). Anecdotally, such HPs often lack confidence providing care for children, resulting in children being brought to the tertiary centre more frequently than necessary. We wanted to identify the information and support needs of HPs in primary and secondary care looking after a child with LSCTS, the views of those providing education to these children, and elicit parents' perceptions about community-based services, to improve overall care for children and families. Questionnaires were sent to 175 community-based HPs and 34 teachers involved in the care of children with LSCTS. Face-to-face or telephone interviews were conducted with 12 parents of patients with LSCTS to establish their perceptions of community-based services. Ninety (51%) completed questionnaires were returned from HPs and 18 (53%) from teachers. Responses indicated low levels of knowledge of LSCTS. Physical, practical and communication information needs were identified by all respondent groups, together with general and condition-specific concerns. Interviews with parents indicated that they thought the level of knowledge about LSCTS in the community was low, which had a negative impact on their willingness to consult local services. Better information provision for HPs, teachers and parents was identified as a means of improving outcomes. Professionals caring for children with LSCTS in the community and in schools have unmet information and support needs, with consequences for children, families, HCPs in both the community and tertiary hospital, and teachers.

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Prevalence of and factors affecting otitis media with effusion in children in the region from Balkans to Caspian basin; A multicentric cross-sectional study

M. Tayyar Kalcioglu, Suela Sallavaci, Nermin Hrncic, Munar Beishenova, Marina Davcheva Cakar, Ljiljana Vlaski, Farzona Adylova, Igor Berezniuk, Ulugbek Khasanov, Cem Uzun, Murat Erinc, Evis Bendo, Selma Hrncic, Cholpon Beysheeva, Valentina Ivanovska, Slobodanka Lemajic–Komazec, Shahnoza Solieva, Volodymyr Berezniuk, Gavkhar Khaydarova, Selis Gulseven Guven

Publication date 19-02-2021


The aim of our study was to contribute to the literature about the prevalence of OME by conducting a research in a wide geography examining most of the associating factors together with a questionnaire. Additionally, possible effects of altitudes and latitudes, concordance between the otoscopic examination findings and tympanometric and acoustic reflex test results were evaluated in 4-7 years old children in the same season in different countries. In the randomly sampled schools from different regions of different cities where people of different scoioecomonic statuses live, 4-7 year-old children were included in the study. The results of the questionnaire covering the potential factors in OME etiology were evaluated together with the results of the otoscopic examination and tympanometry findings, and also the acoustic reflex findings to direct the interpretation in cases of low amplitude - blunted peak tympanograms which can be interpreted as a "Type B" or "Type As". All the results were gathered in the same season. Ten centers from nine countries participated in the study. A total of 4768 children were evaluated. The frequency of OME diagnosed by otosopic examination was 22.48% (n=1072) and the diagnosis rate when otoscopic examination plus type B tympanometry were taken into account was found as 11.3% (n=539) in general population. Factors increasing the prevalence of OME were found as; mother's educational level (p=0.02), child's age (p=0.006), history of upper respiratory tract infection (p=0.001), smoking father (p=0.01), mother being a housewife or laborer (p=0.01), history of allergy (p=0.001), asthma (p=0.04), or allergy symptoms (p=0.02). No direct relationship was found between altitudes or latitudes and prevalence of OME. The important affecting factors found after analyzing all of the potential risk factors in the same model are secondhand smoke exposure, low level of mother's education, mother's occupation, positive history of URTI, and age of the child being less than 7. By paying attention to the factors that increase the prevalence of OME, putting particular emphasis on the preventable ones such as smoking, education, and fighting with allergies could decrease the prevalence of this public health issue.

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The low value of pre-decannulation capped overnight ICU monitoring for pediatric patients

Kevin J. Karlic, Nico M. Espinosa, Brittany E. Fleming, Jennifer L. Helman, Kelly A. Krawcke, Aaron L. Thatcher

Publication date 16-02-2021


To determine the value of pre-decannulation capped overnight ICU monitoring for assessing decannulation-readiness in pediatric patients. This study included all pediatric patients, age 18 and under, with a tracheostomy attempting decannulation at the University of Michigan between 2013 and 2018. Patients who underwent major airway reconstruction immediately prior to decannulation were excluded. Descriptive and comparative statistics were calculated to compare the sub-group of patients who underwent pre-decannulation capped overnight ICU monitoring to those who did not. 125 pediatric patients attempted decannulation for a total of 126 attempts with 105 attempts being eligible for inclusion. 75 eligible attempts included pre-decannulation capped overnight ICU monitoring, while 30 did not. Subsequent rates of successful decannulation were 97.33% (73/75) and 100.00% (30/30), respectively (P = 0.366; 95% CI -8.818-9.260). The pre-decannulation capped overnight ICU monitoring passing rate was 98.67% (74/75) despite a complication rate of 5.33% (4/75). Post-decannulation, 98.08% (102/104) of decannulated patients were monitored inpatient for a minimum of 24 h DISCUSSION: With similar rates of successful decannulation among both sub-groups and previous research demonstrating sufficient ambulatory testing accurately predicts successful decannulation, pre-decannulation capped overnight ICU monitoring is a low-value, high-cost test that can be safely discontinued without compromising patient care. Notably, our study excluded patients undergoing open airway reconstruction immediately prior to decannulation. The 24-h monitoring post-decannulation serves as a safety net for individuals who ultimately fail decannulation.

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"Its a rash: Antibiotic allergies in the modern era of antibiotic stewardship"

Amber D. Shaffer, Manasa Melachuri, Joseph E. Dohar

Publication date 10-02-2021


To determine whether current guidelines emphasizing antibiotic stewardship in pediatrics have been associated with reduced prevalence of antibiotic allergies in children severely affected by otitis media undergoing bilateral myringotomy with tympanostomy tube insertion (BMT) or by recurrent sinusitis or adenotonsillitis undergoing adenoidectomy with or without tonsillectomy. Case series of consecutive patients undergoing BMT or adenoidectomy with/without tonsillectomy for recurrent acute otitis media, recurrent sinusitis, or recurrent tonsillitis during November 2008 or November 2017 at a tertiary care children's hospital. Children with primarily obstructive indications for surgery, with prior tube placement or adenoidectomy, or with surgery by an outside provider were excluded. Demographics, type of surgery, and allergies or allergic symptoms were collected from the electronic medical record. Factors associated with antibiotic allergies were compared using logistic regression, Wilcoxon rank-sum, or Chi-squared test. Seventy-five children who underwent surgery during 2008 and 75 children who underwent surgery in 2017 were included. Overall, median age at surgery was 3.24 years (range 0.56-17.49 years). Seventy-nine (52.7%) patients were female and 95 (63.3%) had private insurance. BMT was the most common surgery (82 children, 54.7%) followed by tonsillectomy with adenoidectomy (46 children, 30.7%), and adenoidectomy without tonsillectomy (39 children, 26.0%). Symptoms of allergic rhinitis were reported by 53 (35.3%) patients, and 11 (7.3%) and 5 (3.3%) had positive environmental and food allergy testing, respectively. Surprisingly, there was not a significant difference between the prevalence of antibiotic allergies in patients undergoing surgery during 2017 (17 patients, 22.7%) compared with 2008 (14 patients, 18.7%) (OR: 1.28, 95% CI: 0.578-2.82, p = 0.546). However, antibiotic allergies were less common in females (OR: 0.413, 95% CI: 0.182-0.937, p = 0.034) and more common in patients with a family history of antibiotic allergies (OR: 36.9, 95% CI: 5.12-∞, p < 0.001). Pediatric otolaryngology surgical patients continue to exhibit a similar and high prevalence of antibiotic allergies in 2017 compared with 2008. Future studies are needed to determine whether this is because of overdiagnosis of antibiotic allergies or a failure of antibiotic guideline adherence to reduce antibiotic allergy prevalence.

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Initial outcomes at a nascent tertiary pediatric thyroid surgical center

David M. Bruss, Alexander J. Kovacs, Himala Kashmiri, Kevin C. Huoh

Publication date 09-02-2021


Previous studies on pediatric thyroid surgical complications suggest that high-volume centers achieve improved outcomes. We hypothesize that initial outcomes from a nascent pediatric surgical practice may be comparable to higher volume centers. Furthermore, we determine whether a low-volume center can safely transition to an intermediate or high-volume center. A retrospective chart review was performed for all pediatric patients undergoing thyroid surgery at a single institution from 2014 to 2020. Surgeries were performed by two pediatric otolaryngologists. All patients were managed postoperatively by a multidisciplinary team of physicians that included pediatric otolaryngologists and endocrinologists. Data collection focused on patient demographics and postoperative complications, including rates of recurrent laryngeal nerve injury and permanent hypoparathyroidism. From 2014 to 2020, a total of 31 patients underwent thyroid surgery at our pediatric thyroid surgery center, 9 of whom underwent neck dissection. The mean age of our cohort was 14.4 ± 3.9 years (range 8 months-20 years). Postoperative pathology results revealed that 15 patients (46.9%) were diagnosed with PTC, 6 (18.8%) with follicular adenoma, and 4 (15.6%) with benign thyroid tissue. One (2.0%) patient had permanent unilateral recurrent laryngeal nerve paralysis and one patient experienced permanent hypoparathyroidism (2.7%). Our initial low complication rate as a nascent pediatric thyroid surgery center suggests that favorable outcomes can be achieved at lower volume surgery centers. In order to increase patient access to high-volume pediatric thyroid surgery centers, new centers must start with lower volumes before ultimately becoming high-volume centers. Our study shows that this can be safely achieved. IV.

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Incidence and survival of salivary gland cancer in children and young adults in Denmark: A nation-wide study for the period 1990–2015

Jakob Schmidt Jensen, Christian Grønhøj, Martin Garset-Zamani, Marie Westergaard-Nielsen, Kristine Bjørndal, Katalin Kiss, Birgitte Charabi, Christian von Buchwald, Thomas Hjuler

Publication date 08-02-2021


The aim of this study was to evaluate incidence and survival of children and young adults with salivary gland cancer (SGC) in Denmark during the period 1990-2015. We included all patients aged 0-24 years registered with primary SGC in the Danish Cancer Registry, the Danish Pathology Data Bank, or the DAHANCA database during 1990-2015. Patients were divided in two age-groups: children (0-17 years) and young adults (18-24 years). Incidence rates, overall survival (OS), and recurrence free survival (RFS) was evaluated in relation to age-group, sex, tumor location, tumor histology, and T-, N-, and M-classification. A total of 70 SGC patients between 0 and 24 years (67% female, n = 47) were included. Thirty-six were children at time of diagnosis, and 34 were young adults. The incidence was higher among young adults compared to children (0.29 vs. 0.11 per 100.000) and showed no significant change during the study period. There were no differences in the distribution of sex, tumor location, or tumor histology between children and young adults. The total 5 and 15-year survival rates were 97.1% and 91.7% for OS, and 97.1% and 83.1% for RFS. The survival rates showed no significant differences according to age-groups, sex, tumor location, or tumor histology. Patients diagnosed in stage T4 had significantly worse OS and RFS. The incidence of SGC among children and young adults in Denmark was low and stable in the period 1990-2015. The overall survival was very high, demonstrating the excellent prognosis for children and young adults with SGC.

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Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010–2017

William T. Basco, Ralph C. Ward, David J. Taber, Kit N. Simpson, Mulugeta Gebregziabher, Robert A. Cina, Jenna L. McCauley, Mark A. Lockett, William P. Moran, Patrick D. Mauldin, Sarah J. Ball

Publication date 07-02-2021


Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.

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Home respiratory polygraphy in obstructive sleep apnea syndrome in children: Comparison with a screening questionnaire

Albane B.R. Maggio, Maurice Beghetti, Hélène Cao Van, Carole Grasset Salomon, Constance Barazzone-Argiroffo, Regula Corbelli

Publication date 04-02-2021


The prevalence of obstructive sleep apnea syndrome (OSAS) in children referred for sleep-disordered breathing reaches up to 59%. We aimed to test the adequacy of a questionnaire compared to home respiratory polygraphy (HRP), in 45 subjects (5-16 years-old), without maxillofacial malformations nor other comorbidities, presenting with symptoms compatible with OSAS. All children passed a 12-items questionnaire (Obstructive Airway Child test: OACT) and the HRP. OSAS was classified in severity according to the apnea-hypopnea index (AHI). With HRP, 60% and 15% children were detected to have at least mild (AHI ≥1) and moderate (AHI >5) OSAS, respectively. The sensitivity of the questionnaire to detect mild and moderate OSAS was good (93% and 71%, respectively) but the specificity was very low (11% and 34%). However, an OACT score under 61 showed a very good negative predictive value for moderate and severe OSAS (87%). With the questionnaire, we could have avoided a complementary PSG or HRP in 25/45 (56%) of our subjects as in children with mild OSAS and without comorbidities only clinical observation is usually advised. The OACT questionnaire has shown to be a good and quick instrument to exclude moderate and severe OSAS in our population of children without maxillofacial malformations. Indeed children scoring under 61 could avoid a constraining and expensive sleep exam. However, if the score is above this cut-off, the performance to recognize OSAS is low and the child's evaluation must be completed by a HRP or PSG.

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Are water precautions necessary after tympanostomy tube placement? A cadaver study

Anthony Sanchez, Gabriel Arom, Hector A. Perez, Laura Royal, TJ O-Lee

Publication date 01-02-2021


To determine whether Armstrong pressure equalization tubes allow passage of water into the middle ear with complete submersion in water up to 76 cm for 2 min. 10 adult cadaver heads were first assessed for the presence of fluid in both middle ears with zero-degree rigid endoscopes, after being submerged for 2 min in a plastic receptacle filled with 76 cm of water. A 25% perforation was then made in the tympanic membrane of one ear. A myringotomy was then made in the tympanic membrane of the contralateral ear, with the placement of a beveled Armstrong pressure equalization tube. The head was then submerged again for 2 min. Both ears were then examined for the presence of fluid in the middle ear using a rigid endoscope and with suction. Eight out of ten (80%) of the heads showed the presence of fluid in the middle ear on the perforation side after submersion, whereas none of the heads showed fluid in the middle ear on the side with the pressure equalization tube. At depths of 76 cm, total submersion in water for 2 min does not facilitate the passage of water into the middle ear via an Armstrong pressure equalization tube.

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Nasopharyngeal microbiome analyses in otitis-prone and otitis-free children

Lei Xu, Josh Earl, Peter Bajorski, Eduardo Gonzalez, Michael E. Pichichero

Publication date 31-01-2021


About 10-15% children develop frequent acute otitis media (AOM) confirmed by tympanocentesis. These children are designated sOP (stringently defined otitis-prone) because all AOM episodes have been microbiologically confirmed. The cause of otitis-proneness in sOP children is multi-factorial, including frequent otopathogen nasopharyngeal (NP) colonization and deficiency in innate and adaptive immune responses. A largely unexplored contributor to otitis proneness is NP microbiome composition. Since the microbiome modulates otopathogen NP colonization and immune responses, we hypothesized that the NP microbiome composition in sOP children might be dysregulated. We performed 16S rRNA sequencing to analyze microbiome composition in 157 NP samples from 28 sOP and 68 AOM-free children when they were 6 months or 12 months old and healthy. Bioinformatic approaches were employed to examine the composition difference between the two populations and its correlation with changes in levels of inflammatory cytokines. A different global microbiome profile and reduced alpha diversity was observed in the NP microbiome of sOP children when 6 months old, compared with that from AOM-free children of the same age. This difference was resolved when groups were compared at 12 months old. We found 4 bacterial genera-Bacillus, Veillonella, Gemella, and Prevotella-correlated with higher levels of pro-inflammatory cytokines in the NP. Those 4 bacterial genera were in lower abundance in sOP compared to AOM-free children. Dysbiosis occurs in the NP microbiome of sOP children at an early age even when they were healthy. This dysbiosis correlates with a lower inflammatory state in the NP of these children.

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The otolaryngologic manifestations of Sotos syndrome 1: A systematic review

David ONeil Danis, Olaf Bodamer, Jessica R. Levi

Publication date 01-03-2021


Sotos syndrome 1 (SOTOS1; MIM:117550) is rare genetic disorder characterized by excessive physical growth before and after birth, distinctive facial features, a large and elongated head, and intellectual disability (Sotos et al., 1964; Tatton-Brown et al., 1993). This systematic review aims to determine otolaryngologic conditions and complications of SOTOS1 based on existing literature through a review of current and past case reports and studies regarding SOTOS1. A systematic review of all published literature (1964-2020) describing otolaryngologic conditions and/or complications of patients with SOTOS1. Twenty journal articles met inclusion criteria. These articles included 160 patients diagnosed with SOTOS1. Of the 160 individuals with SOTOS1 included in this review, 22 (14%) were reported to have otologic conditions. 4 (3%) individuals were reported to have conditions involving the thyroid and parathyroid glands. 2 (1%) individuals were reported to have head & neck tumors. 39 (24%) individuals were reported to have congenital malformations or abnormalities of the head & neck. 47 (29%) individuals were reported to have feeding difficulties. 16% of individuals were reported to have other otolaryngologic conditions. Our review found multiple otolaryngologic conditions present in patients with SOTOS1, including hearing loss, otitis, hyperthyroidism, hypothyroidism, head & neck tumors, congenital malformations (high arched palate, cleft lip and palate, macroglossia), feeding difficulties, respiratory difficulties, and speech disorders. Additional studies should be conducted to further assess these associations.

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Corrigendum to “Positive predictive value for diffusion-weighted magnetic resonance imaging in pediatric cholesteatoma: A retrospective study” Int. J. Pediatr. Otorhinolaryngol. 2020, 139:110416. doi: 10.1016/j.ijporl.2020.110416. Epub 2020 Sep 30.PMID: 33027732

Rémi Hervochon, Monique Elmaleh, Martine Francois, Alix Marhic, Abdullah Bahakim, Natacha Teissier, Thierry Van den Abbeele

Publication date 28-03-2021


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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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