International Journal of Pediatric Otorhinolaryngology 2021-09-08

Endoscopic endonasal management of skull base defects in pediatric patients

Arad Iranmehr, Mehdi Zeinalizadeh, Mohamad Namvar, 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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Corrigendum to “Incidence and potential risk factors for adenoid regrowth and revision adenoidectomy: A meta-analysis” Int. J. Pediatr. Otorhinolaryngol. 137 (2020), Start page (1) –End page (9)/110220

Suchitra Paramaesvaran, Sejad Ahmadzada, Guy D. Eslick

Publication date 21-08-2021


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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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