International Journal of Pediatric Otorhinolaryngology 2022-01-21

Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?

Noah Shaikh, Parker Tumlin, Vincent Morrow, Mustafa G. Bulbul, Steven Coutras

Publication date 18-01-2022


To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications. Retrospective cohort. Tertiary academic hospital. This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded. A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02-69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding. Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

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Step-by-step development and evaluation of a 3D printed home-made low-cost pediatric tracheobronchial tree for foreign body aspiration extractions

Emilien Chebib, Vincent Lemarteleur, Mehdi Azalé, Laetitia Deneufbourg, Pierre-François Ceccaldi, Natacha Teissier

Publication date 14-01-2022


The management of foreign body aspirations (FBA) is dreaded by pediatric physicians due to the high risk of respiratory distress and a potential fatal outcome, favored by a lack of experience of young specialists. Furthermore, there has been an increasing requirement for low-cost simulation. The aim was to describe the step-by-step manufacturing process and to validate a low-cost, easily home-made training model of pediatric tracheo-bronchial tree (pTBT) for simulation-based training in order to teach young physicians to practice foreign body (FBA) extractions. A simulator was designed in order to reproduce the physical and esthetic properties of a pTBT. The production cost of a single simulator was estimated. The simulator was then tested by experienced physicians using a rigid bronchoscope. A manufacturing manual of the simulator is hereby presented. A group of 7 experienced pediatric otolaryngologists performed a FBA extraction in the conditions of installation of an operating room. The result of the survey showed a high fidelity of the simulator in mimicking the biological esthetics and physical properties of a pTBT during a FBA extraction (mean 4.3 ± 0.8). The total cost of the custom-made simulator is about 20.5 € ($23.4) for the production of the first simulator. A highly realistic and easily reproducible pediatric tracheo-bronchial tree simulator is presented and can therefore be used during simulation-based training.

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Inter-rater reliability of the diagnosis of otitis media based on otoscopic images and wideband tympanometry measurements

Josefine Vilsbøll Sundgaard, Maria Värendh, Franziska Nordström, Yosuke Kamide, Chiemi Tanaka, James Harte, Rasmus R. Paulsen, Anders Nymark Christensen, Peter Bray, Søren Laugesen

Publication date 17-01-2022


This study aims to investigate the inter-rater reliability and agreement of the diagnosis of otitis media with effusion, acute otitis media, and no effusion cases based on an otoscopy image and in some cases an additional wideband tympanometry measurement of the patient. 1409 cases were examined and diagnosed by an otolaryngologist in the clinic, and otoscopy examination and wideband tympanometry (WBT) measurement were conducted. Afterwards, four otolaryngologists (Ear, Nose, and Throat doctors, ENTs), who did not perform the acute examination of the patients, evaluated the otoscopy images and WBT measurements results for diagnosis (acute otitis media, otitis media with effusion, or no effusion). They also specified their diagnostic certainty for each case, and reported whether they used the image, wideband tympanometry, or both, for diagnosis. All four ENTs agreed on the diagnosis in 57% of the cases, with a pairwise agreement of 74%, and a Light's Kappa of 0.58. There are, however, large differences in agreement and certainty between the three diagnoses. Acute otitis media yields the highest agreement (77% between all four ENTs) and certainty (0.90), while no effusion shows much lower agreement and certainty (34% and 0.58, respectively). There is a positive correlation between certainty and agreement between the ENTs across all cases, and both certainty and agreement increase for cases where a WBT measurement is shown in addition to the otoscopy image. The inter-rater reliability between four ENTs was high when diagnosing acute otitis media and lower when diagnosing otitis media with effusion. However, WBT can add valuable information to get closer to the ground-truth diagnosis without myringotomy. Furthermore, the diagnostic certainty increases when the WBT is examined together with the otoscopy image.

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Surveillance, Epidemiology, and End Results Database update for pediatric thyroid carcinomas incidence and survival trends 2000–2016

Ananya Tawde, Anita Jeyakumar

Publication date 09-01-2022


Review the trends in pediatric thyroid carcinomas using the Surveillance, Epidemiology, and End Results (SEER) Database. Institutional review board approval was obtained from Mercy-Bon Secours. The National Cancer Institute's SEER database was used for all cases of pediatric thyroid cancer between the years 2000 and 2016 for patients aged 0-19. Patients were grouped by carcinoma histological subtype, disease specific survival based on treatment modality, and demographic data. Treatment methods were compared using Fifteen-Year Disease Specific Survival Curves. 1175 pediatric patients were identified. The average age-adjusted rate of malignancy was 0.3 per 100,000 patients. Incidence of pediatric thyroid cancer was approximately 1:3.6, male to female. The papillary follicular variant histological subtype was the most common (n = 689, 58.6%), followed by papillary (n = 223, 18.9%), follicular (n = 153, 13.1%), and medullary (n = 110, 9.4%). Overall incidence of thyroid carcinomas increased with age, highest in patients aged 15-19 (69.8%). Incidence of medullary thyroid carcinomas was highest in patients aged 0-9. Patients aged 10-19 treated with surgery alone had the highest disease specific survival fifteen-years past initial diagnoses and treatment in all histologic subtypes (p < 0.05). Patients with metastatic medullary thyroid carcinoma at initial diagnosis who underwent surgery alone showed significantly poorer fifteen-year disease specific survival when compared to other histologic subtypes (p < 0.05). There was improved prognosis in pediatric thyroid carcinomas if diagnosed and treated early. All four major histological subtypes exhibit an increase in overall survival rates, (excluding medullary carcinomas).

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Bilateral EABR stimulating mode testing bilateral CI patients refecting binaural integration:a preliminary study

Zhongyan Chen, Yulin Li, Weiluo Huang, Jingning Cheng, Qingling Bi, Wenjing Yang, Jianfeng Liu, Yuan Li

Publication date 09-01-2022


To analyze binaural integration, we used a new stimulation mode of the electrically evoked auditory brainstem response (EABR), to reflect bilaterally implanted cochlear function.
EABR was tested using the following procedure: First, both ears were evaluated separately, with the contralateral speech processor closed (C), followed by another measurement with both processors open (O). Subsequently, the eV latencies and amplitudes were assessed. The Speech, Spatial, and Qualities of Hearing Scale (SSQ), Categories of auditory performance (CAP) and speech intelligibility rating (SIR) scores were used to assess binaural hearing ability subjectively. Fifteen subjects with bilateral CI from 1997 to 2018 were recruited, each diagnosed with severe to profound hearing loss. All SSQ scores, except for one, were greater than six (the exception scored 1.3/0.8/1.0). All CAP/SIR scores except one were greater than 6/4 (the exception scored 0/1). All patients exhibited good quality EABR measurements. The open contralateral processor significantly reduced the eV latency while enhancing the eV amplitude compared to monaural stimulation. The objective EABR results were consistent with subjective speech perception and auditory ability assessed using the SSQ scale. The EABR accurately reflected auditory pathway maturation and development after CI; thus, reflecting accordance with subjective speech and hearing performances. Furthermore, bilateral CI facilitates binaural integration and auditory brainstem plasticity.

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Assessing the use of telehealth for the surgical management of recurrent otitis media

Austin Schafer, Marike Mousset, Natalie Kelly, Abdulrahman Althubaiti, Tran Bourgeois, Charles A. Elmaraghy

Publication date 09-01-2022


To compare the incidence of middle ear effusion (MEE) at the time of bilateral tympanostomy tube insertion (BTI) for recurrent acute otitis media (rAOM) patients initially seen in-office or via telehealth. After obtaining IRB approval from Nationwide Children's Hospital, a total of 524 patients evaluated for rAOM were retrospectively reviewed after being divided into two cohorts: those seen via a telehealth visit from April to June of 2020 (n = 140), and those seen via an in-person visit from April to June of 2019 (n = 384). Recommendation for BTI was captured for each patient following their visit. Clinical characteristics documented at the time of the visit, such as history of intramuscular (IM) antibiotic use and hearing or speech concerns were also captured to determine whether both telehealth and in-person cohorts were similar in clinical presentation. For BTI patients, the presence or absence of MEE in either ear at the time of BTI was recorded. Patients with cleft palate or prior BTI were excluded. 51.43% (72/140) of patients in the telehealth cohort were recommended for BTI. Of those recommended, 87.50% (63/72) underwent BTI. Of these, 31.75% (20/63) had a MEE at the time of BTI. In the in-office cohort, 69.01% (265/384) of patients were recommended for BTI. Of those recommended, 92.83% (246/265) underwent BTI. Of these, 69.92% (172/246) had a MEE at the time of BTI. There were significantly less middle ear effusions in the telehealth cohort compared to the in-office cohort (p < 0.0001). It is well understood that telehealth is limited in its physical exam capabilities. It is possible that the use of telehealth for the surgical management of rAOM may lead to more procedures on patients without MEE.

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Surface modification of the cubic micro-cartilage by collagenase treatment and its efficacy in cartilage regeneration for ear tissue engineering

Yu Sueyoshi, Atsuko Niwa, Yoshihito Itani, Makoto Yamauchi, Shinichi Asamura, Takeshi Teramura, Noritaka Isogai

Publication date 09-01-2022


In order to enhance cartilage regeneration, surface modification of the cubic micro-cartilage with the collagenase treatment was tested and its efficacy to tissue engineer ear cartilage was investigated. Harvested cubic micro-cartilages were treated with collagenase with different digestion time (0, 15, 60, and 120 min). Histological, ultrastructural (SEM and TEM), and Western blot analyses were carried out. Subsequently, A total of 45 dogs were used to tissue engineer ear cartilage. Using collagenase-treated micro-cartilage, the ear cartilage regeneration with the prepared dilution (8, 12.5, 25, 50, 100%) of micro-cartilage block seeding was performed to determine the minimum amount of cartilage tissue required for ear tissue-engineering (n = 6 at each point in each group). At 10 weeks after surgery, samples were resected and subjected to histochemical and immune-histological evaluation for cartilage regeneration. In vitro study on micro-cartilage morphology and western blot analysis showed that collagenase digestion was optimal at 60 min for cartilage regeneration. In vivo evaluation on the reduced proportions of micro-cartilage block seeding onto implant scaffolds under 60-min collagenase digestion determined the minimum amount of cartilage tissue necessary to initiate a one-step ear cartilage regeneration in a canine autologous model, which was 12.5-25% of the original ear size. Tissue-engineering ear cartilage from limited volume of donor cartilage can possibly be achieved by the collagenase treatment on micro-cartilage to expand cartilage regeneration capacity, application of cytokine sustained-release system, and seeding on a suitable ear scaffold material.

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Changes to the practice of pediatric otolaryngology as a consequence of the COVID-19 pandemic

Ashaka Patel, Agnieszka Dzioba, Paul Hong, Murad Husein, Julie Strychowsky, Peng You, Josee Paradis, M.E. Graham

Publication date 07-01-2022


The COVID-19 pandemic has shifted medical practice globally. The objective of this study was to examine the changes to the practice of pediatric otolaryngology internationally due to the COVID-19 pandemic and examine potential contributors. An online survey was designed to assess practice demographics, patterns of COVID-19 related restrictions in communities, and changes to practice and referrals. This was disseminated via an international Covid-19 Whats App™ group of pediatric otolaryngologists. There were 45 respondents of 177 group members (25.4%) from 15 countries. The mean estimated time spent under strictest lockdown measures was 16.2 (±10.7) weeks (range: 1-45 weeks). Operating room time was reduced for 82.9%, with an average reported reduction of 41.5%. Almost all (>75%) of respondents reported reduced referrals for five common conditions: otitis media with effusion (average reported decrease - 56.1%); acute otitis media (average decrease 62.8%); acute mastoiditis (average decrease 66.6%); recurrent pharyngotonsillitis (average decrease 51.0%); and peritonsillar abscess (average decrease 52.1%). COVID-19 cases per million population significantly influenced the acuity of referrals received (p < .05). No conditions were reported as increased in frequency and the acuity of most conditions was reported as unchanged by the majority of respondents. The measures taken to reduce the spread of COVID-19 have resulted in many changes to pediatric otolaryngology practice and the referral patterns of common conditions. Some of these changes may have enduring sequelae.

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Decannulation protocol for short term tracheostomy in pediatric head and neck tumor patients

Peng You, Amy Dimachkieh, Justin Yu, Edward Buchanan, Christina Rappazzo, Tiffany Raynor, Ellis Arjmand, Joshua Bedwell, Randal S. Weber, Michael E. Kupferman, Daniel C. Chelius

Publication date 07-01-2022


While the majority of pediatric tracheostomies are performed in the setting of chronic and complex medical comorbidities, perioperative tracheostomies following head and neck tumor ablation are generally short-term. Deliberate planning is required for decannulation in this setting and no published protocols currently exist. Our study outlines a management strategy for short-term tracheostomy in pediatric patients following head and neck surgery. A retrospective study of pediatric head and neck tumor patients undergoing tracheostomy was performed at a quaternary children's hospital from February 1, 2016 to December 31, 2018. Charts were reviewed for demographics, surgical operation, relevant tracheostomy-related complications, and time to decannulation. Eleven patients with a mean age of 10.4 years (st.dev. 6.7, range: 0.5-23) underwent tracheostomy during their primary ablative/reconstructive surgery. Trans-tracheal pressure monitoring helped direct the need for tracheostomy downsizing and readiness for capping trials. All patients were decannulated before hospital discharge after a mean of 12.8 days (st.dev. 2.5, range: 9-18) and were discharged after a mean of 14.8 days (st.dev. 2.5, range: 11-20). Pediatric head and neck surgery patients can be quickly and safely decannulated with an instructive protocol and multidisciplinary care.

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The impact of COVID-19 pandemic on acute otitis media among the pediatric population

Mariana Heraria Favoretto, Edson Ibrahim Mitre, Melissa Ferreira Vianna, Paulo Roberto Lazarini

Publication date 07-01-2022


The incidence of respiratory diseases has dropped during the school closures at the COVID-19 pandemic including acute otitis media (AOM) among the pediatric population. This study included 2090 patients under 12 years old, that were diagnosed with AOM between March 2019 and February 2021 at the otolaryngology and pediatrics emergency room at a public tertiary hospital in Sao Paulo, Brazil. There was a significant drop in number of AOM cases diagnosed during the quarantine. The group before the pandemic represents 87,2% of the total attendings and the first two months of quarantine had the major attendance discrepancy between the same period during pre-pandemic times. Quarantine isolation measures and school closures may have helped reduce not only the coronavirus spread but also other infectious diseases such as AOM among the pediatric population.

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Auditory evoked potentials in children and adolescents with multiple sclerosis and neuromyelitis optica spectrum disorders

Dayane Aparecida Nascimento Barbosa, Alessandra Giannella Samelli, Danielle Patriota de Oliveira, José Albino da Paz, Carla Gentile Matas

Publication date 03-01-2022


In children, an acute demyelinating disease may evolve as a multiphasic disease with multiple relapses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). The Brainstem Auditory Evoked Potentials (BAEP) and Long-Latency Auditory Evoked Potentials (LLAEP) contribute to the identification of either retrocochlear changes or other central auditory nervous system (CANS) changes. To characterize BAEP and LLAEP in children and adolescents with MS and NMOSD and verify the diagnostic values of these potentials in each of the demyelinating diseases. The 40 participants were divided into two study groups (SG1 - MS, SG2 - NMOSD) and two comparison groups (CG1 and CG2), matched for age (9 years-17 years and 11 months) and sex. Electrophysiological hearing assessment was performed with BAEP and LLAEP. When SG1 and SG2 were compared with CG1 and CG2 regarding BAEP and LLAEP, both SG1 and SG2 presented a higher occurrence of changes. Also, individuals with MS had higher occurrences of BAEP changes, whereas individuals with NMOSD had a higher occurrence of LLAEP changes. BAEP and LLAEP in children and adolescents with MS or NMOSD showed higher latencies and lower amplitudes of some components when these individuals were compared with their peers. These procedures were highly accurate to identify demyelinating diseases. BAEP results were more abnormal in individuals with MS, while LLAEP was so with NMOSD. These findings indicate that the auditory evoked potentials are important instruments for the differential diagnosis of MS and NMOSD, and valuable to monitor disease evolution.

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Pediatric otolaryngology telemedicine amid a pandemic – And beyond

Jennifer L. McCoy, Amber D. Shaffer, Joseph E. Dohar

Publication date 03-01-2022


The coronavirus disease of 2019 (COVID-19) pandemic catalyzed an unprecedented redesign and innovative overhaul of health care delivery thrusting from fringe to mainstream virtual care. With a return to conventional practice, we now must create a research and policy agenda using the changes wrought by COVID-19 to help create a better health care system in its aftermath. The purpose of this study was to assess satisfaction of otolaryngology outpatient visits during the pandemic. A prospective survey study was performed on caregivers of all patients ages 0-26 years old seen in the Division of Pediatric Otolaryngology at our large tertiary care children's hospital from February-April 2020. The three study groups were those seen in-person 6 weeks before telemedicine was implemented (IBTM), those seen in telemedicine during the first 6 weeks (TM) it was implemented at our hospital, and those seen in-person during the telemedicine period (IDTM) in the same timeframe. The survey consisted of satisfaction questions related to their visit, if their child was recommended surgery at the time of the visit, and if the caregiver agreed with the recommendation. A medical record review was also performed. A total of 176 caregivers completed the survey with 113(64.2%) completing the survey for an IBTM appointment, 59(33.5%) for a TM appointment, and 4(2.3%) for an IDTM appointment. There were 100(56.8%) male patients and 167(94.9%) were white. Families gave a higher response for the statement "The ability to communicate with the physician" (p = .012) and "The overall outpatient experience" (p = .004) in the IBTM cohort compared to the TM group. There were no significant differences for the other statements regarding the ability to understand recommendations, courtesy, and knowledge of the physician. Regardless of group, 98.6% of caregivers agreed with surgical recommendation when surgery was recommended. However, when surgery was not recommended at the appointment, caregivers were 11x more likely to disagree with the surgical recommendations, OR:11.49,95%CI:1.44-91.38,p = .005. We conclude that telemedicine was equally well received by patients as compared to traditional live assessments suggesting that virtual care is a viable post-pandemic paradigm change. Satisfaction was rated as "Good" or "Excellent", however, messaging when surgery is not recommended was less acceptable and must be improved to obtain increased caregivers' agreement in an era of shared decision making.

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The effect of Kinesio Taping on drooling in children with intellectual disability: A double-blind randomized controlled study

Maryam Mokhlesin, Majid Mirmohammadkhani, Seyed Abolfazl Tohidast

Publication date 03-01-2022


Drooling is an unintentional spillage of saliva, which can be caused by any condition that affects the neuromuscular control of mouth muscles. There are different treatments for drooling, some of which are novel therapies with unknown efficacy like Kinesio Taping (KT). This study aimed to investigate the effects of adding KT to oral-motor training (OMT) on drooling in children with intellectual disability. This is a double-blind randomized controlled trial in which 18 children with intellectual disabilities participated through convenience sampling. Participants were randomly assigned into 2 groups by block randomization method. Kinesio taping of orbicularis oris, supra-hyoid and masseter muscles and routine OMT were performed for the intervention group. The control group received taping with no stretch as placebo. Pre-post assessment was carried out after four weeks of intervention by the drooling rating scale (DRS) and drooling quotient (DQ) test. Within-group analysis showed a significant reduction in drooling post-intervention in both groups based on DRS and DQ (p < 0.001). Between-group analysis indicated a significant improvement in the intervention group (P = 0.008) with moderate effect size using DQ assessment but this difference was not significant with moderate effect size based on parental reports using DRS. DQ assessment revealed that using KT plus OMT can produce greater improvement than sham taping plus OMT. However, there was not a statistically difference between the two groups based on parental reports using DRS. In addition, within-group analysis showed that drooling reduced in both groups after the intervention both based on DRS and DQ assessments. It can be concluded that adding taping with and without stretch to OMT can be considered as a complementary method to mitigate drooling in children with intellectual disabilities.

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Cost analysis of sialendoscopy for the treatment of salivary gland disorders in children

Nathalia Velasquez, Lauren Gardiner, Vaibhav Ramprasad, Amber Shaffer, Noel Jabbour, Amanda Stapleton

Publication date 02-01-2022


Recent advances in Otolaryngology have changed the diagnosis and therapy for salivary gland disorders. Sialendoscopy-assisted surgery is a minimally invasive, conservative procedure for functional preservation of the affected gland. The goals of this study are to assess the indications, use, and outcomes of pediatric sialendoscopy at a tertiary pediatric institution as well as to analyze the direct cost related to the diagnosis and treatment of patients with sialolithiasis and Juvenile Recurrent Parotitis managed with sialendoscopy. Retrospective cohort study of pediatric patients undergoing diagnostic and/or therapeutic sialendoscopy at a tertiary level children's hospital between 2012 and 2020. Demographic, clinical, surgical variables and direct hospital costs 1 year before and after the sialendoscopy procedure were collected and analyzed. Twenty-two pediatric patients were included. There was male predominance (59.3%). The most common indication for sialendoscopy was Juvenile Recurrent Parotitis. Average age of onset was 6.5 years for patients with JPR and 14.2 years for patients with sialolithiasis. All patients had an average of 4.5 episodes before the first procedure. 8 patients required repeat sialendoscopy for recurrent symptoms. Mean total hospital costs were significantly higher in patients with JRP 1 year before and after the sialendoscopy ($4308.8 vs. $3330) compared to patients with sialolithiasis. Costs of the sialendoscopy and related expenses including anesthesia and PACU cost were similar in both studied groups ($13,506 vs. $13,022.9). Complete resolution of symptoms was achieved in 14 patients with JRP and all patients with sialolithiasis. Sialendoscopy is a low-risk procedure that aids in the treatment for pediatric salivary gland disorders. The costs related to sialendoscopy are substantial and patients with JRP incur higher hospital preoperative and postoperative costs compared to patients with sialolithiasis.

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Ear reconstruction research using animal models: The effect of fat grafting on costal cartilage stents

Xia Chen, Ruhong Zhang, Datao Li, Qun Zhang, Zhicheng Xu, Feng Xu, Yiyuan Li, Tianya Li

Publication date 03-01-2022


For congenital microtia patients with a depressed mastoid area, it is unclear whether autologous fat grafting to fill the depressed area of the cheek will affect the survival of the subsequent grafted costal cartilage stent. An animal model was used for in vivo research to provide guidance for clinical applications. Autologous costal cartilage was implanted in nude mice. Fat samples were collected at different time points and histological examination performed to analyze the activity of chondrocytes and the deposition of the chondrocyte matrix. This nude mouse fat transplantation model study showed that there were statistical differences in chondrocyte viability between the fat filling group and the control group, but there was no statistical difference in the effect on collagen content. Transplanting fat reduces the viability of chondrocytes, but has little effect on collagen matrix deposition.

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Prospective validation of a brief questionnaire for predicting the severity of pediatric obstructive sleep apnea

Catherine L. Kennedy, Bella E. Onwumbiko, Jasmine Blake, Kevin D. Pereira, Amal Isaiah

Publication date 02-01-2022


Pediatric obstructive sleep apnea (OSA) is diagnosed and stratified by polysomnography. However, due to cost and inaccessibility, up to 90% of children undergo tonsillectomy and adenoidectomy (T&A) solely based on clinical criteria. We previously developed a data-driven brief screening questionnaire ('Selected Features,' SF) that predicted OSA severity than alternatives.
The SF asks the parent whether a child: (i) has had breath-holding spells at night over the past 4 weeks, (ii) is a mouth-breather during the day, (iii) has stopped growing at a normal rate any time since birth, and (iv) is overweight. This study sought prospectively validate the SF questionnaire. We conducted a prospective assessment of the predictive accuracy of SF compared to the Pediatric Sleep Questionnaire-Sleep Related Breathing Disorder (PSQ-SRBD) scale in otherwise healthy children with sleep disordered breathing referred for T&A. We compared the model fits of PSQ-SRDB and SF for (i) a linear regression model for the prediction of OSA, and (ii) a logistic regression model for severe OSA, defined as apnea hypopnea index (AHI) > 10. P < 0.05 was significant. A total of 124 patients were included. The average age was 7.3 years (95% confidence interval, 6.6-8.0) and 66 (54%) were male. The racial composition was 54 (44%) black, 41 (33%) white, and 28 (23%) other. The median AHI was 4.8 (interquartile range 12) and 43 (35%) of patients had severe OSA. In linear and logistic regression models, SF outperformed the PSQ-SRBD and null models as measured by Akaike Information Criteria. The overall accuracy in predicting AHI >10 for PSQ-SRBD was 0.65 (0.56-0.73, P = 0.54) compared to 0.73 (0.64-0.80, P = 0.04) for SF. By eliminating redundancy, we have developed a questionnaire with improved prediction of OSA and its severity, in children with high pre-test probability of the condition. While multi-site validation is necessary, SF demonstrates value in screening children prior to T&A in resource-limited environments.

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Pediatric myringoplasty: A study of effectiveness and influencing factors

Ina Foulon, Dylen Philips, Elke Lichtert, Ronald Buyl, Vedat Topsakal, Frans Gordts

Publication date 02-01-2022


Until today, there is no consensus about the ideal age for a myringoplasty in children. In this retrospective study, we study our own series to characterize different prognostic factors to answer questions/dilemmas such as when to carry out surgery in a child with an ear drum perforation, when to postpone surgery or when to use a different technique to improve the outcome after tympanoplasty. We performed a retrospective study on charts of 97 children who underwent a myringoplasty. The same surgeon (IF) treated all included children and with the same classical surgical technique: retro-auricular approach and microscopic underlay placement of fascia of the musculus temporalis. Children with associated disease (cholesteatoma, revision surgery and ossicular chain defects) were excluded. All children had a minimum follow up of 12 months. A successful procedure was defined as a closed eardrum after 12 months and an air bone gap <20 dB. Prognostic factors were inventoried and studied. Success rate after myringoplasty is 80.2% in this pediatric case series. Age was not a statistical significant prognostic factor. Only the history of an adenoidectomy had a positive effect on tympanic closure (p = 0.047).
A negative prognostic factor was the size of the perforation: large perforations showed only 42.9% eardrum closure (p = 0.040). There was a complication rate of 28.9%, in which formation of granulation tissue and ear discharge were most common but easily treated. Tympanoplasty type 1 with musculus temporalis fascia in underlay is a safe and successful technique in children of all ages with eardrum perforations. Our data suggests using a different technique (cartilage tympanoplasty) in cases with large perforation. Postponing surgery is not advocated, unless perhaps in children with poor Eustachian function or adenoidhyperplasia.

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Can pediatric sleep questions be incorporated into a risk model to predict respiratory complications following adenotonsillectomy?

Hannah Starke, Karina T. Canadas, Charles G. Minard, Binal S. Kancherla, Ravish Kapoor, Melanie M. Handley, Michael B. Zelisko, Laura W. Ryan, Rahul G. Baijal

Publication date 02-01-2022


Adenotonsillectomy, one of the most frequent surgical procedures in children, is usually performed for sleep-disordered breathing, a disease spectrum from primary snoring to obstructive sleep apnea. Children undergoing an adenotonsillectomy may be at risk for perioperative respiratory complications, necessitating intervention or escalation of care. However, there is no effective preoperative screening or risk-stratification model for perioperative respiratory complications that incorporates not only clinical history and physical examination but also sleep question responses for children as there is for adults. The aim of this prospective observational study was to develop a risk-stratification model for perioperative respiratory complications in children undergoing an adenotonsillectomy incorporating not only clinical history and physical examination but also sleep question responses. A 25-question sleep questionnaire was prospectively administered preoperatively for 1895 children undergoing an adenotonsillectomy from November 2015 to December 2017. The primary outcome measure was overall perioperative respiratory complications, collected prospectively and defined as having at least one major or minor complication intraoperatively or postoperatively. The incidence of overall perioperative respiratory complications was 20.4%. Preoperative factors associated with perioperative respiratory complications in the multiple regression model were age, race, preoperative tonsil size, the presence of a syndrome, and the presence of a pulmonary disease. None of the sleep questionnaire responses remained in the multivariable analysis. The area under the ROC curve for the risk stratification model incorporating sleep question responses was only 0.6114% (95% CI: 0.60, 0.67). Preoperative sleep question responses may be unable to predict overall perioperative respiratory complications in children undergoing an adenotonsillectomy. A robust risk stratification model incorporating sleep question responses with clinical history and physical examination was unable to discriminate or predict perioperative respiratory complications in our population undergoing an adenotonsillectomy.

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Button battery taping and disposal: Risk reduction strategies for the household setting

Silas Chao, Hannah Gibbs, Keith Rhoades, Christopher Mehrer, Ian N. Jacobs, Kris R. Jatana

Publication date 06-01-2022


Pediatric esophageal button battery (BB) injury occurs rapidly and continues to be a significant source of morbidity and mortality. Unfortunately, a BB that no longer supplies power to a device can still have enough residual voltage to cause injury within the body. Development of additional prevention strategies for consumers may reduce esophageal injury risk. In this study, 24 commercially available button batteries (BBs) were horizontally and vertically wrapped (2 layers, full circumferential coverage, 90° apart) with 6 different types of common household tapes (Scotch®/clear, Scotch®/Magic, masking tape, packing tape/clear, packing tape/brown, black electrical tape) and left at room temperature for 30 days. In addition, 6 of the CR2032 batteries covered with each type of tape were placed in a cadaveric piglet esophageal model for a 4-h period and then compared to controls without tape for tissue pH changes and visible tissue injury. None of the tape-wrapped batteries showed voltage changes nor presented any hazard stemming from BB ingestion. All 6 tape covered batteries placed in the cadaveric piglet esophageal tissue model demonstrated no visible tissue injury and no change in tissue pH in contrast to the controls. Review of BB packaging language from various brands of commercially available CR2032 batteries showed that none had specific disposal recommendations. Both BB and electronics manufacturers should consider instructing the use of common household tape options to cover these BB immediately after removal from a device for either recycling or disposal. Such precautions may help to reduce related ingestion injuries in children.

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Can sleep questionnaires predict adenotonsillectomy outcome for children with sleep disordered breathing?

Depak Patel, Jillian Haszard, Rachel Kee, Laurelle Smith, Sarah Maessen, Elizabeth Schaughency, Barbara C. Galland, Patrick JD. Dawes

Publication date 25-12-2021


Adenotonsillar hypertrophy is the main cause of childhood sleep disordered breathing (SDB) and adenotonsillectomy (TA) the most common treatment. Polysomnography (PSG) for diagnosing SDB is often difficult to obtain with Otolaryngologists usually relying on history and examination when recommending TA. Questionnaires assessing quality of life (QoL) may assist the Otolaryngologists decision making. To explore changes in QoL tools following TA for SDB in children aged 3 to 15 with the aim of identifying whether the Pediatric Sleep Questionnaire (PSQ) or Obstructive Sleep Apnoea -18 (OSA-18) is a better predictor of outcome following TA. QoL was assessed using OSA-18, PSQ and the Pediatric Quality of Life Inventory™ (PedsQL™). Four groups were recruited from three research databases, those with: SDB, recurrent tonsillitis (RT), SDB and RT, or no disease (controls). Children either received TA or underwent observation. QoL questionnaires were administered at recruitment and 3 months later. Test-retest reliability was assessed using Bland-Altman plots. Pre-intervention scores were plotted against changes in scores, with pre-established cut-offs and cut-offs indicated by control group variability. There were 120 children, 25 had no intervention, and 19 were controls. All questionnaires showed test-retest reliability over time. Using the distribution of scores from the control group we estimated the 95th percentile to redefine the cut-off for OSA-18 (reduced from 60 to 46) and PSQ (unchanged from 0.33). Higher pre-operative scores predicted greater reduction following TA, with OSA-18 the most consistent predictor of QoL change. The PSQ classified 86.8% of children undergoing TA above the 0.33 cut-off; whereas OSA-18 classified 73.7% above the 46 cut-off. Of these, 71.2% and 87.5% showed improvement after TA, respectively. Using the 95% confidence interval for change in the control group to identify a 'meaningful' change in score, children with OSA-18 scores >46 had a 93% chance of a meaningful improvement, whereas PSQ scores >0.33 were associated with an 80% chance of a meaningful improvement. OSA-18 is a better predictor of improved QoL than PSQ for TA in children with SDB. We propose a new cut off score (>46) for OSA-18. This may assist Otolaryngologists' decision making when assessing a child with SDB.

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Safety of topical administration of nasal decongestants and vasoconstrictors in paediatric nasal surgery – A systematic review

A.J. Macmillan, K.M. Phoon, O. Edafe

Publication date 24-12-2021


Topical intranasal decongestants are essential in nasal surgery to improve operative field. There are concerns regarding safety in paediatric population. Data on safety and safe dosage are limited. This systematic review evaluated the literature on safety and dosage of intranasal decongestant in paediatric population. We performed a systematic search of Pub Med, EMBASE, Cochrane library for relevant articles. Quality assessment was done on included articles.
A total of 10 articles were included: five case reports; three observational studies; and two randomised control trials. Decongestants evaluated were phenylephrine, oxymetazoline, epinephrine, xylometazoline, and cocaine. In total, 209 patients were included. Side effects reported included bradycardia, tachycardia and hypertension. These were mostly self-limiting and of no clinical compromise to the patients. A total of 4/209 (1.9%) of patients required treatment for these reported effects. No mortality was reported in the included studies. In the paediatric population, the literature suggests that when delivered in a pre-specified, controlled dosage, the haemodynamic effects of phenylephrine, oxymetazoline, xylometazoline are minimal and of no clinical significance. There is scope for further studies to establish safe dosage in the paediatric population given the paucity of current literature.

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Prevalence of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy: A meta-analysis

Fei Kong, Ya-Lei Sun, Bin Yuan

Publication date 01-01-2022


Adenoid or adenotonsillar hypertrophy (AATH) adversely affects cardiovascular function, leading to pulmonary hypertension (PH). This meta-analysis of observational studies aimed to estimate the prevalence of PH in children with AATH. A meta-analysis was performed by searching the Pub Med, EMBASE, and Cochrane Central Register of Controlled Trials databases from their inception to 1 July 2021, for all studies that extracted data about PH prevalence in children with AATH. PH prevalence was calculated for each included study and as a pooled estimate with a 95% confidence interval. A total of eight studies were included in this analysis. The pooled prevalence of PH in children with AATH was 35.0% (95% CI [18.0%, 52.0%]). The subgroup analysis demonstrated that the prevalence of PH in children with adenotonsillar hypertrophy was higher than that with adenoid hypertrophy with or without tonsillar hypertrophy (39.0%, 95% CI [14.0%, 65.0%] vs. 22.0%, 95% CI [17.0%, 28.0%], respectively). The prevalence derived from the prospective and cross-sectional studies were 45.0% (95% CI [13.0%, 76.0%]) and 20.0% (95% CI [14.0%, 25.0%]), respectively. America and Africa had lower prevalence rates than Asia (24.0%, 95% CI [1.0%, 46.0%], 27.0%, 95% CI [17.0%, 38.0%], and 48.0%, 95% CI [-2.0%, 98.0%]), respectively. The prevalence of studies with diagnostic criterion (a mean pulmonary artery pressure higher than 20 mm Hg) was 50.0% (95% CI [6.0%, 94.0%]). The pooled prevalence of studies with diagnostic criterion (a mean pulmonary artery pressure higher than 25 mm Hg) was 25.0% (95% CI [13.0%, 36.0%]). The meta-analysis showed a prevalence of PH in children with AATH of 35.0%, demonstrating that this condition is a frequent complication of AATH. To better understand its clinical impact, more prospective evaluations are urgently needed.

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