International Journal of Pediatric Otorhinolaryngology 2021-02-24

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

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

Publication date 08-02-2021


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

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

Wesley L. Davison, David A. Gudis

Publication date 29-01-2021


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

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

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

Publication date 16-02-2021


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

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

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

Publication date 10-02-2021


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

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Initial outcomes at a nascent tertiary pediatric thyroid surgical center

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

Publication date 09-02-2021


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

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

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

Publication date 19-02-2021


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

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

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

Publication date 07-02-2021


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

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

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

Publication date 04-02-2021


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

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

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

Publication date 01-02-2021


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

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

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

Publication date 31-01-2021


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

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This is in response to the Letter to the Editor for our publication “Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia” submitted by Pinchman et al. (IJPORL-D-20-01791)

Cyrus C. Rabbani, Zachary E. Pflum, Michael J. Ye, John D. Gettelfinger, Senthil Sadhasivam, Bruce H. Matt, John P. Dahl

Publication date 14-01-2021


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Letter to the editor: In support of "Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia"

Elizabeth Pinchman, Benjamin Metcalfe, Mamie Higgins, Jason Mouzakes, Melissa Ehlers

Publication date 03-01-2021


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Efficacy of cartilage conduction hearing aids in children

Takanori Nishiyama, Naoki Oishi, Kaoru Ogawa

Publication date 26-01-2021


Cartilage conduction hearing aids (CC-HAs) are novel hearing aids that use the third hearing pathway of cartilage conduction. We assessed the efficacy of CC-HAs and the hearing effects and safety of additional tape compression over the transducer in children with hearing loss. The patients (n = 42) underwent a one-month free trial of CC-HAs. Forty of them were patients with auditory canal atresia or stenosis. CC-HA-aided and unaided hearing thresholds (48 fitted ears) were determined using standard audiograms, after which participants could choose to purchase the device or not. We calculated the purchase rates and compared the patient characteristics between the purchase and non-purchase groups along with the purchase reason (or not). We applied additional tape compression over the CC-HA transducer and assessed the hearing effects and side effects. CC-HA led to hearing improvements at all frequencies. Overall, 72.92% of participants purchased a CC-HA after the trial. By applying additional tape compression over the CC-HA transducer, the stability and hearing gains were improved mainly at low frequencies, and no side effects such as dermatitis were observed. CC-HAs are efficacious in producing hearing improvements in children, especially in patients with atresia or canal stenosis who cannot use air conduction hearing aids. Furthermore, we found that the additional tape compression over the transducer was an easy and a safe method for improving the hearing effects and stability of the CC-HA.

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Supraglottoplasty in the management of laryngomalacia in children with down syndrome: A systematic review

Sara Salloum, Yasmina Mahsoun, Talal Al-Khatib, HaniZ. Marzouki, Faisal Zawawi

Publication date 22-01-2021


Children with Down syndrome (DS) who have Laryngomalacia represent a specific management challenge due to their inherent multiple levels of airway obstruction and hypotonia. Therefore, the purpose of this study is to determine the outcome of supraglottoplasty (SGP) in children with DS. A systematic review was performed following the PRISMA guideline. Data were collected from online medical databases- CINAHL, Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid MEDLINE in process, Pub Med, and Scopus. all publications that address the outcome of supraglottoplasty in children who are less than 18 years old with Down syndrome prior to December 2018 were collected.
The data were collected on different phases: Screening review using search words and controlled vocabularies during the period of November-December 2018, followed by a detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles. Nine articles were included in the qualitative analysis. These articles included 231 subjects, out of which 32 children with DS met the inclusion criteria. Twenty patients (62.5%) were considered successfully treated and 12/32 failed including 1/32 (3.1%) mortality in the postoperative period. The duration of follow-up was 12-102 days. All of the patients whose treatment failed had significant comorbidities. Although the success of SPG in children with DS is less than in otherwise healthy children, it remains an option especially in patients without comorbidities. Preoperative counseling of the families and thorough assessment are necessary to determine candidacy for SPG in children with DS.

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Loss of smell and taste in COVID-19 infection in adolescents

Lakshit Kumar, Namrata Kahlon, Avani Jain, Jasleen Kaur, Mitasha Singh, A.K. Pandey

Publication date 22-01-2021


To study the prevalence, clinical course and outcomes of olfactory and taste dysfunction in COVID-19 positive adolescents. This prospective study was carried out from May to August 2020. The adolescents, aged 10-19 years, who were detected COVID-19 positive by RT-PCR with mild to moderate disease were included in the study.
The following epidemiological and clinical outcomes were studied: age, sex, general symptoms, olfactory and taste dysfunction. Out of 141 patients included in the study, there were 83 males (58.9%) and 58 females (41.1%). The age varied from 10 to 19 years with an average of 15.2 years. Forty patients (28.4%) had olfactory or taste dysfunction. Out of these 40 patients, 28 patients (19.8%) had both olfactory and taste dysfunction. Of the 34 patients (24.1%) who complained of olfactory dysfunction, 16 patients complained of hyposmia and 18 patients complained of anosmia. Dysgeusia was reported by 34 patients (24.1%). The duration of OTD varied from 2 to 15 days with an average of 5.7 days. Loss of smell and taste are common symptoms in COVID-19 positive adolescents. It recovers spontaneously within a few weeks, along with the resolution of other symptoms.

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Proposed ultrasound algorithm to differentiate thyroglossal duct and dermoid cysts

Ellen Tokarz, Puneet Gupta, John McGrath, Adam R. Szymanowski, Jerry Behar, Philomena Behar

Publication date 24-01-2021


1) To assess reproducibility of the previously established SIST score. 2) To determine inter-observer agreement in using ultrasound (US) characteristics to differentiate thyroglossal duct cyst (TGDC) from dermoid cysts (DC) 3) Improve the method used to pre-operatively differentiate TGDC from DC. Retrospective chart review. Tertiary care pediatric hospital.
SUBJECTS AND METHODS: An electronic medical record was queried to identify children with midline neck masses who underwent pre-operative neck US and had a histopathologic diagnosis of either TGDC or DC. Two pediatric radiologists, blinded to the pathologic diagnosis, evaluated the US images and documented the presence of pre-determined characteristics of each mass. Potential differentiating factors were analyzed for their predictive power. The SIST (septations, irregular walls, solid components = TGDC) score was determined as well as inter-observer agreement. Using the characteristics that had significant predictive power, we used the data to develop an algorithm to improve predicting cyst type. Pathologically, there were 47 TGDC and 25 DC. The inter-observer agreement about the pathologic diagnosis between the two radiologists was substantial, K = 0.66. Overall, the SIST score predicted the correct diagnosis 67% of the time. Radiologist 1 and radiologist 2 were more accurate than the SIST score alone, making the correct diagnosis 96% and 86% of the time, respectively. In our study, we found that the most important US characteristics in differentiating TGDC and DC are: internal Septations, depth relative to Strap muscles, Shape and Solid parts (4 S algorithm). The SIST score criteria were individually shown to be significant and sensitive in recognizing DC, however, they were not specific and often misclassified TGDC as DC. We developed a new sequential filtering algorithm that more accurately differentiates cysts. This new algorithm uses step-wise filtering of characteristics, first for Septations, then for depth to Straps, then Shape of the cyst and lastly Solid parts (4 S algorithm). This algorithm correctly categorized cyst type in 100% of patients in our study. Pre-operatively differentiating TGDC and DC continues to be a challenge. Using our 4 S algorithm, we can more definitively differentiate TGDC from DC compared to the SIST score. All SIST score characteristics were significant and sensitive in detecting dermoid cysts, however, not very specific. The radiologists' judgment and accuracy was better than the SIST score.
The 4 S algorithm uses sequential filtering of important characteristics: Septations, depth to Straps, Shape of cyst and lastly Solid parts to improve diagnostic accuracy.

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Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management

Ashley L. Miller, Justin C. McCarty, Regan W. Bergmark, Shekhar K. Gadkaree, Michael S. Cohen, Gillian R. Diercks, Donald J. Keamy, Leila A. Mankarious, Christopher J. Hartnick

Publication date 22-01-2021


Pediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not. Retrospective cohort study of patients 0-18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred. A total of 4098 patients with a median age of 6 years old (IQR 4-10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3-8) in the non-ibuprofen group. No difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.

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Postoperative dysphagia immediately following pediatric endoscopic laryngeal cleft repair

Patrick Kiessling, Alyssa Smith, Cassandra Puccinelli, Karthik Balakrishnan

Publication date 18-01-2021


In pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies. A retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24 h following surgery. Thirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24 h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively. Endoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.

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Acoustic parameters of voice in typically developing children ages 4–19\u202fyears

Raymond D. Kent, Julie T. Eichhorn, Houri K. Vorperian

Publication date 16-01-2021


Report data on acoustic measures of voice in sustained vowels produced by typically developing children, aged 4-19 years, to add to the cross-sectional reference values in a pediatric database. Recordings of sustained vowel/ɑ/phonation were obtained from 158 children (80 males, 78 females) aged 4-19 years who were judged to be typically developing with respect to speech and voice. Acoustic analyses were performed with the Multidimensional Voice Program (MDVP™) and the Analysis of Dysphonia in Speech and Voice (ADSV™), both from Pentax Medical.
Values from both MDVP and ADSV are reported for children in the following age cohorts: 4-6 years, 7-9 years, 10-12 years, 13-15 years, and 16-19 years. The data in this study complement previously published data and contribute to a pediatric reference database useful for research and for clinical practice related to children's voice. Acoustic parameters most sensitive to age and sex are identified.

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Development of a novel mandibular distraction osteogenesis simulator using Computer Aided Design and 3D printing

Chelsea L. Reighard, Allison R. Powell, Tatum Y. Zurawski, Deborah M. Rooney, Charles A. Keilin, David A. Zopf

Publication date 15-01-2021


Micrognathia, a component of Robin Sequence, can cause glossoptosis, failure of palatal fusion, and critical obstruction of the airway. Mandibular distraction osteogenesis (MDO) is at times offered to anteriorly translate the mandible and tongue, relieving airway obstruction. MDO is an intricate reconstructive procedure that may be ideal for teaching using a high-fidelity educational simulator, allowing early hands-on experience in a zero-risk environment. To design a novel, low-cost, high-fidelity neonatal MDO simulator that can be used for trainee education and refinement of surgical technique. A novel MDO simulator was developed using additive manufacturing techniques. Three experts in MDO surgery completed a 20-item survey, rating the simulator's physical attributes, the realism of experience, the simulator's value, its relevance to practice and the surgeon's ability to perform tasks on a 4-point Likert scale. Computer Aided Design (CAD) and 3D printing allowed for the production of a realistic surgical simulator that emulates important aspects of MDO surgery. This preliminary evaluation indicated adequate means across the five domains relevant to the simulator's fidelity and usability (M = 3.33 to 3.75) out of a maximum of 4 points. Lowest rated items were consistent with expert comments allowing future refinement on subsequent iterations. Consumable material costs per model were $9.39 USD. The MDO model demonstrated adequate fidelity and holds promise as a skill-development tool for surgeons in training. Further studies are planned to determine its utility as a training and assessment tool.

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Red ear syndrome in children: Review of literature and report of three cases

Antonina DAmico, Cristina Galati, Maria Laura Manzo, Federica Reina, Giovanna Martina Nocera, Vincenzo Raieli

Publication date 14-01-2021


Red ear syndrome (RES) is a neurological syndrome that is characterized by attacks of redness and pain that is localized in the earlobe, accompanied by a burning sensation, swelling or otalgia. The exact pathophysiology of RES is not known. Several pediatric cases have been described. They show an extreme variability in clinical presentation and therapeutic response, and therefore there are numerous difficulties in the diagnostic-therapeutic approach and in the comprehension of the physiopathology. The goal of this report is to present three clinical cases of red ear syndrome in children. These cases show various characteristics that can give useful indications regarding the differential diagnosis and the pathogenetic mechanisms that are involved, particularly when they are compared with cases published in the literature.
We report three pediatric RES cases: 1) a boy whose condition offered a typical example of the association that occurs between migraine and RES. 2) a girl with idiopathic RES. 3) a child who suffered RES attacks that showed many similarities with trigeminal autonomic cephalalgias. Our clinical series shows the different ways in which RES can be expressed and they support the reported scientific literature. We suggest that the different forms of RES have a common final autonomic pathogenetic mechanism that is activated by parasympathetic hyperactivity and sympathetic inhibition. The different temporal characteristics, frequency, etc. may depend on the activation of distinct physiopathological modules that are related to the pain circuits, as suggested by the modular theory which describes that groups of neurons are defined as a module, where each module is responsible for a symptom and the individual's headache is defined by the activated modules.

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Button batteries and typical swallowed foreign bodies can be differentiated in high-resolution X-Rays

Johannes Voelker, Christine Voelker, Joachim Voelker, Jonas Engert, Phillipp Schendzielorz, Rudolf Hagen, Kristen Rak

Publication date 10-01-2021


Button battery ingestions have emerged as an increasing medical issue in recent years, especially for children. The frequent use of these energy sources in small appliances and toys is responsible for their ubiquitous occurrence in households. In addition to other possible foreign bodies, button batteries are particularly dangerous as they can cause severe complications in the aerodigestive tract. The study aimed for a detailed analysis of specific radiographic identifiers of button batteries and similarly configured potential esophageal foreign bodies in high-resolution X-ray scans. A selection of potentially hazardous button batteries - in cases of ingestion (CR2032) or aspiration (LR44, LR1130) - was made. Other clinically relevant radio-opaque objects of similar size and shape have been selected accordingly. High-resolution X-ray scans (33.3 lp/mm) were made using an in vitro model in porcine esophageal preparations. A systematic, comparative analysis was carried out with the digital radiographic images. In the study described, the selected foreign bodies were scanned at distinct angles in high image quality. Using button batteries, radiographically details of their internal structures were shown that have not yet been described. The known markers, as well as new detailed characteristics, were found in the experimental setting.
The differentiation from other typical esophageal foreign bodies was possible by analyzing four relevant identification features: the edge properties, internal structures, the size, and differences in 0°/90° scans. The study results reveal that specific features of potential esophageal foreign bodies can be identified by improved radiographic resolution, contrast, and dynamics. Thus, the diagnostic reliability in distinguishing 'high-risk foreign bodies' from less dangerous ones could be increased. In the future, button batteries could be detected more reliably with intelligent digital image analysis and enhanced radiographic technology. This may further support clinical triage algorithms and help reduce medical complications in cases of foreign body ingestions.

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Plurality of perspective: Doctor-parents of deaf children in a low-to middle-income country

Bianca Birdsey, Lavanithum Joseph

Publication date 22-01-2021


Pediatric deafness is an important consideration in neurodevelopment. Early identification and intervention are major factors in seeing that deaf children reach their full potential. Often, it is the medical professionals who themselves have limited knowledge about hearing loss or the consequences of delayed language acquisition. These knowledge gaps can negatively influence the timeous and holistic care that children with hearing loss require. With a dual experiential expertise gained through both parenting children with disabling hearing loss and being medical doctors, the purpose of this study was to better understand the field of pediatric hearing loss through doctors' insights gained as parents. Interpretative Phenomenological Analysis was the approach used for this qualitative enquiry. Five South African participants with children between the ages of two and ten years, were selected using purposive sampling and an in-depth semi-structured interview used as the data instrument. Thereafter, three levels of thematic analysis were conducted. Generally, doctors have limited knowledge of pediatric deafness. Perceptions towards deafness are typically through a medical-model lens, while appreciation of Universal Newborn Hearing Screening is lacking. Through exploring the various gains of parenting a deaf child, participants acknowledged the power of the lived experience in changing their own practice as both parents and practitioners. Doctors need to know more about pediatric deafness. The pathway of care from identification to intervention in South Africa needs revision. Exposure to the lived experience is a powerful means of enabling expert insights to influence such change in a practical and meaningful way.

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Comparing foreign body injuries patterns between Turkey and European Countries: are female Turkish children more vulnerable?

Emrah Aydın, Danila Azzolina, Solidea Baldas, Megan A. French, Dario Gregori, Giulia Lorenzoni

Publication date 12-01-2021


The present study aimed at analyzing and comparing Foreign Body (FB) injuries patterns in children from Turkey and other European countries in order to assess any country and culturally specific aspects of FB risk. Data from Susy Safe register were included in the analysis. For this study, ICD-935 (mouth, esophagus and stomach) and ICD-934 (trachea, bronchus, and lung) cases from European countries and from a single center in the Istanbul Bahcelievler State Hospital, Turkey, were extracted from the Susy database. A Multiple Correspondence Analysis (MCA) approach was employed to identify differences or similarities between the groups of FB injuries. The Turkey dataset has a larger proportion of females in comparison to the European data (p-value 0.002). According to the MCA analysis, the first two dimensions are explaining 48.11% of the variability (dimension 1, 37.44%; dimension 2, 10.67%). The three largest contributions to dimension 1 are via naturalis removal, not hospitalized, and ICD-935. The greatest contributions to dimension 2 are FB type, and consistency. The most interesting study finding is the higher incidence of females suffering a FB injury in ICD-934-935 in the Turkey dataset compared to that seen in the European dataset and also higher than that for all ICD locations within the Susy Safe register. The higher incidence of females tends to go against the belief that boys suffer higher FB injuries and needs to be further investigated.

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Risk factors, causes, and rates associated with hospital readmission after pediatric neck mass surgery

Alisse Singer, Alex Goel, Brooke M. Su-Velez, Alisha West

Publication date 12-01-2021


To understand rates, risk factors, and costs associated with hospital readmission in pediatric patients who underwent neck mass excision. This was a retrospective review of the Nationwide Readmissions Database (NRD) between 2010 and 2014 of select neck mass procedures, defined as affecting the following: thyroid, salivary gland, cervical lymph nodes, branchial cleft, thymus, and head and neck vessels. We analyzed rates and causes of 30-day readmissions using univariate and multivariate logistic regression. There were a total of 11,824 weighted cases identified with a 30-day readmission rate of 9.0% and a mean age of 9.5 years old. The sex distribution of patients undergoing neck mass procedures was 55.8% female and 44.2% male. The most common cause of readmission was associated with a comorbid condition likely unrelated to the neck mass procedure (53%). The most common procedure-related readmission causes were associated with a postoperative neck mass (14.4%), wound (13%), and infection (6.5%). In the multivariate model, number of procedures≥5 (OR: 2.11, 95% CI: 1.28-3.49), number of chronic conditions≥1 (OR: 2.33, 95% CI: 1.16-4.66), length of hospital stay of≥7 days (OR: 2.43, 95% CI: 1.48-0.3.98), and cervical lymph node procedure (OR:2.61, 95% CI: 1.47-4.63) were associated with higher readmission risk. Readmission after surgery for pediatric neck masses is relatively common, with an average of 9.0%. Risk factors associated with readmission include length of initial hospital stay, number of chronic conditions, number of procedures performed, and undergoing a cervical lymph node procedure.

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Association between allergic rhinitis-related factors and sleep duration in adolescents: Korea National Health and Nutrition Examination Survey V (2010–2012)

Kijeong Lee, In Hak Choi, Yeji Hong, Hoyoung Lee, Sang Hag Lee, Tae Hoon Kim

Publication date 17-01-2021


Previous studies have shown that sleep and allergic rhinitis (AR) is closely associated, bidirectionally affecting each other. Adolescence is a period that adequate sleep is essential, and the burden of AR increases, both of which greatly affect the quality of life. The aim of the present study was to investigate the correlation between inappropriate sleep duration and each AR-related subjective/objective factor in Korean adolescents. We analyzed the data of 1936 adolescents aged between 12 and 18 years who participated in the Korea National Health and Nutrition Examination Survey from 2010 to 2012. Data on sleep duration, physician-diagnosed AR, and presence of rhinitis symptoms were collected using a self-administered questionnaire. Nasal endoscopic findings, including watery rhinorrhea and pale inferior turbinate mucosa, and aeroallergen sensitization based on serum specific immunoglobulin E levels were examined. There was a higher prevalence of AR (23.68%) in the inappropriate sleep duration group than in the control group (16.56%; odds ratio = 1.56, p = 0.0024). The presence of endoscopic findings of AR showed a positive association with inappropriate sleep duration in males (odds ratio = 1.52, p = 0.008). In addition, in all three indoor allergens investigated, aeroallergen sensitization was not associated with inappropriate sleep duration. Inappropriate sleep duration was associated with increased prevalence of AR in Korean adolescents. Especially, this association was relevant in nasal endoscopic findings in male.

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Profiles and predictors of auditory functioning in abacus-trained children

K.V. Nisha, M. Sanjana, V.S. Rohith, K. Rajalakshmi, Prashanth Prabhu

Publication date 23-01-2021


The present study explored the auditory benefits of abacus-training using a battery of tests (auditory acuity, clarity, and cognition). The study also aimed to identify the relative contributions of auditory processing tests that are most sensitive to the effects of abacus-training. The study was conducted on 60 children aged between 9 - 14 years. These participants were divided into two groups (abacus trained and untrained) of 30 each, who underwent a series of auditory functioning tests.
The battery of tests included: auditory acuity (frequency, intensity, temporal, binaural and spatial resolution), auditory clarity (speech perception in noise), and auditory cognition (working digit and syllable memory). Statistically (t-test and Mann Whitney U test), significant changes were observed in the spatial resolution, auditory clarity, and cognition tests, suggestive of positive outcomes of abacus training at the higher-order auditory processing. This finding was complemented by the discriminant function (DF) analyses, which showed that clarity and cognitive measures helped for effective group segregation (abacustrained and untrained). These measures had significantly higher contributions to the DF. The findings of the study provide evidence of the multi-component benefits of abacus training in children and the transferability of learning effects to the auditory modality.

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Population-based survival of pediatric rhabdomyosarcoma of the head and neck over four decades

Steven D. Curry, Zi Yang Jiang, Kunal S. Jain

Publication date 11-01-2021


Clinical trials have reported increases in the survival of pediatric rhabdomyosarcoma (RMS) from 25% in 1970 to 73% in 2001. The purpose of this study was to examine whether survival of pediatric patients with RMS of the head and neck improved at the US population level. A population-based cohort of patients with rhabdomyosarcoma of the head and neck aged 0-19 years in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2013 was queried. The cumulative incidence competing risks (CICR) method was used to estimate risk and survival trends. 718 cases were identified for analysis. Survival rates at 1-, 5-, and 10-years after diagnosis were 91.2%, 73.2%, and 69.4% respectively. Survival rates at 1 year after diagnosis increased from 82.6% to 93.1% during the study period. In the subdistributional hazard analysis, there was a significantly improved disease-specific risk of death in the first year after diagnosis. Overall risk of death did not improve significantly. Favorable prognostic factors included age <10 years at diagnosis, smaller tumor size, absence of distant metastasis, localized tumors, earlier stage at presentation, grossly complete surgical resection, and embryonal or botryoid histology. Disease-specific survival in the first year following diagnosis improved, but the change in overall survival at the population level was not statistically significant. These findings should be interpreted in light of the inclusion of patients with distant metastasis at diagnosis, who have poor prognoses, together with the limited statistical power afforded in studies of rare diseases.

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Surgery for obstructive sleep apnea in young children: Outcome evaluated by polysomnograhy and quality of life

Britt Øverland, Hanne Berdal, Harriet Akre

Publication date 09-01-2021


Hypertrophy of adenoid and tonsils is the most common risk factor for OSA in children, and adenotonsillectomy is considered the first-line treatment. The effect of surgery for OSA in children varies considerably between studies, and few studies have focused on the effect in young children under 5 years of age. Thus, the aim of this study was to: 1) evaluate the effect of surgery for OSA in young children using objective data from polysomnography and parent-reported symptoms using questionnaires, and 2) identify predictors of residual OSA following surgery. This is a prospective cohort study of children aged 2-4 years who were referred for surgery to treat OSA. Measures collected before and after surgery included polysomnography (PSG), Pediatric Sleep Questionnaire (PSQ), OSA-18 and clinical data. 56 children completed a preoperative and postoperative PSG. Their median age was 3.1 (IQR 2.6-3.1) years. After surgery, 63% had an obstructive apnea hypopnea index (OAHI) < 1, 82% had an OAHI < 2 and 95% had an OAHI < 5. Parent-reported OSA-18 and PSQ scores improved significantly after surgery. In logistic regression analyses, higher preoperative OAHI was the only significant clinical predictor of residual OSA after surgery. There was a high resolution rate after surgery for OSA in this group of young children, with significant improvements in both the OAHI measured with PSG and parent-reported symptoms. The only clinical predictor of residual OSA after surgery was higher preoperative OAHI.

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Translation and validation of the LittlEars auditory questionnaire in Kannada

Abishek Umashankar, Thejas B, Prashanth Prabhu

Publication date 14-01-2021


The aim of the study was to translate and validate the LittlEARS Auditory Questionnaire (LEAQ) in Kannada. The translation procedure followed a traditional translation, back translation, and content validity process before administering. The finalized version was administered on 87 children with 67 normal hearing children and 20 hearing-impaired children. The tool had good internal consistency, good reliability, and a norm curve could be established. The Cronbach alpha value for item correlation ranged from 0.26 to 0.79. A significant difference was found between normal hearing individuals and hearing impaired. The LEAQ tool has been translated and validated for the Kannada speaking population and can be used as a screening tool for children up to two years of age and as a subjective outcome measuring tool for hearing aid and Cochlear Implant user.

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Factors associated to functional recovery of left vocal fold motion impairment at two-years-old age in very preterm infants

Patricia W. Garcia-Marcos, Patricia Pastor-Costa, Pedro Mondejar-Lopez, Manuel Sanchez-Solis, Luis Garcia-Marcos, Jose A. Diaz-Manzano

Publication date 08-01-2021


To describe a cohort of neonates with left vocal fold motion impairment (LVFMI) and the factors associated to it in the neonatal period; procedures required during LVFMI treatment; and clinical outcomes at the age of 2-years. An additional objective was to study those factors which are likely to be most associated to functional recovery of LVFMI at this age. A cohort of patients born in a tertiary care hospital with a diagnosis of left VFMI was included.
Factors registered were: gender; clinical presentation at the time of examination; diagnosis of other laryngeal defects associated; data related to their neonatal period (gestational age, congenital heart defects corrective surgery required, neurologic disease, bronchopulmonary dysplasia, non-invasive ventilation required, invasive ventilation required, and tracheostomy required); treatment applied for LVFMI (tracheostomy and/or laryngeal surgery); need of language and hearing therapy; and outcomes considered by the pediatric otolaryngologist at the 2 years-old follow-up visit. A total of 56 patients with LVFMI diagnosis were included. Only 10 patients (17.9%) showed functional recovery from LVFMI at the age of 2 years. We found significant negative association between this recovery and language and hearing therapy (p = 0.03), which was also associated to psychomotor retardation (p < 0.001). Multivariate analysis produced similar results, being language and hearing therapy the only significant factor associated to a worse outcome (OR = 4.77 [CI95% 1.14; 20.08] p = 0.03). Psychomotor development retardation is negatively associated to functional recovery of full speech in a preterm infant's population with LVFMI diagnosis, regardless of other factors related to LVFMI etiology and severity.

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Integrating congenital cytomegalovirus screening within a newborn hearing screening program: Is it worthwhile?

Rachael Beswick, Lauren McHugh, Julia E. Clark

Publication date 11-01-2021


The aim of the present study was to review the potential impacts and barriers to upscaling a pilot congenital Cytomegalovirus (cCMV) screening program into a state-wide permanent universal newborn hearing screening (UNHS) program. This study reviewed the outcomes of the cCMV screening program pilot operating at three maternity hospitals to standard state-wide laboratory notifications in Queensland, Australia between August 2014 to April 2018. Stakeholder interviews were also conducted to inform state-wide program implementation. Of the 485 infants tested for CMV on a saliva swab at the pilot sites, 4 (0.8%) returned a positive result. Review of the state-wide laboratory infant CMV PCR notifications for the same time-period revealed more than half of infants with cCMV (63.7%) would not have been detected under a state-wide targeted screening program as they either passed newborn hearing screening, were deceased, symptomatic, or were born <34 weeks gestational age. Barriers to state-wide program implementation included program-level factors (timing of the cCMV screen, funding, cross-agency communication, workforce and training) and community-level factors (low public cCMV awareness and prevalence). Although cCMV screening alongside UNHS is achievable, a number of barriers need to be addressed prior to state-wide program implementation.

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Bioinformatics analysis of candidate genes involved in ethanol-induced microtia pathogenesis based on a human genome database: GeneCards

Yangyang Lin, Zhensheng Hu

Publication date 09-01-2021


Ethanol used by women during pregnancy increases the risk for microtia in the foetus. Traditionally, laboratory experiments and Mouse Genome Informatics (MGI) have been used to explore microtia pathogenesis. The aim of this study was to screen and verify hub genes involved in ethanol-induced microtia and to explore the potential molecular mechanisms. Overlapping genes related to ethanol and microtia were acquired from the Gene Cards database and filtered by confidence score. These genes were further analysed via bioinformatics. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis results were visualized with the cluster Profiler R package. A protein-protein interaction (PPI) network was constructed based on data from the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database. Overall, 41 genes related to both ethanol and microtia were identified. The genes most relevant to ethanol-induced microtia pathogenesis included FGFR-2, FGFR-3, FGF-8, TP53, IGF1, SHH, CTNNB1, and PAX6, among others. Most genes were strongly enriched for tissue and organ development in GO analysis. Additionally, many genes were enriched in the Ras, FoxO, MAPK, and PI3K-Akt signalling pathways in KEGG analysis. Bioinformatics analysis was conducted on genes currently known to be related to ethanol-induced microtia pathogenesis. We propose that mechanisms involving FGF-family genes, TP53, IGF1 and SHH contribute significantly to ethanol-induced microtia and the accompanying malformation of other structures.

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A retrofacial approach of round window vibroplasty during Vibrant Soundbridge implantation for patients with congenital ear malformation

Jie Li, Danni Wang, Chunli Zhao, Lin Yang, Ran Ren, Shouqin Zhao

Publication date 08-01-2021


To describe the specific retrofacial surgical approach for application of Vibrant Soundbridge (VSB) to the round window (RW) in patients with congenital ear malformation. Four patients with congenital ear malformation were implanted with VSB unilaterally through a retrofacial approach in present study. During the operation, the round window niche was identified through a retrofacial pathway and the floating mass transducer (FMT) was attached to the RW inferiorly. Satisfied outcomes were confirmed after surgery. No intraoperative or postoperative surgical complications were observed in all patients. When the facial nerve was aberrant or it was unable to access the RW through the classic facial recess pathway during the round window vibroplasty, the retrofacial approach could be a valid and feasible alternative approach.

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The effects of swallowing exercise and non-nutritive sucking exercise on oral feeding readiness in preterm infants: A randomized controlled trial

Marziyeh Ostadi, Fariba jokar, Amir-Mohammad Armanian, Mahboobeh Namnabati, Yalda Kazemi, Marziyeh Poorjavad

Publication date 08-01-2021


Preterm infants demonstrate problems with pharyngeal swallowing in addition to sucking problems. Oral motor intervention and nonnutritive sucking (NNS) were introduced for promoting oral feeding skills in preterm infants. NNS cannot cover all the components of oral feeding. In another hand, the swallowing exercise (SE) can accelerate the attainment of independent oral feeding in the preterm infants. The current study sought to examine if a combined program of NNS and SE compared with a program that only involves NNS would be more effective on oral feeding readiness of premature infants. This randomized controlled trial was conducted in a neonatal intensive care unit (NICU). 45 preterm infants were recruited in three groups. In the group I, infants were provided with NNS twice a day. The group II received a program that involved 15 min of NNS and 15 min of SE, daily. Both interventions were provided 10 days during two consecutive weeks. The group III, control group, just received the routine NICU care. All infants were assessed by functional oral feeding outcome measures including postmenstrual age (PMA) at the start of oral feeding, PMA at full oral feeding, transition time (days from start to full oral feeding), PMA at discharge time and also the infant's dependency on tube-feeding at discharge time after interventions. Also, all infants were assessed via Preterm Oral Feeding Readiness Scale (POFRAS) before and after intervention. No significant differences were observed in the PMA mean at start of oral-feeding (P = 0.29), full oral-feeding (P = 0.13), discharge time (P = 0.45) and the mean of transition time (P = 0.14). Compared to the control group, more infants in the group II were discharged without tube-feeding (P = 0.01). The mean of POFRAS was significantly higher in both groups I and II compared to the group III (P = 0.02 and P = 0.01, respectively). This score was, however, not statistically different between the groups I and II (P = 0.98). Both studied interventions were superior to routine NICU care in enhancing the oral feeding readiness of preterm infants based on the POFRAS score. The studied combined program of NNS and SE, and not NNS program, could significantly increase the number of discharged infants without tube-feeding compared to control group.

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Hearing outcome in infants following correction of maternal hypothyroidism during pregnancy

Indu Varsha G, SM Azeem Mohiyuddin, Prashanth Babu A, Apoorva H M, K.N.V. Prasad, Munikrishna N

Publication date 12-01-2021


There is significant prevalence of overt and subclinical hypothyroidism in pregnant women in rural areas. Maternal hypothyroidism is known to cause congenital hypothyroidism resulting in sensorineural hearing loss. Anti-Thyroperoxidase antibodies are known to cross placental barrier. There is no literature on hearing assessment in infants born to women whose hypothyroidism was corrected during pregnancy. Do these infants suffer hearing loss? Our study addresses this question. 140 infants born to women on treatment for hypothyroidism during pregnancy and 140 infants born to euthyroid women were evaluated for hearing by Brainstem Evoked Response Audiometrry at 1 and 4 months age. Anti-TPO antibodies were estimated at 4 months of age. There was no clinical hearing deficit or delay in neurological development in infants born to women undergoing treatment for hypothyroidism during pregnancy. However wave V latency on BERA was slightly prolonged in them compared to infants born to euthyroid women. There was absence of wave V when maternal subclinical hypothyroidism persisted till parturition. However within 6-8months of age the wave V latencies corrected to normal. Anti-TPO antibodies were within normal range at 4months age. Maternal hypothyroidism when corrected before parturition does not affect hearing in the infants clinically. The mild delay in wave V on BERA corrects within first year of life. However larger studies to assess hearing in infants born to women having overt hypothyroidism during first trimester of pregnancy may be desirable to assess whether hearing is adversely affected in them.

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Predictors of postoperative complications in paediatric patients receiving grommets – A retrospective analysis

Luke Chenkan Wang, Charles Edward Giddings, Debra Phyland

Publication date 08-01-2021


Insertion of middle ear ventilation tubes (MEVT), tympanostomy tubes or grommets is one of the most common paediatric surgical procedures performed by ENT surgeons worldwide. Outcomes may be complicated by postoperative otorrhoea and ventilation tube blockage. To identify risk factors associated with early postoperative complications of MEVT insertion. In a case-control study, set in a tertiary hospital in Melbourne, Australia, 590 paediatric patients undergoing grommet insertion between February 2017 and February 2018, 311 patients (205 males & 106 females; median age of 3.86 years) met the inclusion criteria and had identical middle ear status bilaterally. Tympanostomy tube insertion and postoperative topical otic antibiotic drops. Patient age, gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, season of surgery, diagnosis and time to first medical review were examined. The duration of topical otic antibiotic drops used and tube patency and presence of otorrhoea at 6-week postoperative review were also recorded. At the first medical review, 8.7% of patients (n = 27) developed otorrhoea from one or both ears, 6.4% of patients (n = 20) had an obstructed MEVT in one or both ears. Exposure to intraoperative [IO] and postoperative [PO] antibiotic drops were significantly less associated with developing postoperative otorrhoea compared to non-exposure (IO: Odds Ratio [OR] = 0.15, 95%CI 0.04 to 0.57, p = 0.005; PO: OR = 0.21, 95%CI 0.58 to 0.76, p = 0.017). There were no statistically significant associations between antibiotic drop exposure and grommet blockage (p > 0.05). There was a significant association between developing postoperative otorrhoea and patients receiving surgery during the colder months of Winter/Autumn (OR = 3.17, 95%CI 1.14 to 8.84, p = 0.028), as well as patients aged less than 3 years (OR = 2.66, 95%CI 1.01 to 7.03, p = 0.049). There was a statistically significant association between serous effusions and grommet blockage compared to no effusion (OR = 4.03, 95%CI 1.03 to 15.7, p = 0.045). There were no statistically significant associations identified between otorrhoea and gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, diagnosis and time to first medical review. There were no statistically significant associations between grommet blockage and age, gender, indication for surgery, concurrent surgery, season or number of previous grommets. 8.7% of patients developed otorrhoea within 6 weeks post-operatively. Undergoing the procedure during winter/autumn, age <3 years were associated with developing otorrhoea. Topical antibiotic exposure was inversely associated with developing postoperative otorrhoea. 6.4% of patients had grommet blockage. Presence of serous middle ear effusion intraoperatively was a statistically significant indicator for developing grommet blockage.

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Health literacy rates among pediatric tracheostomy caregivers

Christine Settoon, Adele K. Evans

Publication date 08-01-2021


As health outcomes and disparities become more important in national healthcare, physicians must be aware of every patient's health literacy in order to deliver effective care. Our goal was to measure the health literacy rates in the caregivers of our pediatric tracheostomy population. These caregivers specifically have an immense responsibility that requires a certain capacity for understanding and learning complex skills. Thus far there have been no studies or surveys investigating the rates of health literacy in this population or tracheostomy patients in general. Caregivers' literacy rates were measured by administering a Test of Functional Health Literacy in Adults (TOFHLA). This test uses actual materials that patients might encounter in a typical clinic and consists of a reading comprehension and numeracy section. To assess impact of the complex care on caregiver quality of life, we simultaneously administered the Pediatric Tracheostomy Health Status Instrument (PTHSI), a validated caregiver quality of life measurement. Caregivers of children with tracheostomies were recruited and surveyed during the Pediatric Tracheostomy Clinic between July 2019-October 2019. Twenty - six caregivers completed the TOFHLA; 24 completed all three parts - the TOFHLA, the demographic survey, and the PTHSI. Health literacy rates among patient families in the out-patient setting with experience with tracheostomy were deemed "adequate" in 85% of caregivers; the remaining 15% of caregivers scored "inadequate". Overall adult literacy rates in the general population in this state are 26% "inadequate." Approximately 80% of our caregivers rely solely on Medicaid for healthcare insurance and nearly half of participants reported an annual household income less than $5000. Ages of caregivers ranged from 20 to 61 years, with no significant correlation to health literacy. The average PTHSI score was 36 (SD 8.6), denoting a moderate level of caregiver burden but no correlation to the caregiver health literacy score was found. When comparing caregiver health literacy scores in relation to education level, caregivers with college and post-graduate education had higher literacy scores than those with a high school education, p = .0086. In addition, when comparing African American to white caregivers, white caregivers were found to have higher health literacy scores, p = .036. Notably, caregiver burden as measured by the PTHSI score did not differ significantly between caregivers in lower income and higher income levels, p = .91. Health literacy measurements for caregivers of children with complex medical conditions exceed the health literacy rates of the general population in our state, potentially biased by the intensive training provided to families during their prolonged hospitalization. Healthcare disparities may impact the medically complex child differently from the healthy child. Assumptions about health, wealth and caregiver burden may be inaccurate and warrant further evaluation. Assessing health literacy before institutionalization has occurred may enable us to more accurately design caregiver training programs to further augment literacy and health literacy.

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Airway foreign bodies in pediatric patients: An analysis of composition and age via HCUP KID

Tyler Wanstreet, Jad Ramadan, Michele M. Carr

Publication date 01-01-2021


To compare outcomes for children food and non-food airway foreign body (AFB) diagnoses and to compare outcomes for patients age <2 versus ≥2 years with an AFB diagnosis. Data from 2016 HCUP KID was used to compare outcomes for food and non-food AFB diagnoses based on location in the larynx, trachea, bronchus, and whole group (including these three specified locations and location unspecified). Outcomes were also compared for children aged <2 versus ≥2 years. Demographic data included age, race, gender, primary payer, location and teaching status of the hospital. Available co-morbidity data included APR-DRG mortality and APR-DRG severity. Outcomes were length of stay (LOS), total charge, mortality, and performance of a tracheotomy. 2973 patients were included. 49.1% were less than 2 years old, the remainder (50.9%) were between 2 and 20 years old. Food AFBs made up 26.0% and 74.0% were other specified non-food AFBs. Overall mortality was 3.7%, and 3.8% underwent tracheotomy. Children with non-food AFBs were significantly older, had significantly longer median LOS, and higher median total charges, when compared to food AFBs. Non-food AFBs had a significantly higher likelihood of tracheotomy. Patients aged 2 or more years with bronchial AFBs had significantly higher total charges, LOS, and APR-DRG risk mortality and severity than <2 year old patients with bronchial AFBs. AFBs remain a serious health concern, especially non-food objects in older children which have elevated risks.

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Implementation of a screening tool for primary ciliary dyskinesia (PCD) in a pediatric otolaryngology clinic

Steven K. Brennan, David Molter, Maithilee Menezes, Katherine Dunsky, David Leonard, Judith Lieu, Keiko Hirose, Guy Hazan, Amjad Horani, Thomas Ferkol, Steven L. Brody

Publication date 04-01-2021


Primary ciliary dyskinesia (PCD) is a rare genetic disease arising from motile ciliary dysfunction and associated with recurrent and chronic upper and lower respiratory tract infections. Pediatric otolaryngologists may see these patients prior to the development of lung disease. Features of PCD may overlap with other suppurative respiratory diseases, creating diagnostic challenges. A simple screening tool would be beneficial to identify potential patients who have chronic upper respiratory tract disease requiring further specialist evaluation. To test a simple screening tool consisting of four questions to detect PCD in children with chronic otitis media and chronic rhinosinusitis seen in a tertiary otolaryngology clinic. A prospective, single site, observational study in a tertiary care pediatric otolaryngology clinic. Children aged 3-17 years diagnosed with chronic otitis media or rhinosinusitis with onset at less than 2 years of age were recruited. All study subjects had at least one of four key clinical features for PCD as determined by answers to screening questions, while control subjects had none. All participants completed a medical history questionnaire and nasal nitric oxide measurements. Those with reduced nasal nitric oxide levels were referred to our PCD center for further evaluation. A total of 153 patients were screened and 62 subjects were enrolled. Of those, 35 were enrolled as study subjects and 27 as matched controls. Study subjects had mean age of 7.5 years (3.2-16.5) with pre-screening diagnosis of chronic otitis media (n = 29) or chronic rhinosinusitis (n = 6). Control subjects (n = 27) had mean age 7.2 years (3.0-16.3) with pre-screening diagnosis of chronic otitis media (n = 25), and chronic rhinosinusitis (n = 2). There were no differences in subject demographics or mean nasal nitric oxide values between the two groups (179.8 vs 210.8 nl/min). Ten individuals had low nasal nitric oxide values, 7 of which were normal on repeat testing. Three subjects failed to return for follow up evaluations. Four referrals were made for further evaluation on the basis of clinical symptoms and nasal nitric oxide results. While no new cases of PCD were detected, a subject and his sibling with recurrent sinopulmonary infections were referred for immunologic evaluation. The use of standardized screening questions can be used in an otolaryngology clinic to identify patients who require further evaluation for PCD or primary immunodeficiency.

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"How I do it: Proximal cochlear implant electrode fixation using Neds Knot"

Faisal Zawawi, Sharon L. Cushing, Adrian L. James, Karen A. Gordon, Blake C. Papsin

Publication date 31-12-2020


Electrode extrusion is an under-recognized complication of cochlear implants, especially in those with straight electrodes. This paper describes in details the steps to perform proximal fixation of an electrode around the incus buttress using Ned's knot technique. Written and video illustration is included. Ned's Knot is an easy technique that can help diminish the extrusion rate of straight cochlear implants electrodes.

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Protocol for outpatient management in cleft lip and palate repair

María Santos, Jacqueline García, Stephanie Graf, Carlos Giugliano

Publication date 15-01-2021


Cleft lip is a common malformation in Chile. The standard care for cleft lip and palate repair is inpatient admission; this is mainly to observe complications and administer intravenous fluids, antibiotics, and analgesics. In our center, however, a strict selection of patients undergo ambulatory surgeries. In this paper, we illustrate our experience managing outpatient cleft lip and palate repair and show that it is possible to carry out a successful ambulatory surgery with few to no complications in children and adults with cleft lip and palate.

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Hearing screening in neonates with hyperbilirubinemia

Zahraa Muhammed Ezzeldin, Eman Sharaf, Hussein Sherif Hamdy, Yasmine Ashraf Abdelwahab Selim

Publication date 29-12-2020


Hyperbilirubinemia is toxic to the auditory pathways and to the central nervous system, leaving sequelae such as hearing loss and encephalopathy. The damage to the auditory system occurs primarily within the brainstem and cranial nerve VIII, and manifests clinically as auditory neuropathy spectrum disorder. to establish the relationship that exists between hyperbilirubinemia at birth as a risk factor of neonatal hearing loss in children born in ABOU-EL-REISH hospital.
we carried out of 60 neonates categorized into two groups: Group (A n = 30), neonates with hyperbilirubinemia; Group (B n = 30), neonates without hyperbilirubinemia. Ten neonates were boys and twenty were girls from group A and eleven boys and nigh-teen girls from group B.
There was significant statistical difference between group A and group B regarding ABR (P-value = 0.001) and a statistical difference regarding OAE (P-value = 0.103 in the right ear and 0.028 in the left ear). Also, our study shows the area under the curve and the diagnostic accuracy of total serum bilirubin (TSB) level for detection of hearing screening results (ABR) at a cut-off point 21 mg/dl (P-value = 0.008 and 0.009 in the right and left ears respectively.) CONCLUSIONS: Our study showed a relevant association between bilirubin levels and abnormal hearing screening results and the importance of combined screening with OAE and ABR tests.

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Hearing-related quality of life, developmental outcomes and performance in children and young adults with unilateral conductive hearing loss due to aural atresia

A.L. Smit, Y.R.W. Burgers, H.F.N. Swanenburg de Veye, I. Stegeman, C.C. Breugem

Publication date 02-01-2021


While research has shown that children with single sided deafness have a lower quality of life and developmental outcomes compared to normal hearing peers, little is known about these domains in children with unilateral congenital conductive hearing loss due to aural atresia. This study aims to investigate the hearing-related quality of life, developmental outcomes and educational performance in children and young adults with unilateral conductive hearing loss due to aural atresia. Nineteen children and young adults with unilateral aural atresia received a set of five questionnaires. Hearing-related quality of life (SSQ), general quality of life (Kidscreen-27), speech and language development (CCC-2-Nl), educational performance and problems in social-emotional and behavioral domains (CBCL/YSR/ASR) were measured with validated questionnaires. Scores on the questionnaires were compared to their norm scores. Mann-Whitney U tests and independent t-tests were used to identify significant differences between age groups. Mean scores on the SSQ subscales were speech 6.78, spatial 5.00 and quality 6.98. Mean scores on the Kidscreen-27, CCC-2-NL, CBCL/YSR/ASR fell within normal or non-clinical range. A high number of cases needed speech therapy (60.7%) or special measures in class (79.3%) or showed grade repetition (>30%) in primary or secondary school. Children and young adults with unilateral conductive hearing loss due to congenital aural atresia showed lower scores regarding hearing-related quality of life compared to normal-hearing peers. The result show similarities with children with single sided deafness. Regarding general quality of life, speech and language development and in social-emotional and behavioral domains the studied children and young adults seem to develop according to norm scores. It is important to observe these children closely as they may need guidance during education to allow them to thrive.

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Herpes simplex laryngitis: Comparison between pediatric and adult patients

Kevin Bachrach, Jessica R. Levi, Lauren F. Tracy

Publication date 13-01-2021


Infection with herpes simplex virus (HSV) typically causes limited oral and genital symptoms, however HSV can also affect the larynx and result in severe aerodigestive symptoms. Due to the rarity of HSV laryngitis, the symptoms and clinical course of are not well understood. This study aims to more completely characterize HSV laryngitis in order to aid clinicians in understanding and recognition of HSV laryngitis. Comprehensive literature search of MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews to identify articles relating to HSV laryngitis. Patient demographics, presenting signs and symptoms, treatment and clinical course were extracted from the selected manuscripts. There were 31 studies on HSV laryngitis that identified 36 patients (17 pediatric, 19 adult). The average age for pediatric patients was 11 months (9 M, 8F) and 52 years for adults (11 M, 8F). In the pediatric population, stridor was more common at presentation in comparison to the adult population (p < .01). Adults more commonly presented with dysphagia (p = .03) and dysphonia (p < .01) Adult patients were significantly more likely to undergo tracheotomy than pediatric patients (p = .047). The mean length of inpatient hospital stay was 21.2 days in pediatric patients and 15.8 days for adult patients. HSV laryngitis has a unique presentation in pediatrics and adults, but is nonspecific in both populations leading to delays in diagnosis and treatment. HSV laryngitis is associated with significant morbidity including multi-week hospital stay and risk for needing tracheostomy in both adults and pediatric population which demonstrates need for clinical awareness of this complication of HSV infection.

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Juvenile recurrent parotitis: Review and proposed management algorithm

John Wood, Ed C. Toll, Francis Hall, Murali Mahadevan

Publication date 10-01-2021


Despite being the second most common salivary disease in childhood, the aetiology and appropriate management of juvenile recurrent parotitis (JRP) remains uncertain. Consequently patients may be misdiagnosed, or even undergo indeterminate or potentially invasive procedures without benefit. This article reviews the current understanding of the epidemiology and pathophysiology of JRP, and to appraise the management options available. Medline and Google Scholar databases were searched and peer reviewed journal articles assessed. The epidemiology of JRP remains uncertain, and the clinical presentation of JRP can vary widely in frequency and severity. Diagnosis is still largely based on clinical signs and symptoms including parotid swelling, pain and fever. Investigation typically focuses on the exclusion of other diseases and immunodeficiencies, however there are noted typical radiological findings on both ultrasound and magnetic resonance imaging. The ideal management of this condition still remains unclear, however symptoms typically resolve by puberty. Treatment focuses on minimally invasive procedures such as sialography and sialendoscopy to reduce the frequency and severity of acute episodes. Acute episodes of JRP can occur up to 30 times per year and have a significant impact on the quality of life of an affected child. Consequently a management algorithm is proposed based on the exclusion of other pathology. There is increasing evidence for non-ablative, minimally invasive approaches such as sialography and sialendoscopy to reduce the impact of this disease.

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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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Anesthesia for extraction of a fractured COVID-19 nasopharyngeal swab

Varun Suresh

Publication date 17-01-2021


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