International Journal of Pediatric Otorhinolaryngology 2020-11-29

Pediatric laryngeal sarcoma: Systematic review and pooled analysis

Taha A. Mur, William R. Pellegrini, Zaroug Jaleel, Heather A. Edwards, Jessica R. Levi

Publicatie 30-10-2020


Sarcomas are a rare, diverse tumor class of mesenchymal origin affecting all age groups. Survival after diagnosis is influenced by disease site. To date, there are no analyses evaluating treatment of pediatric sarcoma within the larynx specifically. A structured literature review following PRISMA guidelines was preformed to identify case reports of pediatric (age 17 and younger) laryngeal sarcoma. Twenty-nine case reports documenting 37 pediatric patients diagnosed with sarcoma in the larynx were identified since 1980. The majority of patients were male (79.4%). The most common histological subtypes were rhabdomyosarcoma (69.4%) and synovial sarcoma (19.4%). The supraglottis was the most common site of disease (62.1%) among laryngeal subsites. Only two patients were known to have succumbed to their disease. Overall survival was not statistically impacted by primary site of tumor, treatment strategy, histology or gender. Soft tissue sarcoma is rarely found in the pediatric larynx. Patient and tumor characteristics studied were not shown to affect outcomes. Increased documenting of high-quality case reports is needed to advance understanding of this disease.

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Oral mucosal calcified nodule requiring palatoplasty

Emma Panico, Kyle Robinette, David Kelly, Brian Wiatrak

Publicatie 10-11-2020


Calcinosis cutis describes a condition of pathologic calcium deposition in the dermis. Several subtypes exist, including the subepidermal calcified nodule. The oral mucosal calcified nodule (OMCN) was posited in 1992 as a specific term for a subepidermal calcified nodule occurring in the oral cavity, and since that time only six such lesions have been described in the literature. This report explores a case of OMCN on the palate of a 3-month-old infant with the goal of supplementing extant literature, providing a consideration of the differentials of palatal lesions in the pediatric population, and describing a unique instance in which OMCN resulted in a full-thickness defect requiring palatoplasty for repair.

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Cochlear electrode array tip fold-over in incomplete partition-I – A case report

Luluh Alsughayer, Yazeed Al-shawi, Medhat Yousef, Abdulrahman Hagr

Publicatie 29-10-2020


Electrode tip fold-over is a rare complication of cochlear implantation (CI), especially in lateral wall (LW) electrodes. We describe a case of LW electrode tip fold-over in a patient with incomplete partition type-1 (IP-I). Preoperative measurement of cochlear length is important for optimal CI electrode selection. In cochlear malformation, Stenvers x-ray is superior to spread of excitation in detecting tip fold-over. Despite tip fold-over, hearing threshold, speech reception threshold, and word recognition score were almost symmetrical bilaterally. Therefore, revision surgery should be reserved for patients with persistent symptoms or markedly affected speech performance, in whom deactivation did not suffice.

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Pseudo-cobra neck deformity due to aplasia cutis congenita

Noah Z. Feit, Wesley L. Davison, Anthony P. Sclafani, Vikash K. Modi

Publicatie 26-10-2020


Aplasia cutis congenita is a rare but heterogeneous group of conditions characterized by the absence of one or more areas of skin sometimes extending to deeper tissues. The disorder as a solitary neck lesion has yet to be reported in the literature. Our patient presented with a pseudo-cobra neck deformity secondary to aplasia cutis congenita. Guidance on optimal management for non-scalp and more "benign" presentations of this disorder is lacking.

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Laryngotracheal injuries after intubation in pediatric seizure patients: A case series and a review of the literature

David Z. Allen, Rishabh Sethia, Erin Hamersley, Charles A. Elmaraghy, Tendy Chiang

Publicatie 26-10-2020


Acute management of seizures may require intubation with an endotracheal tube (ETT) in addition to benzodiazepine administration. Although necessary for management at times, intubation can lead to laryngotracheal injury as has been reported at length in both the adult and pediatric populations. A review of the literature shows no prior reports of laryngotracheal injuries following intubation in actively seizing pediatric patients. We share our experience with two pediatric patients who had laryngotracheal injuries after being emergently intubated with large ETT's during management of their seizures. We describe two unique cases in the pediatric seizure population associated with laryngotracheal injuries with the goal of emphasizing appropriate ETT sizing for intubation.

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Isolated hyoid bone fracture in a child due to a fall

Mansharan Kaur Chainchel Singh, Sheue Feng Siew, Poh Soon Lai

Publicatie 18-10-2020


Hyoid bone fractures due to blunt trauma are rare accounting for only 0.002% of all head and neck fractures with most documented fractures being due to strangulation, hanging, motorcycle helmet straps, sports injuries and rarely as a complication of intubation. However, they are even rarer in the paediatric age group. We present a hyoid bone fracture in a two-year-old child as a result of a fall down three steps. Hyoid bone fractures though generally heal well with conservative treatment must be diagnosed early to avoid air way obstruction leading to morbidity and mortality.

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Management of pediatric laryngeal webs secondary to severe croup and traumatic intubation

Alex Waler, Kyle Sanchez, Sergio Santino Cervantes, Cynthia Chen

Publicatie 18-10-2020


Laryngotracheobronchitis is a common, typically self-limiting viral infection. However, severe laryngotracheobronchitis can require urgent intubation to prevent imminent airway obstruction. The concurrent inflammation and urgency make laryngeal trauma more likely. We report two cases of children who underwent emergent intubation for acute respiratory distress due to viral laryngotracheobronchitis and subsequently developed anterior laryngeal webs. Both underwent laryngoplasty with keel placement, with resolution of their laryngeal webs. These cases describe pediatric laryngeal web formation as a rare complication of traumatic intubation and a novel technique for endoscopic keel placement.

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Use of an intraocular handpiece for the removal of magnets from the oropharynx of a pediatric patient

Prahasit Thirkateh, Sarah M. Walner, David L. Walner

Publicatie 14-10-2020


With the increasing availability of magnets within household objects and toys, otolaryngologists must be aware of the propensity of ingestions or impaction of magnets within the upper aerodigestive tract of pediatric patients. We describe a case of a 21-month old male who presented with throat pain after swallowing ten 0.5-inch magnetic balls, after which evaluation revealed the adherence the the of three magnets within the posterior oropharynx and an additional seven magnets in the small intestine. After an initial failed attempt to remove the pharyngeal magnets with forceps, the magnets were successfully removed using an ophthalmic intraocular magnet handpiece designed for ophthalmologic procedures. Use of this device should be taken into consideration for similar cases.

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Dacryoendoscopic examination for location of internal orifice of congenital lacrimal fistula: A case series

Shinjiro Kono, Patricia Ann L. Lee, Hirohiko Kakizaki, Yasuhiro Takahashi

Publicatie 06-10-2020


We examined the location of the internal orifice of congenital lacrimal fistula using a dacryoendoscope in 5 patients. A suture inserted from the skin orifice and passing into the lacrimal drainage system through the fistula track was identified using a dacryoendoscope. Consequently, the suture passed into the lacrimal sac in all patients. Although the internal orifice had been reported to be predominantly located in the common canaliculus, the methods previously used for identification of the internal orifice were less accurate. The results in our study suggest a higher incidence of congenital lacrimal fistulae connected with the lacrimal sac.

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Identification of a novel CYP26A1 mutation in a Chinese family with congenital microtia

Peipei Guo, Zhonglei Ji, Haiyue Jiang, Xin Huang, Changchen Wang, Bo Pan

Publicatie 17-11-2020


Microtia is defined as a congenital malformation characterized by a small, abnormally shaped auricle, with atresia or stenosis of the auditory canal. This study investigated a mutation of the cytochrome P450, family 26, subfamily A, polypeptide 1(CYP26A1) gene, which is considered important in craniofacial development, in a family affected with microtia. Whole-exome sequencing (WES) was performed on the proband and his family members to identify disease-associated variants. Computational predictions of the altered protein were analyzed using several bioinformatics tools. The wild-type (WT) and mutant forms of CYP26A1 cDNA were transfected into human embryonic kidney cells, and the mRNA and protein levels were compared using quantitative polymerase chain reaction (qPCR) and Western blot analyses. In this two-generation family, the proband and his mother were diagnosed with unilateral microtia. Unilateral microtia and ipsilateral accessory ear were observed in one of the twins, who were sisters of the proband. The father and the other twin showed no abnormal clinical features. A heterozygous mutation of a C to T in the CYP26A1 gene, which leads to truncation of the CYP26A1 protein, was identified in this family. The nonsense mutation cosegregated with patients and was absent in normal members of the family. The prediction software indicated that it was a possibly pathogenic mutation. The structure of the protein varied significantly between the WT and mutant proteins. Functional analysis showed that this mutation caused a significant decrease in both the mRNA and protein levels. Our findings suggest that this mutation of CYP26A1 may be a pathogenic factor leading to the phenotypes of microtia and accessory ear in this family. Further studies are needed to prove the function of this mutation and to explore the possible mechanism by which this variant is involved in the occurrence of microtia.

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Prevalence and causes of visual impairment among hearing impaired students in Lagos, Nigeria

Temiloluwa M. Abikoye, Olufisayo T. Aribaba, Kareem O. Musa, Oluwatobi O. Idowu

Publicatie 16-11-2020


To determine the prevalence and causes of visual impairment in hearing-impaired students in Lagos, Nigeria and to assess their level of ophthalmic care utilization. Descriptive cross sectional study carried out in a primary school for hearing impaired students in Lagos, Nigeria. Socio-demographic characteristics, medical and ocular history were obtained. Ocular examination comprised of distance and near visual acuity assessment; cover tests; anterior segment examination and direct fundoscopy. Visually impaired students had cycloplegic refraction, dilated fundoscopy and subjective refraction. In-depth interviews were carried out for parents of students requiring referral for further eye care. One hundred and nine students participated in the study. The prevalence of visual impairment was 19%. The causes of visual impairment were refractive error (11%), amblyopia (6%), cataract (1%) and macular scarring (1%). A lower mean age (p = 0.020) and ocular misalignment (p = 0.037) were associated with visual impairment on multivariate analysis. The spectacle correction coverage was 11% and only 8% of the students had prior ophthalmic care utilization. Ignorance of ocular morbidity and perceived inaccessibility of eye care were cited by parents/guardians as reasons for poor utilization of eye-care services. A high prevalence of visual impairment was found among the hearing impaired students; uncorrected refractive error and refractive amblyopia were the most prevalent causes. The level of prior ophthalmic service utilization was found to be low. It was recommended that ophthalmic services especially refractive services should be made available in schools for the hearing impaired.

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Understanding child anxiety before otoplasty: A qualitative study

Neetin Prabhu, Wyatt MacNevin, Margaret Wheelock, Paul Hong, Michael Bezuhly

Publicatie 14-11-2020


Pre-operative anxiety in pediatric patients is a major concern in surgical care due to the future medical and behavioral consequences that can occur. The objective of this study was to understand the factors that lead to pre-operative anxiety before otoplasty. Participants at a Canadian pediatric hospital were identified to discuss their experience with otoplasty and any anxiety they experienced using a semi-structured interview. Interviews were transcribed and analyzed using a qualitative semantic thematic approach. Major themes were identified and supporting quotes were extracted from the interviews. Ten participants were enrolled in the study. Three main themes (and seven subthemes) were identified: concern for post-operative well-being (perception by others, physical well-being, and negative experiences), fear of the unknown (surgical uncertainty, vulnerability), and support (family and friends, surgeon). Otoplasty was shown to be an emotional experience for participants with multiple sources of anxiety being identified. While most anxiety sources were similar to those for other pediatric surgeries, a number were specific to otoplasty and its post-operative care plan. This understanding of anxiety will allow physicians and care teams to better prepare patients and their families for otoplasty and enhance the patient's overall experience.

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A new dimension of success in the management of airway disease in children with neurological deficit

Vivianne Beatrix Christina Kokje, Maxime Mermod, Martina Bertinazzi, K. Sandu

Publicatie 10-11-2020


Anomalies of the larynx and trachea can cause respiratory distress in infants and older children. Depending on its nature, degree and extent of the disease invasive open surgery is indicated. Non-airway-related co-morbidities increase the challenges in its treatment. Neurological deficit poses a great challenge as it is associated with hypotonia and causes diminished laryngeal coordination. The definition of success in treatment of laryngotracheal disease has always focused on the post-operative functional outcomes: breathing, voice swallowing. The aim of this study is to describe a new dimension of success in the management of laryngotracheal disease in children with moderate neurological deficit, where the expected functional gain is less than in otherwise healthy children. This retrospective observational study includes all patients who have undergone open reconstructive airway surgery between 2012 and 2017. Control patients without neurological deficit and cases with moderate neurological deficit were included. Functional outcome data was obtained from clinical records and two questionnaires were filled in by the parents of the children: one the pediatric voice-handicap index (pVHI) and a quality of life questionnaire. Thirty-two children were included of which ten had moderate neurological deficit. Both groups revealed post-operatively an improvement in the functional outcomes: breathing, voice and swallowing, however, as expected, a trend was observed towards less functional improvement in children with neurological deficit. Both groups reveal a remarkable gain in quality of life (QoL). Indicating the QoL to be an unidentified, dimension of success in the management of laryngotracheal disease in children with moderate neurological deficit.

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Pediatric oropharyngeal microbiome: Mapping in chronic tonsillitis and tonsillar hypertrophy

Jacopo Galli, Lea Calò, Brunella Posteraro, Giorgia Rossi, Francesco Paroni Sterbini, Gaetano Paludetti, Maurizio Sanguinetti

Publicatie 08-11-2020


Aim of our study was to map the adenotonsillar lymphoid tissues' microbiome identifying its potential etiopathogenetic role in children affected by chronic tonsillitis or tonsillar hypertrophy with Obstructive Sleep Apnea Syndrome (OSAS). In our study, we examined tonsillar swabs from healthy children and children affected by chronic tonsillitis or by tonsillar hypertrophy with Obstructive Sleep Apnea Syndrome (OSAS). Microbiome's analysis was performed and bacterial 16Sr RNA gene was sequenced according to metagenomic principles. Variability was described according to the biodiversity concept, indicating species found in a certain environment and changes they undergo adapting to different environmental conditions. The most significant differences concern variation of microbes in a single sample (alpha diversity) of some phyla in children affected by chronic tonsillitis compared with alpha diversity in healthy children and in children affected by OSAS with tonsillar hyperplasia. Proteobacteria are prevalent in chronic tonsillitis group, Fusobacteria and Spirochete in OSAS and Firmicutes, Actinobacteria, and Bacteroidetes were found in healthy children. Finally, comparison between the groups showed that children with OSAS with tonsillar hypertrophy had a higher presence of the Fusobacterium genus. Recurrent upper airway inflammatory and/or infectious processes are polymicrobial; chronicity of such processes appear to be related to variations in microbiome's composition and interaction among various taxonomic units. Knowledge of the microbiomes' composition together with traditional clinical biomarkers can also determine relationships between oropharyngeal microbiome and systemic pathologies to determine preventive changes in lifestyle, eating habits, environmental exposure and use of probiotics.

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Outpatient Sistrunk procedure: A retrospective analysis

Christopher Pool, Mattie Rosi-Schumacher, Christopher Ehret, Tonya S. King, Meghan N Wilson

Publicatie 07-11-2020


The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a Sistrunk procedure via either same day surgery or overnight observation. A retrospective review of patients undergoing Sistrunk procedures between January 1, 2008 to January 1, 2019 was performed. 76 cases were identified for review. Bivariate and multivariable analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement. No patients had life-threatening adverse events. There was no difference in complication rates between same day discharge (17%) and overnight observation (23%, p = 0.47). Otolaryngologists were more likely to admit patients overnight (88% vs. 14%, p = 0.042) as well as place a drain (97% vs. 24%, p < 0.001) when compared to pediatric surgeons. Drain placement was associated with overnight observation (73% vs. 3%, p < 0.001). Multivariable logistic regression demonstrated drain placement (OR 21.9, 95%CI (2.5-189.7), p = 0.005) and otolaryngologist as operative surgeon (OR 11.7, 95%CI (2.8-48.2), p < 0.001) as strong predictive variables for overnight observation. There was no association between other investigated variables and adverse events or overnight stay. Same day Sistrunk operations are safe in select healthy patients. Overnight observation appears to be driven by drain placement and surgeon practice patterns.

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Change in body weight, body fat and body water in children after tonsilloadenoidectomy

Ivana Pajić Matić, Tomislav Stojadinović, Ivo Matić, Siniša Maslovara, Karolina Veselski

Publicatie 05-11-2020


To assess what was the cause of weight loss in children in early postoperative period after tonsilloadenoidectomy. Prospective study conducted at Department of ENT, Head and Neck Surgery, General Hospital "Dr. Josip Benčević" Slavonski Brod, Croatia. In total 31 patients aged 6-22 years that underwent tonsilloadenoidectomy. The study was performed using specially designed questionnaires from January 2017 until August 2017. Results of pain assessment and administrated analgesic therapy, postoperative complications and inception of eating were completed through the questionnaire. During the study, children were weighed before tonsilloadenoidectomy, 24 h after tonsilloadenoidectomy and the seventh postoperative day where age, height, weight, body fat, body mass index (BMI), muscle mass and body water were recorded. Weighing was performed by the "Body Structure Analyzer BC-420MA" TANITA. Data analysis revealed a significant reduction in mass, body fat, body mass index (BMI) and muscle mass in the children up to 10 years of age, as well as in the children that were 11 years and older. In children up to 10 years of age, there was no significant change in body water (%), while body water in the group of patients aged 11 and over was significantly higher on the seventh postoperative day (Friedman test, P = 0.02). In the total sample, there was a significant decrease in body weight, body fat (%), body mass index and muscle mass (Friedman test, P < 0.001), while there was a significant increase in body water (Friedman test, P = 0.003). There is no significant correlation between pain intensity and individual parameter change in all subjects, nor in age groups. Water is an important factor of muscle mass. It plays an essential role in musle repair and growth, since it's crucial for protein synthesis. Poorly hydrated muscle loses it's weight, since musle cells don't have enough water in themselves. Good hydratation, especially among children up to 10 years old in early post tonsilloadenoidectomy period is important to keep muscular mass and power.

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Airway emergency management in a pediatric hospital before and during the COVID-19 pandemic

Christopher S. Thom, Hitesh Deshmukh, Leane Soorikian, Ian Jacobs, John E. Fiadjoe, Janet Lioy

Publicatie 02-11-2020


Children's hospitals frequently care for infants with various life-threatening airway anomalies. Management of these infants can be challenging given unique airway anatomy and potential malformations. Airway emergency management must be immediate and precise, often demanding specialized equipment and/or expertise. We developed a Neonatal-Infant Emergency Airway Program to improve medical responses, communication, equipment usage and outcomes for all infants requiring emergent airway interventions in our neonatal and infant intensive care unit (NICU). All patients admitted to our quaternary NICU from 2008 to 2019 were included in this study. Our program consisted of a multidisciplinary airway response team, pager system, and emergency equipment cart. Respiratory therapists present at each emergency event recorded specialist response times, equipment utilization, and outcomes. A multidisciplinary oversite committee reviewed each incident. Since 2008, there were 159 airway emergency events in our NICU (~12 per year). Mean specialist response times decreased from 5.9 ± 4.9 min (2008-2012, mean ± SD) to 4.3 ± 2.2 min (2016-2019, p = 0.12), and the number of incidents with response times >5 min decreased from 28.8 ± 17.8% (2008-2012) to 9.3 ± 11.4% (2016-2019, p = 0.04 by linear regression). As our program became more standardized, we noted better equipment availability and subspecialist communication. Few emergency situations (n = 9, 6%) required operating room management. There were 3 patient deaths (2%). Our airway safety program, including readily available specialists and equipment, facilitated effective resolution of airway emergencies in our NICU and multidisciplinary involvement enabled rapid and effective changes in response to COVID-19 regulations. A similar program could be implemented in other centers.

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Rabbit model of consistently survivable subglottic stenosis using a modified brush technique

Justin Wilson, Edward Utz, Kastley Marvin, Isaac Schwartz, Christopher Johnson, Philip Gaudreau

Publicatie 02-11-2020


Several animal models of subglottic stenosis (SGS) have been described in the literature, however many result in severe stenosis that requires early intervention and carry a high mortality rate. This limits the application of the model and may require the use of additional animals to achieve desired results due to procedural complications. A novel endoscopic method of inducing SGS in a rabbit model was developed as part of a larger investigation on the treatment of this condition. The objective of this study was to develop an animal model for survivable subglottic stenosis. 12 New Zealand white rabbits underwent 2 trials of prolonged intubation that were not successful in inducing SGS. A partially sheathed nylon brush injury technique was then designed and implemented. Airway assessment consisted of rigid bronchoscopy 6 weeks and 8 months after injury. 12 rabbits undergoing subglottic brush injury had focal posteriorly based subglottic stenosis on bronchoscopy at 6 weeks and 8 months post-injury. One rabbit was euthanized after the brush induced subglottic injury but prior to 6 week bronchoscopy due to an unrelated orthopedic injury. This animal was therefore excluded from analysis and replaced. No rabbits required early airway intervention or sacrifice. All survived a period of 8 months. Inducing subglottic injury with a partially-sheathed nylon brush safely and reliably creates a controlled SGS with zero procedure-related mortality over 8 months. This model could be the basis for a longer-term evaluation of subglottic scar evolution and intervention.

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Inter-rater reliability in diagnosis and treatment of type one laryngeal cleft: A blinded observational study

Christopher Ian Newberry, Patrick Carpenter, Hilary McCrary, Geoff Casazza, Jonathan Skirko, Jeremy Meier

Publicatie 02-11-2020


Type one laryngeal cleft (T1LC) has been implicated as a major contributor to aspiration in non-syndromic pediatric dysphagia. Despite an increasing incidence, there remains controversy in diagnosis and treatment algorithms. The primary objective of this study was to evaluate the inter-rater reliability (IRR) for the diagnosis and treatment of T1LC. A retrospective analysis was conducted to identify children evaluated for a T1LC from 2016 to 2017 at a single tertiary care center. The microlaryngoscopy video recordings depicting palpation of the interarytenoid region with a right-angle probe were reviewed. These recordings were shown to blinded pediatric otolaryngologists and each surgeon's determination of the presence or absence of a T1LC as well as recommended treatment (observation, injection laryngoplasty, or endoscopic cleft repair) was recorded and compared against the other blinded surgeons. Fleiss's kappa was calculated to evaluate IRR in both diagnosis and treatment. Eight pediatric otolaryngologists were included in the study with a mean post-training experience of 15 years (range 1-35 years). The inter-rater percent agreement in diagnosis of our patient population was 28.6% (range 3.7-71%) with a kappa value of 0.31 (p < 0.0001). In regard to management, the inter-rater percent agreement in treatment was 11.4% (range 0-35%) with a kappa value of 0.14 (p = 0.01). This study highlights the challenges and variation that exists among surgeons in diagnosing and managing potential T1LC. Further standardizing the endoscopic examination and treatment algorithm may reduce diagnostic and treatment discordance.

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Risk assessment of postoperative pneumonia among children undergoing otolaryngologic surgery: Derivation and validation of a preoperative risk profiling

Olubukola O. Nafiu, Christian Mpody, Kris R. Jatana, Charles Elmaraghy, Joseph D. Tobias

Publicatie 29-10-2020


Postoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated. To identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified. Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups. Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3-28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53-15.48). We identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this "vital few". Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality. Not applicable.

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Development of Persian Lexical Neighborhood Tests

Mohammad Majid Oryadi-Zanjani, Ali Zamani

Publicatie 06-11-2020


Spoken word recognition (SWR) is a complicated process whereby through listening to a word or sentence we automatically connect each word's acoustic signal to its stored representations in the mental lexicon. We hypothesized that the children's performance on SWR would be influenced by the lexical difficulty and word length. The aim of the study was to develop the Persian Lexical Neighborhood Tests (PLNTs) as a lexically controlled toolkit based on the Neighborhood Activation Model to measure the SWR of Persian-speaking children. The research project was carried out in two phases (Weber and Scharenborg, 2012) [1]: development of the PLNTs (Luce and Pisoni, 1998) [2]; Using PLNTs in children with normal hearing. In Phase 1, to determine the lexical difficulty of words (easy, hard, and neutral), we calculated word frequencies and neighborhood densities for the words elicited from the 461 well documented language samples of Persian-speaking children aged 2-5 years old. Accordingly, four lexically controlled words subscales were generated by selecting appropriately easy and hard key words include: Persian Monosyllabic Lexical Neighborhood Test (PMLNT)-easy, PMLNT-hard, Persian Disyllabic Lexical Neighborhood Test (PDLNT)-easy, and PDLNT -hard. In Phase 2, The PLNTs were performed by sound field at different levels of signal to noise ratio (SNR) on twenty children with normal hearing between the ages of 6-12 year. The participants performed significantly better on SWR using the PLNTs consisting of easy words compared to the PLNTs consisting of hard words and using disyllabic words compared to monosyllabic words. Moreover, the participants' performance on SWR improved overall with increasing the SNR levels. The PLNTs is a lexically controlled assessment toolkit independent of vocabulary and language competency that can be used to measure the SWR performance in Persian-speaking children under spectrally degraded conditions.

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Repair of damage to the skin flap during total auricular reconstruction with tissue expansion

Wang Changchen, Lu Xiaosheng, Wei Bin, Yang Meirong, Zhang Ye, Pan Bo

Publicatie 30-10-2020


Auricular reconstruction with tissue expansion has been widely used in children with microtia. Base on the experience of using tissue expander, more patients have undergone a modified auricular reconstruction using a framework wrapped by expanded skin flap without fascial and skin graft transplantation. Skin damage is a common complication that may lead to serious outcomes, such as infection and distortion. Promptly repair is particularly important when using this modified technique. This work aims to record the site and other information on damage to the expanded skin flap, and to apply various salvage methods according to the site and stage. From January 2017 to September 2019, 170 patients who underwent total auricular reconstruction without fascial and skin graft were followed up. All patients who had skin damage received corresponding prompt treatment. Details on the site, occurrence time, and salvage methods were noted. A total of 19 patients were found to have skin damage during the follow-up period. The defect size ranged from 10 mm Skin damage is a common complication, and it should receive more attention while applying this modified auricular reconstruction using tissue expansion. The site, occurrence time, and other information provide reference to improve the reconstruction without fascial or skin graft transplantation. Salvage methods, such as retroauricular skin flap and retroauricular fascia, have been treated as highly efficient backup methods and have achieved satisfying results.

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Endoscopic management of pediatric extubation failure in the intensive care unit

Yupeng Liu, Wenjin Wu, Qi Huang

Publicatie 30-10-2020


This study investigated the endoscopic findings associated with pediatric extubation failure (EF) and evaluated the prognosis of endoscopic procedures. We retrospectively reviewed the data of children with EF in the intensive care unit from January 1, 2013 to December 31, 2019. Fifty-one children receiving endoscopic examination were enrolled in this study. EF was defined as the need for reintubation within 72 h of the first attempted extubation. Thirty-three children (65%) were successfully extubated after endoscopic procedures, and 18 children (35%) failed in extubation. There was a higher percentage of children transferred from other hospitals with intubation in the failure group (56% vs 12%, p = 0.002). Subglottic stenosis (SGS) (35%) and laryngeal and tracheal granulation (33%) were two of the most common findings. Fourteen patients (82%) with granulation were successfully extubated. Two children in the failure group were diagnosed with mitochondrial myopathies (chrM:3243) and congenital myasthenic syndrome (CHAT). The success rate in cases of SGS reached 83% (15/18). Five patients diagnosed with laryngomalacia and another 3 patients with tracheomalacia failed extubation after supraglottoplasty and needed a temporary tracheostomy. Granulation and subglottic stenosis were the leading causes of extubation failure. Patients transferred with intubation might have a poor prognosis after endoscopic procedures. Neuromuscular and metabolic disorders could be a hidden reason for extubation failure.

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The prevalence of swallowing dysfunction in children with laryngomalacia: a systematic review

Hussein Jaffal, Andre Isaac, Wendy Johannsen, Sandra Campbell, Hamdy G. El-Hakim

Publicatie 30-10-2020


Laryngomalacia (LM) is commonly diagnosed in infants and children with upper aerodigestive symptoms. In the literature, the focus has been on the respiratory impairment, with fewer studies addressing swallowing dysfunction (SwD). The objective of this study is to systematically review the literature for evidence on the prevalence of SwD in children diagnosed with LM. A search was conducted on the following databases: OVID Medline, Ovid EMBASE, EBSCO CINAHL, PROSPERO, and Cochrane Library. We included all the studies that reported on children with LM and documented objective swallowing assessment using fiberoptic endoscopic evaluation of swallowing (FEES) or videofluoroscopic swallowing study (VFSS). Two authors independently screened all the studies, assessed the level of evidence in the included studies, and extracted data. Risk of bias assessment and pooled data analysis were performed. The search yielded 512 abstracts. Four studies met the selection criteria representing 425 children. Three studies were retrospective uncontrolled case series and one was a prospective cohort study. In all studies but one, an instrumental assessment of swallowing was selectively performed in patients with clinical indicators of SwD. The pooled estimate (range) of prevalence of SwD was 49% (13.9-90.6%). The literature suggests a high prevalence of SwD in children with LM, however the level of evidence is low and generalizability is poor. The wide range of prevalence figures suggests a significant variability in the threshold and indications to assess swallowing in children with LM.

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Recurrent tonsillitis and parental perceptions of tonsillectomy during the COVID-19 pandemic

Elliot Heward, John Rocke, Nirmal Kumar, Steve Izzat

Publicatie 30-10-2020


The coronavirus outbreak has triggered the implementation of nationwide social distancing measures. We aimed to investigate the impact on patients with recurrent tonsillitis and parental perceptions towards tonsillectomy during the COVID-19 pandemic. A telephone questionnaire was conducted for all children awaiting tonsillectomy for recurrent tonsillitis after social distancing for 2 months at our centre. The COVID-19 lockdown period was compared with the 2 months prior to lockdown. Forty-four children had been social distancing at home during lockdown. There was a significant reduction in tonsillitis episodes during the 2-month lockdown period in comparison with 2 months prior to lockdown (p = 0.0001). In 70% (n = 31) of cases parents wanted their child's tonsillectomy during the coronavirus outbreak. These findings demonstrate that viral exposure is a key factor in the pathophysiology of recurrent tonsillitis and that social distancing measures can reduce the frequency of recurrent tonsillitis. Despite the overall reduction in tonsillitis frequency during the lockdown period, the majority of parents wanted their child's tonsillectomy during the coronavirus outbreak. This demonstrates the impact tonsillitis has on the patient and their family's quality of life.

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International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population

Jaime Doody, Ahmed Alkhateeb, Karthik Balakrishnan, Joshua Bedwell, John Carter, Sukgi S. Choi, Alan T. Cheng, Sam J. Daniel, John Dahl, Alessandro De Alarcon, Pierre Fayoux, Catherine K. Hart, Christopher Hartnick, Nico Jonas, Michael Kuo, Nikki Mills, Harlan Muntz, Richard Nicollas, Seth Pransky, Roger Nuss

Publicatie 30-10-2020


Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation. Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy. Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method. Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: CONCLUSION: This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

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Maturation of speech perception in noise abilities during adolescence

Jain Chandni, P.G. Vipin Ghosh, K.B. Chetak, Lakshmi Aishwarya

Publicatie 26-10-2020


Speech perception encompasses the perception of spectro-temporal cues. These cues include temporal envelope, temporal fine structure, and spectral shape of the signal. Extraction of these cues is essential for speech perception and, most importantly, for perceiving speech in the presence of noise (SPIN). Speech perception in noise scores improves with age in children and is crucial in their routine communications, including classroom learning. Though it is established that the speech perception in noise improves with age in children, the age at which SPIN scores become adult-like and the differences in the maturation pattern between the ears remains unclear. The present study aimed to assess and understand the maturation pattern of speech perception in noise abilities during adolescence. The study included 146 participants who were divided into six crossectional age groups. Participants were in the age range of 10-15 years and adults of 18-19 years. SPIN was assessed for right and left ears for each of these sub-groups. The scores were compared across the different subgroups for both the ears. Results demonstrated that SPIN scores in the right ear were matured by the age of 10 years and were comparable with the right ear SPIN scores in adults. Pairwise comparison using Bonferroni's corrections for multiple comparisons of left ear SPIN scores revealed that SPIN scores in the left ear become adult-like between 13 and 14 years of age. Findings of the current study can be attributed to the morphological changes and differences in the developmental changes across the different regions of the cortex.

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Non-accidental trauma presenting with nasal septal hematoma or abscess

S. Ghadersohi, C.R. Francom, J.D. Prager

Publicatie 23-10-2020


Failure to diagnose non-accidental trauma (NAT) leaves the victim at risk of further injury or even death. It is incumbent upon physicians and other health care personnel to identify trauma patterns that have a high likelihood of being caused by NAT. The objective of this study is to discuss the presentation of nasal septal hematoma (NSH) or nasal septal abscess (NSA) as a sign of NAT. This is a retrospective case series of patients presenting with nasal septal hematoma or abscess between 2010 and 2019. The primary endpoint was the etiology of the injury. Secondary endpoints included demographics, concomitant injuries and treatments rendered. There were 28 patients who presented with septal hematoma or abscess. The etiologies included 20 (71.4%) due to accidental trauma, four (13.8%) with NAT, one infectious, and three unknown. All four NAT patients were male and infants with an average age of 5.4 months (SD 4.6) significantly (p = 0.0069) younger than 10.3 years (SD 5.1) in the accidental trauma group. There was a delayed time to presentation for the NAT patients compared to other etiologies. Two of four NAT patients were initially thought to have a congenital midline nasal dermoid, yet surgical intervention revealed a hematoma. Further NAT evaluation noted concomitant injuries including rib fractures and intracranial injuries in 75% of the NAT patients. Presentation of a child with NSH/NSA prior to the onset of ambulation or with a delayed time to presentation should prompt suspicion and further workup for NAT.

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Changes in auditory function in premature children: A prospective cohort study

Irina V. Savenko, Ekaterina S. Garbaruk, Elena A. Krasovskaya

Publicatie 24-10-2020


To analyze the age-specific pattern of auditory function in preterm children as a function of their gestational age at birth. longitudinal cohort study. a prospective cohort study involved 271 preterm children aged from 6 months to 15 years old. Children were divided into two groups: 70 children with a gestational age at birth of 32-36 weeks (Group 1) and 201 children with a gestational age of 22-31 weeks (Group 2). Hearing was assessed by ABR, ASSR, OAE, behavioral audiometry, and pure tone audiometry. Additionally, for some children, CT, MRI, and GBJ2 evaluations were performed. Assessments of hearing impaired children were performed 3-4 times a year for children under 2 years of age; 2-3 times a year for children from 2 to 5 years of age; and 1-2 times a year for children over 5 years of age. Infants without any hearing problems were examined 2-3 times during their first year of life, followed by annual examinations as they aged. The initial hearing examination identified SNHL and ANSD in 18 children (25.7%) and 64 children (31.8%) in Group 1 and Group 2, respectively. No significant difference in the occurrence of auditory impairment in the two groups was found at the initial assessment (p > 0.05). Further long-term follow-up revealed changes in hearing in 16 children: 15 from Group 2 and only one child from Group 1. Four different kinds of hearing changes were noted: hearing recovery to normal levels in children with ANSD; late onset hearing loss; the transformation of ANSD to SNHL, and vice versa. The age, factors, and possible mechanisms of such changes are discussed in the article. The auditory function in prematurely born children tends to be unstable, especially at a very early age. In very preterm infants, it may either deteriorate or improve. Infants born before 31 weeks' gestation require long-term follow-up at least until they are 3-4 years of age. Caution is advised regarding very early cochlear implantation for children born before 32 weeks of gestation age.

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“The importance of preoperative evaluations prior to pediatric otorhinolaryngological surgery”

Beatriz Pallarés Martí, Natsuki Oishi, José Ramón Alba, Francisco Javier García Callejo, Enrique Zapater

Publicatie 24-10-2020


To describe the results of preoperative evaluations prior to pediatric surgery. We reviewed a total of 99 patients, with mean age of 6.53 + 2.39 years, an average of 11.04 months after their inclusion on the surgical treatment list. These patients were obtained from General University Hospital of Valencia surgery waiting list between October 2015 and July 2016. We have reassessed all the patients before their surgery date and analyzed the results: the indication had changed or not. In the case of indication changed, the outcome was subdivided into: extension, reduction, or surgery no indicated because a clinical resolution. After waiting on the list for surgery for an average of 11 months, the initial surgical indication had changed in 52 patients (52%), this groups was subdivided into: 33 patients (33%) had spontaneously resolved by the time of their reassessment and their clinical symptoms no longer met the criteria for surgery, the indication for surgery was extended in 10 patients (10%) and was reduced another 9 patients (9%). We found a statistically significantrelationship (p = 0.034) between the age of the patients at the time of the preoperative re- evaluation and modifications made to the initial surgery indication. Our results show the dynamic evolution of benign Waldeyer-ring related pathologies in the pediatric population due to physical growth and immune development. The clinical evaluation prior to benign pediatric surgery is recommended In specially in the group over 5 years.

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Revision cochlear implantation using a double array device in the post-meningitis ossified cochlea

Chanan Shaul, J.Thomas Roland, Jean-Yves Sichel, Riki Salem, Ronen Perez

Publicatie 23-10-2020


To describe the surgical technique and outcome in a series of patients who underwent revision cochlear implantation using a double array or split electrode device. All patients developed ossified cochleae due to meningitis and were functioning poorly with the previous implant. Four patients between the ages of 4-15 years underwent revision with five double-array cochlear implant devices. One patient underwent bilateral revision surgery. All patients had previous meningitis with CT and MRI imaging studies that demonstrated completely ossified cochleae. The time interval range between the disease and the initial cochlear implantation and was 4 months to 3 years. The patient's data were retrospectively analyzed with emphasis on the surgical technique, the number of electrodes inserted, and the number of active electrodes at follow-up. In addition, pre and post-revision surgery function was compared. The revision surgery was carried out 2-11 years after the initial surgery. Two tunnels, basal and apical, were drilled in the ossified cochlea. In each of the tunnels, 5 to 11 electrodes were inserted. While the number of active electrodes before revision was 0-5, after revision with the double array, it was increased to 8-12, resulting in improved auditory and speech function. Revision cochlear implantation with a double array implant using the two tunnel technique can increase the number of active electrodes. This leads to a better outcome in post-meningitis children with completely ossified cochleae and a poor functioning previous device.

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Systematic review of endoscopic-assisted surgical management for congenital nasolacrimal duct obstruction

Skylar Trott, Nicole Colgrove, Philip Westgate, Matthew Bush, Kenneth Iverson

Publicatie 23-10-2020


Epiphora is a common presenting complaint in infants affecting up to 6% of infants in the United States. It is most frequently due to congenital anomalies of the nasolacrimal duct system, termed congenital nasolacrimal duct obstruction (CNLDO). Nasolacrimal duct probing is widely accepted as the primary surgical intervention in cases that fail conservative management. Recently, nasal endoscopy has been combined with traditional probing to improve success rates and outcomes. Several studies have been conducted, but the results have been inconclusive overall. The goal of this systematic review is to examine the existing literature on the role of nasal endoscopy during nasolacrimal duct probing and evaluate patient outcomes. A systematic search was performed in PubMed, MEDLINE, The Cochrane Library, ClinicalTrials.gov, LILAC, and EMBASE to identify peer-reviewed research. Eligible studies were those containing original peer-reviewed research in English addressing nasolacrimal duct probing for congenital nasolacrimal duct obstruction in conjunction with nasal endoscopy. Two investigators independently reviewed all articles and extracted data. Bias was assessed using the Cochrane Collaboration's tool, the Newcastle-Ottawa Assessment scale, and the NIH Quality Assessment scale. A literature review ultimately yielded 11 articles that were selected and included in our analysis. Of the seven case series, the success rate was 92.5% for a total of 492 eyes. Of the four cohort/case-control studies, the success rate in conventional probings was 75.3% for a total of 293 eyes. In probings with nasal endoscopy, the success rate was 95.3% for 162 eyes. Overall, there was a high risk of bias and variation in data reporting amongst studies. Infants with congenital nasolacrimal duct obstruction that does not resolve with conservative treatment often require surgical intervention. Based on this systematic review of the current literature, nasal endoscopy is a useful adjunct for nasolacrimal duct probing.

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Rapid telemedicine implementation in the context of the COVID-19 pandemic in an academic pediatric otolaryngology practice

Nandini Govil, Nikhila Raol, Ching Siong Tey, Steven L. Goudy, Kristan P. Alfonso

Publicatie 21-10-2020


To describe the implementation of telemedicine in a pediatric otolaryngology practice during the coronavirus disease 2019 (COVID-19) global pandemic. A descriptive paper documenting the development and application of telemedicine in a tertiary academic pediatric otolaryngology practice. A total of 51 established patients were seen via telemedicine within the first 2 weeks of telemedicine implementation. Seven (7) patients were no shows to the appointment. The median patient age was 5 years old, with 55% male patients. Common diagnoses for the visits included sleep disordered breathing/obstructive sleep apnea (25%) and hearing loss (19.64%). Over half (50.98%) of visits were billed at level 4 visit code. The majority (88%) of visits during the first 2 weeks of telemedicine implementation in our practice were completed successfully. Reasons that patients did not schedule telemedicine appointments included preference for in person appointments, and lack of adequate device at home to complete telemedicine visit. Limitations to our telemedicine practice included offering telemedicine only to patients who had home internet service, were established patients, and English-speaking. Trainees were not involved in this initial implementation of telemedicine. COVID-19 has driven the rapid adoption of telemedicine in outpatient medicine. Our group was able to institute an effective telemedicine practice during this time.

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Mismatch Negativity in children with Phonological Disorders

Amália El Hatal de Souza, Julia Dalcin Pinto, Carolina Lisboa Mezommo, Eliara Pinto Vieira Biaggio

Publicatie 21-10-2020


to characterize the latency, amplitude and area variables of the Mismatch Negativity (MMN) elicited with verbal stimuli in children with PD, in addition to assessing whether this potential can be a useful tool in capturing auditory perception and discrimination deficits related to this disorder. MMN was recorded using a combination of speech contrast consisting of acoustic syllables [da vs ta], as the standard and deviant stimuli, in 34 children aged between 5 and 8 years. 14 children of the sample were already diagnosed with Phonological Disorder (PD) while 19 were characterized with typical development. No statistically significant differences were observed for the MMN responses recorded between children with PD and their typically developed peers. The results suggest that the MMN may not be the most suitable procedure to assess auditory perception and discrimination deficits that could potentially be related to PD.

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Comparisons of performance in pediatric bone conduction implant recipients using remote microphone technology

Hillary Snapp, Kari Morgenstein, Chrisanda Sanchez, Jennifer Coto, Ivette Cejas

Publicatie 19-10-2020


For children with hearing loss, remote microphone (RM) technology can significantly improve access to speech in environments with poor signal-to-noise ratios (SNRs), such as classrooms. Yet, this has never been studied in bone conduction device (BCD) users, a common treatment for children with irresolvable conductive hearing loss resulting from anatomical malformations of the outer ear. The objective of this study was to investigate the benefits of RM technology on speech perception in noise in pediatric BCD users with Microtia/Atresia. A secondary aim was to assess parent and child perceptions of RM technology before and after exposure to RM technology. Participants included 10 pediatric bone conduction implant users with unilateral conductive hearing loss ages 7-17 years, and their guardians. Speech perception in noise for soft and moderate inputs was assessed with and without RM technology. Guardians actively observed the child's hearing performance with and without the RM and were asked to complete a questionnaire assessing their perceptions about their child's performance. Children were also administered the questionnaire prior to and immediately following exposure to the RM technology. Participants showed improved speech understanding in noise for both soft and moderate speech inputs when using the RM with their BCD compared to their BCD alone. Questionnaire results indicated good parent-child agreement. Further, significant improvements were reported for child understanding speech, parent hearing domains after exposure to the RM. No significant differences were noted for ease of use/likability. Significant hearing in noise benefits were observed with RM technology for children using BCDs. Consistent with objective findings, children reported improved speech understanding with the RM. Improved parental perceptions of hearing benefit following exposure to the RM suggests that active participation may serve as an effective strategy to help improve parent understanding of the benefits of RM technology for their child.

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The influence of oral language environment on auditory development

Thaís Regina Monteiro, Caroline Nunes Rocha-Muniz, Renata Filippini, Aline Albuquerque Morais, Eliane Schochat

Publicatie 09-11-2020


The purpose of this study was to compare the auditory processing of hearing children who were immersed in an oral language environment during early childhood with that of children who were poorly exposed to oral language during the same period. Sixty children aged between 5 and 10 years participated in this study. They were divided in two groups. Group 1 comprised of 30 children who had deaf signer parents, and Group 2 comprised of 30 children who had hearing parents. These children underwent the following auditory processing tests: Pediatric Speech Intelligibility, Dichotic Digits, Pitch Pattern Sequence, Gaps-in-Noise, and Memory Tests for Instrumental and Verbal sounds. Group 1 had significantly poorer performance than that of Group 2 in all tests. In addition, an analysis by age range revealed that the differences between groups were more pronounced in younger children (5-6 years). The results indicate that the development of auditory skills is strongly influenced by access to oral linguistic sounds. Thus, a child's exposure to an oral language environment from birth is important to the adequate development of the auditory system functions.

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The concatenation of association between gastroesophageal reflux and obstructive adenotonsillar hypertrophy

Milind Sagar, Prem Sagar, S.K. Kabra, Rajeev Kumar, Saumyaranjan Mallick

Publicatie 18-10-2020


Gastroesophageal reflux (GER) is frequently seen in patients with adenotonsillar hypertrophy. However, the sequential association between GER and adenotonsillar hypertrophy is unknown. This leads to unpredictable outcomes while treating patients of adenotonsillar hypertrophy with GER. The objective of this study is to evaluate the prevalence of GER and gastroesophageal reflux disease (GERD) in paediatric patients with obstructive adenotonsillar hypertrophy (OATH), and to assess the effect of adenotonsillectomy (AT) on GER as well as GERD. In this prospective cohort study, consecutive pediatric patients with grade III/IV hypertrophy of adenoid or/and tonsillar tissue who were planned for AT were recruited after excluding comorbidities predisposing to GER. Symptoms of GERD using Gastro Esophageal Reflux Questionnaire for Young Children (GERQ-YC) and Reflux Indices (RI) obtained from 24-h ambulatory esophageal pH monitoring were evaluated in all patients pre-operatively and 12 weeks following AT. A total of 49 patients with OATH with average age of 6 years were included in this study. With a RI of >4.3% as the threshold for making the diagnosis of GER on esophageal pH monitoring, the prevalence of GER was 20.4%. The average RI preoperatively was 15.7% which reduced to 1.7% following AT (p = 0.004). Among the 10 patients with preoperative GER, 80% of the patients had no evidence of GER after surgery. New incidences of GER was not observed post operatively in this cohort. As per the GER symptom scoring system, 31% of the parents reported GERD pre-operatively which resolved completely in all patients following surgery. - In this study, the prevalence of GER proven by 24 h ambulatory esophageal pH monitoring is 20% in pediatric patients with OATH. Following AT, GER resolved in 80% of cases and was reduced substantially in the remaining cases in the subset of patients with pre-operative GER. The symptoms of GERD based on parents' recall of child's previous symptoms may not accurately represent presence of GER. Our results suggest that OATH can result in GER due to increased negative intra-thoracic pressure as a result of breathing against an obstructed upper airway and hence, GER subsides following surgical removal of the obstructive pathology. To establish this concatenational association of OATH and GER, larger studies are mandated.

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Yield of preoperative findings in pediatric airway foreign bodies - A meta-analysis

Gil Zoizner-Agar, Sabah Merchant, Binhuan Wang, Max M. April

Publicatie 18-10-2020


Foreign body (FB) aspiration into the airway is a significant cause of pediatric morbidity and mortality, yet the clinical presentation is diverse and dynamic. There are conflicting recommendations which pre-procedural findings support performing a bronchoscopy, the gold standard for diagnosis and removal of FBs, however a procedure that entails general anesthesia and possible risks. Decision whether to proceed to a bronchoscopy may be challenging. Our goal was to enhance decision-making by analyzing the diagnostic values of the different pre-procedural findings in this setting. A comprehensive search was performed in PUBMED, EMBASE and Cochrane Review databases to find studies from the last 19 years that reported pre-procedural history, physical examination and radiological findings in patients who had bronchoscopies. Studies were included of pediatric populations if they contained bronchoscopy results (positive and negative for foreign body) with a breakdown according to pre-intervention findings. Titles and abstracts retrieved from our search were screened. Thereafter, full-texts were carefully reviewed and selected for inclusion if the aforementioned criteria were met. PRISMA guidelines for systematic review and meta-analyses were followed. Cumulative weighted prevalence, sensitivity, specificity, positive and negative predictive values of each pre-procedural finding were calculated, as well as for the "classic triad" (history of an acute event, wheezing, and unilateral decreased breath sounds). Calculation for other combinations of findings, or optimally, constructing a weighted score based on all the findings for each specific patient were not possible to perform, as the specific data breakdown is rarely reported. Fifteen studies met inclusion criteria, totaling 5606 patients who underwent bronchoscopies. All studies but one were single center based and all except one were retrospective. No single finding has both positive and negative predictive values over 50%. The "classic triad" has 90% specificity, however only 35% sensitivity. The data is very heterogeneous with regard to pre-procedural findings and how best to guide treatment according to them. This meta-analysis provides cumulative weighted metrics for each finding, to optimize decision-making for the individual patient. Future reporting of data should be enhanced, so that combinations of findings for a specific patient can be used to optimize management. 4.

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Quality indicators for the diagnosis and management of pediatric tonsillitis

Justin Cottrell, Jonathan Yip, Paolo Campisi, Neil K. Chadha, Ali Damji, Paul Hong, Sophie Lachance, Darren Leitao, Lily HP. Nguyen, Natasha Saunders, Julie Strychowsky, Warren Yunker, Jean-Philippe Vaccani, Yvonne Chan, John R. de Almeida, Antoine Eskander, Ian J. Witterick, Eric Monteiro

Publicatie 30-10-2020


Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

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Severe tracheobronchial harm due to lithium button battery aspiration: An in vitro study of the pathomechanism and injury pattern

Johannes Voelker, Christine Voelker, Jonas Engert, Philipp Schendzielorz, Rudolf Hagen, Kristen Rak

Publicatie 15-10-2020


Button battery incidents have become a rising medical issue in recent years, especially for infants. The increasing number of these cases can be explained by the expanding use of objects of everyday life and toys. As a result, button batteries in many households are ubiquitous in different states of charge. The extremely long shelf-life and the increasing energy densities of lithium button batteries boost the potential medical complications of accidental swallowing. The study aimed to analyze the pathophysiology of damage to tracheobronchial structures by button batteries aspiration over time. CR2032 and CR927 lithium button batteries (3.2/3.0 V) were exposed to porcine trachea preparations intraluminal at 37 °C in intervals up to 36 h. Measurements were made of the voltage curve, the discharge current, and the resulting pH values around the electrodes. The effects on tissue were examined using macroscopic time-lapse images and microscopic pictures of sections of the fixed specimens over time. The examinations showed a tissue electrolysis reaction directly after the beginning of battery exposure, which led to an immediate coagulation impairment of the respiratory epithelium. Over time, a strongly alkaline environment was established around the batteries. The resulting tissue colliquation caused profound tissue damage beyond the basal membrane of the mucosa, affecting the tracheobronchial cartilage after only 4 h of exposure time. After 12 h, there was significant necrosis of the annular ligaments of the trachea and the peribronchial pulmonary tissue. After completion of the experimental exposure time of 36 h, there was still a sufficient residual voltage on all button batteries of the experiments. Besides accidental ingestion, the aspiration of button batteries is a life-threatening situation. The partial or complete acute airway obstruction in the trachea or the bronchi initially is the leading symptom, as with any foreign body aspiration. However, the results of the investigations show that even after a short exposure time, relevant tissue damage can be caused by the electrolysis reaction of the battery. After 12 h, a profound destruction of cartilage, connective tissue, and smooth muscles was observed in vitro, which may cause significant consequential damage in vivo. These findings reveal the need for rapid diagnosis and immediate foreign body removal after any battery ingestion. Moreover, the results show how relevant prevention of these accidents is, and that future safety modifications of these types of battery by the manufacturers would be appropriate.

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Congenital nasolacrimal duct obstruction update study (CUP study): Paper II - Profile and outcomes of complex CNLDO and masquerades

Oshin Bansal, Nandini Bothra, Abhimanyu Sharma, Mohammad Javed Ali

Publicatie 18-10-2020


To assess the profiles and outcomes of complex congenital nasolacrimal duct obstruction (C-CNLDO). Retrospective interventional case-series was performed on patients diagnosed with C-CNLDO and managed at a tertiary care Dacryology Institute from Jan 2016 to June 2019. Complex CNLDO was diagnosed based on intraoperative findings during probing and are defined as entities where CNLDO is secondary to, or associated with complex embryonic entities like buried probe, mal-development or non-development of bony NLD, additional proximal lacrimal dysgenesis, atonic sac, or associated craniofacial syndromes and craniofacial dysostosis. The parameters studied include patient demographics, clinical presentation, types of C-CNLDO, management modalities, and outcomes. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test. For patients who underwent a dacryocystorhinostomy (DCR), a minimum follow-up of 1-year post-DCR was considered for outcome analysis. Of the 2714 cases of CNLDO managed during this period, 482 (17.75%) were diagnosed as complex CNLDO. C-CNLDO showed predilection to the male gender (60.3%, 291/482). A significant number of patients (40.2%, 194/482) presented beyond 36 months of age. The common subtypes of C-CNLDO were atonic sacs (33.8%, 163/482), buried probes (19.7%, 95/482), and associated proximal lacrimal drainage anomalies (11.2%, 54/482). Since C-CNLDO is usually confirmed during the initial endoscopy-guided probing, the managements varied based on the type of C-CNLDO. Silicone intubation and/or balloon dacryoplasty (BDCP), and/or additional minimally invasive procedures were added to the initial endoscopy-guided irrigation and probing based on the nature of C-CNLDO. The overall resolution rate with these non-bypass modalities was 72.6% (350/482). Although the success rates start dropping in C-CNLDO patients beyond 3-years of age, significant success rates with multi-modal (non-bypass) management were noted in age-groups 3-5 years (71.8%, 79/110) and encouraging results (38.5%, 27/70) in 5-10 years age group. The anatomical and functional outcomes in those who underwent endoscopic or external dacryocystorhinostomy with a follow-up beyond 1-year was 96.4% (55/57). The age at presentation is delayed in patients with C-CNLDO. Multi-modal endoscopy-guided management facilitates the identification of several sub-types of C-CNLDO, and achieves significantly high favourable outcomes in older children. C-CNLDO refractory to probing, intubation and BDCP demonstrates high success with external or endoscopic dacryocystorhinostomy.

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Pediatric head and neck rhabdomyosarcoma: An analysis of treatment and survival in the United States (1975–2016)

Christina Darwish, Timothy Shim, Andrew D. Sparks, Yeshwant Chillakuru, David Strum, Daniel A. Benito, Ashkan Monfared

Publicatie 14-10-2020


Rhabdomyosarcoma (RMS) is the most common soft tissue head and neck sarcoma in children. Stringent analysis of survival data is imperative to optimize treatment. The National Cancer Database (NCDB, 2004-2016) and the Surveillance, Epidemiology, and End Results Program (SEER, 1975-2016) were queried for patients ages 0-19 with RMS of the head and neck. Survival trends were analyzed using univariable logistic regression and Chi-square pairwise comparisons. Survival by treatment was analyzed using log-rank tests, Kaplan Meier, and multivariable Cox-proportional hazards regression. 1147 (63.3% age <10 years, 54.3% male) and 459 (71.4% age <10 years, 53.6% male) patients were identified in NCDB and SEER, respectively. In NCDB, embryonal (n = 625, 54.5%) and alveolar (n = 300, 26.2%) were the most common histology and nonparameningeal/non-orbital (n = 634, 55.3%), followed by parameningeal (n = 303, 26.4%) and orbital (n = 210, 18.3%) the most common location. Five-year overall survival (OS) was 70.3% with lower mortality risk for embryonal histology (adjusted HR [aHR] = 0.69, p = 0.0038). Orbital tumors had greatest survival (5-year OS = 92.4%) of all sites, and their mortality risk was higher with chemotherapy and radiation compared to surgery and radiation (aHR = 6.27, p = 0.0302). SEER analysis showed average increased survival by 4% per year (p < 0.0001), but no significant 5-year OS difference when comparing 1976-1980 and 2006-2010 (p = 0.0843). Major prognostic factors for survival in childhood RMS of the head and neck were embryonal histology, orbital site, extent of disease, and use of SRT for orbital tumors. Larger population studies are required to demonstrate survival differences between treatment modalities for other sites.

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Eosinophilic esophagitis with and without airway involvement in children – A comparative analysis

Varun Bora, Anthony Olive, Eric Chiou, Priya Raj, Deepak Mehta

Publicatie 14-10-2020


Eosinophilic esophagitis (EoE) is an allergic disease characterized by marked eosinophilic infiltration and inflammation of the esophagus eventually leading to esophageal dysfunction. This condition at times may involve the airway leading to breathing difficulties. To compare the course of EoE in patients with or without airway involvement. A retrospective chart review was done on patients with a diagnosis of Eosinophilic Esophagitis and that were managed in our Aerodigestive clinic from 2012 to 2018. A total of 121 EoE patients were included in the study. Each patient's disease course was examined for pertinent information including - but not limited to - age at presentation, allergies, endoscopic and pathology results, treatments prescribed, and time to resolution. The data was analyzed for any differences between the airway and non-airway groups for each of these variables. The variables that were analyzed showed no significant difference between patients suffering from EoE with (n = 19) and without (n = 102) airway involvement. However, patients with airway disease trended towards being younger in age at presentation as compared to those without airway symptoms (6.68 years vs. 9.69 years, p = 0.69). Analysis of endoscopic and pathology findings revealed no difference. Similarly, no differences were found between the prescribed treatments. Kaplan-Meier estimates of time to disease remission indicated that 50% of patients had resolution at one year, regardless of airway involvement (p = 0.31). Our findings indicate that the disease course of patients with EoE does not vary depending on the presence of airway symptoms. Thus, patients with airway symptoms should not be diagnosed or treated any different than those without airway symptoms.

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Patterns of pediatric cervical spine fractures in association with mandibular and facial fractures

Jonathan A. Harounian, Garrett Ni, Michele M. Carr

Publicatie 14-10-2020


To determine the incidence, demographics, and outcomes of concurrent cervical spine (C-spine) fractures in pediatric facial trauma. The Kids' Inpatient Database (KID) from the 2016 Healthcare Cost Utilization Project (HCUP) was queried for various facial fractures using International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes. Mandible fractures were further subdivided into fracture site. Patients aged 0-18 were included, and rates of C-spine fracture were analyzed with regards to demographic factors, length of stay, total charges, mortality rate, hospital characteristics, and concurrent facial fractures. Of 5568 patients included, 4.18% presented with C-spine fracture. Children with C-spine fractures were significantly older (15.02 vs 12.76 years, p < 0.001) and length of stay was significantly longer (11.33 vs 6.44 days, p < 0.001). There was no difference in rate of C-spine fracture when stratified by gender, time of week/year, hospital location/type, or facial fracture other than subcondylar fractures. Subcondylar fractures were positively associated with C-spine fractures (OR 2.08, p = 0.002). C-spine fractures were associated with significantly higher mortality, length of stay, rate of tracheostomy, transfer out of index hospital, and total hospital charges. A significant association exists between subcondylar mandible and C-spine fractures. Awareness of this information is vital for clinicians who manage pediatric facial trauma and alerts them to the need to rule out C-spine fractures in this group as these patients have significantly higher lengths of stay, total mean hospital costs, mortality and tracheostomy rates.

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Systematic review of rigid and flexible esophagoscopy for pediatric esophageal foreign bodies

Weining Yang, Daniel Milad, Nikolaus E. Wolter, Evan J. Propst, Yvonne Chan

Publicatie 12-10-2020


Esophageal foreign body (EFB) is a common presentation in pediatric hospitals. Rigid and flexible esophagoscopy are both primary modalities used for EFB removal. By systematically reviewing the literature, we sought to assess success and complication rates of both rigid and flexible esophagoscopy in pediatric EFB retrieval. A systematic search of the literature was performed in MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, CINAHL. Two authors independently reviewed 74 abstracts and included studies that documented success rates of flexible and rigid esophagoscopy for EFB retrieval. The certainty and quality of the overall body of evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development and Evaluation approach. Five retrospective chart reviews published between 1993 and 2016 identified 955 patients with a mean age of 4.2 (range 3.2-5.3 years). Foreign bodies were localized to the upper esophagus in 69.6%, middle esophagus in 13.0% and lower esophagus in 11.5%. Coins (82.1%) and food boluses (8.5%) comprised the majority of EFB. The success rate of foreign body retrieval was 95.4% with rigid esophagoscopy and 97.4% with flexible esophagoscopy. Complication rates were 2.4% for rigid esophagoscopy and 3.4% for flexible esophagoscopy. Rates of successful foreign body retrieval (odds ratio [OR] = 1.9 [95% CI 0.9-3.8; p = 0.07]) and complications (OR = 0.9 [95% CI 0.3-2.3; p = 0.79]) were not significantly different across modalities. There were no mortalities in any of the studies analyzed. Flexible and rigid esophagoscopy are equally safe and effective for the retrieval of EFB in children. Otolaryngologists, gastroenterologists, and pediatric general surgeons can be consulted for foreign body retrieval depending on institutional policies and resource availability.

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Nasal function and cardio-respiratory capacity of adolescent with external nasal dilator

Carlos Henrique Santos Ferreira, Ricardo Reis Dinardi, Cássio da Cunha Ibiapina, Cláudia Ribeiro de Andrade

Publicatie 12-10-2020


the external nasal dilator (END) has been employed for the purpose of aiding sporting performance. The objective of this study was to evaluate nasal function and cardio-respiratory capacity in healthy adolescent athletes using the END. double-blind, crossover clinical trial in which adolescents were evaluated while using the experimental and placebo END during physical exercise. Values for peak nasal inspiratory flow (PNIF), nasal resistance (NR) and maximal oxygen uptake (VO for the 71 adolescents evaluated, the use of the experimental END, compared to the placebo, produced a significant improvement in values of PNIF (177.4 ± 20.9 L/min and 172.8 ± 20.2 L/min) (p = 0.020), NR (0.24 ± 0.16 and 0.27 ± 0.16) (p = 0.007), VO the END reduced NR, increased PNIF and improved VO

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Usefulness and practical insights of the pediatric video head impulse test

Kyu-Sung Kim, Yoon Kun Jung, Ki Jong Hyun, Min Ji Kim, Hyun Ji Kim

Publicatie 12-10-2020


The video head impulse test (vHIT) is a diagnostic tool to examine patients experiencing dizziness by assessing the function of the semicircular canals. vHIT has been widely studied in adults but relatively less so in children. The aim of this study was to evaluate the causes of dizziness and the results of vHIT in children. We also identified factors that affect the vHIT results such as artifacts and technical errors. Retrospective review; SETTING: Tertiary care center. A total of 39 patients who visited our clinic for dizziness from 2014 to 2017. The gain of vestibulo-ocular reflex, refixation saccades, and artifacts were analyzed using vHIT. We analyzed 691 individual vHIT traces and categorized the artifacts into 8 categories. Twenty-three males and 16 females were included. The mean age was 13.84 ± 2.60 years (range, 7-18). Common causes of dizziness were benign paroxysmal vertigo of childhood (25.6%), vestibular neuritis (20.5%), and vestibular migraine (17.9%). The sensitivity and specificity of vHIT based on the bithermal caloric test results were 40% and 94%, respectively. The analysis of vHIT traces revealed that the children had higher artifact ratios of vHIT than the adults. The main artifacts were high gain and blinking eyes. The vHIT results showed a higher percentage of artifacts in children than in the adults. More careful efforts are required to obtain more accurate results during the test, and it is necessary to check for technical errors while interpreting the results.

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"Pediatric nasal dermoid- a decades experience from a South Indian tertiary care centre"

P. Naina, G.E. Jonathan, M. Prabhakar, A. Irodi, K.A. Syed, M. John, A.M. Varghese

Publicatie 10-10-2020


Nasal dermoid sinus cyst (NDSC) are uncommon congenital lesions in children. To review the clinical and radiological presentation and study the surgical outcomes of this uncommon lesion. Retrospective chart review of all children diagnosed with nasal dermoid from 2010 to 2020 at a tertiary referral hospital in South India was executed. The medical records were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes and literature review was performed. A total of 25 children [Mean age 3.7 yrs (Range 2-9 yrs)] with nasal dermoid sinus cysts were treated in the last decade. While 13 presented with a sinus, 11 presented with cyst and 1 had both. The lesions mainly involved the upper third of the nose in 10 children, middle one third in 6 and upper one third in 9 children. All underwent Magnetic Resonance Imaging, in 11 Computed Tomography also was done. A flow chart of the lesion characteristics and its management has been presented. Intraoperatively intracranial extension was present in four children. The approach to intracranial extension and corresponding literature review has been presented. Follow up ranged from one to six years. (Median 3.5 yrs) and no recurrence or complication was noted. Nasal dermoid is an uncommon congenital anomaly. Preoperative evaluation must include imaging to assess extent and rule out intracranial extension. Surgical strategy depends on whether presentation is as sinus or cyst and location and extent of lesion. All surgical approaches have a good surgical and cosmetic outcome.

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Radiological evidence to changes in the olfactory bulb volume depending on body mass index in the childhood

Murat Karaoglan, Hale Colakoglu Er

Publicatie 10-10-2020


Energy balance is preserved through the exchange between body weight and adipose tissue across the multi-faceted complex network that is composed of the sensorial, metabolic, and neuro-endocrine circuits. The olfactory control of energy homeostasis is maintained through the interplay between the olfactory bulb (OB) and adipose tissue. While extremely studied, most researches still report controversial results and sensorial regulation of obesity is not fully understood. This study aims to investigate the interplay between olfactory bulb volume (OBV) as a radiological clue of sensorial control and obesity in children. Children (n = 195) were classified into four groups based on body mass index (BMI) percentiles: normal weight (n = 89), overweight (n = 31), obese (n = 32) and morbidly obese (n = 43). OBV were calculated using MRI. Mean OBV was higher in children with obesity than in those of normal weights. The means of OBV are found higher in the overweight and obese children (43.76 ± 9.50-49.29 ± 8.61 mm This study reveals that OBV is higher in obese children. Also, it shows that there is a positive correlation between OBV and BMI in overweight and obese children and a negative correlation in the morbidly obese group. These radiological bimodal changes in OBV indicate that olfactory control acts to provide energy balance, mediated by positive in the overweight and obese children, negative feedback in the morbidly obese group.

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Effect of delivery mode on neonate auditory brainstem responses to air- and bone-conducted stimuli

Andrew Stuart

Publicatie 10-10-2020


The object of this study was to examine if caesarean section delivered neonates have different middle ear function relative to neonates with vaginal delivery. Auditory brainstem responses (ABRs) were examined in caesarean section delivered (n = 23) and vaginally delivered (n = 29) neonates. ABRs were also evoked with air- and bone-conducted stimuli (i.e., clicks and CE-Chirps) and presented at a screening intensity level (i.e., 30 dB nHL). Wave V latencies and amplitudes were examined as a function of mode of delivery and stimuli. Statistically significant longer wave V latencies evoked with air-conducted stimuli were seen in caesarean section delivered neonates (p = .042). There was no statistically significant difference in wave V latencies with bone-conducted stimuli among the two groups of neonates (p = .42). There were no significant differences in wave V amplitude between neonates with caesarean section and vaginal delivery for air-conducted (p = .42) stimuli. Wave V amplitudes were not significantly different as a function of mode of delivery with CE-Chirp stimulus (p = .41). Wave V amplitudes were significantly larger for the caesarean section delivered neonates with the bone-conducted click stimulus (p = .036). The ABR wave V latency disparity with air- and bone-conducted stimuli support the notion that differences in middle ear function exist between the two groups of newborns. It was speculated that delayed fluid resorption in the middle ear exists in neonates with caesarean section delivery compared to those with vaginal delivery.

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Anthropometry: A clue for Otorhinolaryngology surgical indications in children

Francisco Alves de Sousa, Afonso Domingos Castro, André Sousa Machado, Ana Nóbrega Pinto, Miguel Bebiano Coutinho, Cecília Almeida e Sousa

Publicatie 10-10-2020


There are reports in literature concerning the relation between some maternal and neonatal factors and future risk of disease, including atopy, recurrent infections and obstructive sleep disturbances, three common pathologies eliciting surgery in children. To evaluate if maternal and neonatal factors can relate to Otorhinolaryngology surgical indications in a cohort of children treated in a tertiary referral center. A retrospective analysis of data from children submitted to primary Otorhinolaryngology surgery in the pediatric ambulatory unit of Centro Hospitalar Universitário do Porto between March 2016 and March 2020 was performed. Children with orofacial congenital anomalies were excluded and 1256 children met the eligibility criteria. The associations between maternal and neonatal factors and the development of atopy, recurrent infections and obstructive sleep apnea were analyzed. Atopic children showed higher birth weight percentile (p < 0,001) and birth weight-for-length index (p < 0,001) compared with non-atopic. Weight-at-surgery was also higher in atopic patients (p = 0,002). Maternal atopy significantly increased the risk of children atopic disease (p < 0,001; Odds Ratio 4,359). Children indicated for surgery for recurrent infections showed lower birth weight-for-length index (p = 0,038) and lower probability of atopic disease (p < 0,001). Recurrent acute otitis media related to both lower birth weight-for-length index (p = 0,002) and birth body mass index (p = 0,023). There was not a significant higher incidence of sleep apnea in preterm infants (p = 0,488). Obstructive sleep apnea patients showed lower weight-at-surgery percentile (p = 0,045). This work suggests an association between birth anthropometric measurements and atopic and infectious diseases later in life, irrespective of gestational age. There was no consistent association between perinatal parameters and obstructive sleep apnea, but the impact of disordered breathing in childhood anthropometry was significative.

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Cross-cultural adaptation of the sinus and nasal quality of life survey (SN-5) to Spanish

Christian Calvo-Henríquez, Beatriz Valencia-Blanco, Borja Boronat-Catalá, Juan Maza-Solano, Águeda Díaz-Anadón, Sandra Kahn, Jose D. Moure-Gonzalez, Ana Faraldo-García, Gabriel Martinez-Capoccioni

Publicatie 09-10-2020


There is a high prevalence for rhinitis with an increasing trend. However, there is a lack of specific quality of life pediatric questionnaires for sinonasal symptoms. The Sinus and Nasal Quality of Life Survey (SN-5) is the only validated instrument specifically designed with this objective. In this work we have translated and validated the Spanish version of the SN5 questionnaire. The SN5 was translated according to the World Health Organization recommendation for the translation and adaptation of instruments. The final version of the Sp-SN5 was administered twice (day 0 and day 7) to 137 participants with and without sinonasal symptoms. Reliability was measured with Cronbach α, temporal stability was measured with intraclass correlation coefficient. External validity was assessed with a ROC curve comparing a cohort of cases (children going to turbinate radiofrequency ablation) and controls (asymptomatic children). A Spearman correlation between the total result of the Sp-SN-5 questionnaire and the QOL score showed a strong negative correlation in the general sample and all the age subgroups. Internal consistency measured with Cronbach α was 0.87 for 5 items and was still over 0.83 after removing each item of the test. The intraclass correlation coefficient (ICC) for test-retest measurements was 0.94. The receiver operating characteristic (ROC) curve for all the included participants showed a very high area under the curve (0.998). The Sp-SN-5 questionnaire was successfully translated and cross-culturally adapted into Spanish, and the translated version exhibited adequate properties. The survey was effective in assessing the quality of life of pediatric patients with sinonasal complaints and can be used for this purpose both in a clinical setting and in future research.

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Validation of the Mandarin versions of CAP and SIR

Liyan Wang, Min Shen, Wei Liang, Weijie Dao, Lijun Zhou, Meihua Zhu

Publicatie 08-10-2020


The present study aims to develop the Mandarin versions of Categories of Auditory Performance (CAP) and Speech Intelligibility of Rating (SIR), verify their reliability and validity, and establish standardized values of the Mandarin CAP and SIR. In doing that it will provide an effective tool for evaluating the auditory skills and speech production of Mandarin-speaking hearing-impaired children. The preliminary Mandarin versions of the CAP and SIR were determined using the back-translation method and then administered to 191 cases aged 0-6 years. A pre-test was conducted on the Mandarin-speaking hearing children, and according to the pre-test and data analysis, the questionnaires were perfected. Formal questionnaires were administered to 103 Mandarin speakers aged 0-6 years, to get the test-retest reliability and inter-rater reliability. A test was conducted on 60 Mandarin-speaking children aged 0-2 years and 60 Mandarin-speaking children aged 3-6 years to get the criterion validity of the CAP and SIR. A total of 5059 Mandarin-speaking typically hearing children aged 0-6 years in China were finally selected for the CAP and SIR assessment to calculate the CAP and SIR scores for each age group. Pre-test data showed a strong positive significant correlation between age and the scores of CAP and SIR, respectively (r1 = 0.817, p < 0.01; r2 = 0.836, p < 0.01). In terms of test-retest reliability, the two CAP scores were significantly and positively correlated (r = 0.981, p < 0.01), and the two SIR scores were also significantly and positively correlated (r = 0.983, p < 0.01). With regard to the inter-rater reliability, the two CAP scores (r = 0.983, p < 0.01), and the two SIR scores (r = 0.997, p < 0.01) were both significantly and positively correlated. As for the criterion validity, CAP and the two efficacy scores were highly significantly correlated (r = 0.721, p < 0.01) and a significant positive correlation (r = 0.283, p < 0.05); along the same lines SIR and the two efficacy scores were both highly significantly correlated (r1 = 0.698, p1<0.01; r2 = 0.428, p2 < 0.01). Standardized values (Mean CAP and SIR scores of each age group) of the Mandarin CAP and SIR were provided. The Mandarin versions of the CAP and SIR are reliable and valid as tools to assess the hearing and speech ability in Mandarin-speaking children. The Mandarin standardized values are helpful to monitor the rehabilitation outcome of hearing-impaired children.

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Positive predictive value for diffusion-weighted magnetic resonance imaging in pediatric cholesteatoma: A retrospective study

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

Publicatie 08-10-2020


The aims of this study were first to calculate the Positive Predictive Value (PPV) of DW-MRI to detect cholesteatoma and then to analyze false positives. All temporal bone MRI with DWI sequences performed in our pediatric university hospital between 2005 and 2015 were included retrospectively. 46 patients with a cholesteatoma diagnosis on the MRI report and who underwent surgery were studied. The number of DW-MRI for identification of cholesteatoma has grown in ten years. We calculated an 89% Positive Predictive Value. DW-MRI sensitivities were 100.0% and 70.7% for respectively keratin and squamous epithelium. DW-MRI hypersignal is not synonymous of cholesteatoma diagnosis. Indeed, this diagnosis relies on the importance of a proper otoscopic examination, a suggestive medical history, CT scan data and analysis of other MRI sequences, including T1-weighted sequence, to rule out other etiologies of middle ear DW-MRI hypersignal.

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Effects of familial Mediterranean fever on the middle ear

Asli Cakir Cetin, Ceyhun Acari, Hande Evin, Ahmet Omer Ikiz, Gunay Kirkim, Erbil Unsal

Publicatie 09-10-2020


To evaluate middle and inner ear function and hearing status of children with familial Mediterranean fever (FMF). We assigned 56 patients with FMF to the study group and 52 healthy volunteers to the control group. The mean age of patients in the study and control groups were 10.10 ± 3.70 and 9.77 ± 3.74 years, respectively. Physical examination and hearing evaluation were performed in both groups. The audiological test battery included 226-Hz tympanometry, pure tone audiometric evaluation, acoustic stapedial reflex measurements, distortion product otoacoustic emission recording, and wide-band tympanometry assessment. The groups were similar in age and sex ratio (p > 0.05 for both comparisons). Pure tone audiogram and distortion product otoacoustic emission results were also similar for both groups (p > 0.05). The ipsilateral acoustic stapedial reflex were present in both of the groups and all participants had Type A tympanogram. The contralateral acoustic stapedial reflex thresholds were significantly higher in the familial Mediterranean fever group (p < 0.05 for all comparisons). The ambient and peak pressure absorbance values of wide-band tympanometry were significantly lower at 2000 Hz and significantly higher at 4000 Hz in the familial Mediterranean fever group (p < 0.05 for both comparisons). The severity and duration of disease adversely affected the absorbance values of wide-band tympanometry at 2000 and 4000 Hz (p < 0.05). To our knowledge, this is the first study to demonstrate the adverse subclinical effects of familial Mediterranean fever on the middle ear. We recommend that children diagnosed with FMF should be closely monitored for future clinical middle ear pathologies.

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Results of the Universal Neonatal Hearing Screening in a Tertiary Care Hospital in Mexico city

Carlos Fabián Martínez- Cruz, Mayra Norma Ramírez-Vargas, Patricia García-Alonso Themann

Publicatie 07-10-2020


Universal Neonatal Hearing Screening (UNHS) includes as its main objective, that all Newborns (NB) receive an audiological evaluation during their first month of life. To determine the prevalence of hearing loss in a population of healthy NB in a tertiary care hospital in Mexico City. A prospective cross-sectional study was designed. The period was from October 1, 2011 to May 15, 2019. UNHS was performed with a flowchart in three phases using Transient Evoked Otoacoustic Emissions and Brainstem auditory evoked potentials. Data were analyzed using descriptive statistics. 14,000 NB were evaluated, 28,000 ears. Gender was distributed in n = 7038 (50.3%) males and n = 6962 (49.7%) females. The mean age at the time of the first UNHS study was 48.3 ± 22.2 days. Hearing loss was confirmed in n = 31 (0.22%) NB, in 20 (64%) of the cases with hearing loss there were no documented audiological risk factors. The prevalence of hearing loss was 2.2 per 1000 NB in a tertiary care hospital in Mexico City. Diagnosis and early habilitation of hearing loss in NB constitute quality indicators in health care and guarantee the best prognosis for NB with hearing loss.

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Auricular reconstruction with modified expanded two-flap method in Goldenhar Syndrome: 7-Year experiences

Wenshan Xing, Jin Qian, Bingqing Wang, Yue Wang, Jintian Hu, Qingguo Zhang

Publicatie 07-10-2020


Goldenhar Syndrome (GS) is a systematic polymalformational disease characterized by microtia, hemifacial microsomy, ocular anomalies, abnormal vertebra and other deformities. These congenital malformations brought severe physical and mental stress to the patients. Auricular reconstruction has always been the primary appeal of the patients and their families to achieve a better facial balance and harmony. However, multiple deformities made it a great challenge to perform this technique. In this study, we reported a modified expanded two-flap method of auricular reconstruction, which is more applicable for patients with Goldenhar Syndrome. Between January of 2012 and September of 2019, 69 cases of Goldenhar Syndrome underwent auricular reconstruction with the modified expanded two-flap technique. Auricular reconstruction was performed in three surgical stages. In the first stage, a 50 ml kidney-shaped tissue expander was embedded in mastoid region and the retroauricular skin expanded. In the second stage, the autologous rib cartilage was harvested and the ear framework fabricated. The expander was further removed, and then enveloped by the expanded flap, retroauricular fascial flap and a free skin graft. In the third stage, the reconstructed ear was further trimmed, including lobule transposition and tragus reconstruction. The patients were followed for 6 months to 7 years. There were 63 cases (91.3%) responded satisfied outcomes in size, shape, position and bilateral symmetry. One case suffered expander leakage and tissue expansion accomplished after the expander was replaced. Hematoma was occurred in four cases and removed to complete the reconstruction. Complications of cartilage exposure were observed in one case. Modified expanded two-flap method is effective and safe in auricular reconstruction for patients of Goldenhar syndrome with long term satisfying results. Level of Evidence IV.

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Telemedicine in paediatric otorhinolaryngology: Lessons learnt from remote encounters during the Covid19 pandemic and implications for future practice

Shradha Sharma, Mat Daniel

Publicatie 07-10-2020


Covid19 has necessitated new methods of conducting outpatient consultations. At our institute, patient-facing paediatric ENT appointments were replaced with telemedical consultations. We performed a prospective analysis of the outcomes following telephone consultations with parents and describe our experience of remote consulting during a pandemic, and the possibilities for future applications of telemedicine in paediatric ENT. 215 patients were appropriately referred to the paediatric ENT clinic, 65% of these patients were deemed suitable for remote telephone consultation. Following a telephone call, 50% did not need further ENT clinic management, most commonly due to being listed for surgery (20%) or discharged (18%). The treating consultant assessed 81% of phone consultations as being effective. When given the choice, patients reported that 29% would choose a telephone consultation whilst 43% preferred a face to face consultation. Our experience has shown that there are areas of paediatric ENT that can be streamlined effectively by substituting face to face consultations with telephone consultations. However, prospective evaluation of these remote contacts suggest that telephone consultations are not a panacea and cannot be indiscriminately applied to all. Instead, the strategies to take forwards into a post Covid19 practice are vetting of referrals, individualised treatment plans, and giving patients a choice.

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Incidence of cure and residual obstructive sleep apnea in obese children after tonsillectomy and adenoidectomy stratified by age group

Tonya Lee, Sharon Wulfovich, Ellen Kettler, Javan Nation

Publicatie 07-10-2020


Current clinical guidelines by the American Academy of Pediatrics recommends adenotonsillectomy (T&A) as the first-line treatment for pediatric OSA. However, obese children experience a decreased incidence of cure from T&A compared to non-obese children, with obesity increasing risk of residual post-operative OSA by up to 3.7-fold. In addition to obesity, increased age has also been linked to more severe baseline OSA, among other factors. In this study, we examined how age effects the post-operative outcome in obese children with OSA. A retrospective chart review was performed to assess post-operative T&A polysomnography outcomes of obese children. Inclusion criteria included patients who were 17 years old and younger, underwent T&A, were obese and had both pre- and post-operative sleep studies. The patients were split into 3 different groups based on their age: Group 1 (0-6 years old), Group 2 (7-11 years old), and Group 3 (12-17 years old). 55 patients were included in the study: 13 in Group 1, 20 in Group 2, and 22 in Group 3. For Groups 1, 2, and 3 respectively, data averages were BMI percentile 99.20, 98.49, and 98.92 (P = 2.77); z-score 2.79, 2.36, and 2.45 (P = 0.026), tonsil size 3.17, 3.15, and 3.23 (P = 0.898), adenoid size 2.42, 2.05, and 1.77 (P = 0.015), time between the preoperative and postoperative PSG 179, 240, and 202 days (P = 0.481), and time from surgery to postoperative PSG 126, 170, and 127 days (P = 0.544). The average preoperative oAHI was 52.56, 41.23, and 43.49 (P = 0.732), post-operative oAHI was 1.94, 4.79, and 4.44 (P=.417); and change in oAHI was 50.62, 36.44, and 39.25 (P = 0.617). When comparing the age group of 0-6-year-olds to the older remaining patients, the post-operative oAHI was the only variable to show a significant difference between the two-groups with a P value of 0.038. The percentage of patients with post-operative resolution of OSA (oAHI<2), mild, moderate, and severe OSA, respectively, were 53%, 29%, 9%, and 9% for all patients, 70%, 23.1%, 7%, and 0% for group 1; 50%, 35%, 5%, and 10% for group 2; and 45%, 27%, 13%, and 13% for group 3. The percent of the patients requiring post-surgical nighttime airway support were 18%, 7%, 15%, and 26% for Groups All, 1, 2, and 3, respectively. We found that despite having the highest rates of obesity and the most severe OSA, obese patients under 7 years old performed better following T&A, with greater cure rate, overall reduction of oAHI, and decreased need for post-surgical nighttime airway support.

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Image-guided surgical navigation for bone-conduction hearing device implant placement

Michael Shih, Sarah A. Gitomer, Geran Barton, Yi-Chun Carol Liu

Publicatie 18-10-2020


For pediatric patients, bone-conduction hearing devices (BCHD) have demonstrated excellent outcomes. Unique to this population, BCHD implant surgeries can be technically challenging in children due to thinner, developing bone and syndromes with atypical anatomy. Image-guided surgical navigation (IGSN) clarifies underlying skull structure, potentially improving outcomes. IGSN is commonly used in otorhinolaryngologic surgeries, but current use in BCHD placement surgeries remains unprecedented. We report favorable results of IGSN in BCHD implantation for three children with complex otologic anatomy: two syndromic patients with variable temporal bone thickness, and one with prior mastoidectomies. The three patients each underwent a successful hearing implant surgery without significant intra- or post-surgical complications. All patients had good audiologic outcomes. We report using IGSN to assist in BAHA or BONEBRIDGE™ implant surgery for three medically complicated patients. For stereotactic imaging, the patients each received pre-operative high-resolution CT scans using the paranasal sinus fusion protocol without contrast. The first patient was a 6-year-old male with CHARGE-associated abnormal temporal bone anatomy, atretic left auditory nerve, and bilateral chronic tympanic membrane perforation and otorrhea resulting in bilateral mixed conductive and sensorineural hearing loss. The patient thus was unable to consistently tolerate hearing aids. The second patient was an 18-year-old male with Rosai-Dorfman disease, history of bilateral chronic mastoiditis and middle ear infections, bilateral mastoidectomies, and bilateral malleus and incus removal resulting in mixed conductive and sensorineural hearing loss. The third patient was an 11-year-old male with Treacher Collins Syndrome, bilateral microtia, and bilateral atresia of the external auditory canals resulting in bilateral conductive hearing loss. The patients each underwent a successful hearing implant surgery without significant intra- or post-surgical complications. All patients had good audiologic outcomes. Intraoperative IGSN can be a beneficial adjunct to BCHD implant placement surgeries for pediatric patients with abnormal temporal bone anatomy. IGSN can help identify the optimal surgical implantation sites, thereby reducing the risk for major morbidities associated with BCHD implantations. Furthermore, our findings expand application of IGSN use to placement of both BAHA and BONEBRIDGE™.

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Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma

Avinash Shekhar Jaiswal, Rakesh Kumar, Alok Thakar, Rajeev Kumar, Hitesh Verma, Ashu Seith Bhalla, Arvind Kumar Kairo, Aanchal Kakkar, Suresh Chandra Sharma, Pirabu Sakthivel

Publicatie 07-10-2020


Juvenile nasopharyngeal angiofibroma is the vascular and locally aggressive tumor of the posterior nares and nasopharynx. Endoscopic excision is the preferred surgical modality in early Radkowski stages. The prime challenge is intraoperative bleeding. Literature is in favor of the use of plasma ablation to overcome surgical challenges. To evaluate the effectiveness of plasma ablation technique in the surgical management of juvenile nasopharyngeal angiofibroma. The current study recruited 36 patients of clinico-radiologically diagnosed cases of primary JNA of stage I and II (Modified Radkowski). In prospective arm, 18 consecutive patients were recruited, who underwent plasma ablation assisted endoscopic excision. In retrospective arm, 18 consecutive patients who underwent excision by traditional endoscopic instruments in the past two years, were recruited. Both the groups were compared for baseline characteristics, intraoperative blood loss, duration of surgery, length of hospital stay, and recurrence rates. The use of plasma ablation decreased overall blood loss by 338 ml (mean difference) which was not statistically significant (p = 0.26). On subgroup analysis, the use of plasma ablation significantly decreased mean blood loss (648 ml, p = 0.046) and duration of surgery (83 min, p < 0.001) in patients who underwent embolization. No statistically significant difference was noted between two groups in length of hospital stay (p = 0.36) and recurrence rates (p = 0.64). Plasma ablation is an effective technique available to decrease blood loss and duration of surgery during endoscopic excision of post embolized stage I and II patients of JNA.

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Feasibility of same day surgery for pediatric second branchial cleft anomalies

Christopher Pool, Christopher Ehret, Linda Engle, Junjia Zhu, Meghan N Wilson

Publicatie 06-10-2020


The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation. A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement. There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay. Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

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Outcome of drug induced sleep endoscopy directed surgery in paediatrics obstructive sleep apnoea: A systematic review

Jeyasakthy Saniasiaya, Jeyanthi Kulasegarah

Publicatie 10-11-2020


Paediatrics obstructive sleep apnoea have been discussed to a great degree over the recent years and remains a conundrum till date. The advent of instrumentation has aided upper airway evaluation in determining the site and degree of upper airway collapse for targeted and effective surgical planning. The literature was reviewed to determine the outcome of Drug Induced Sleep Endoscopy (DISE) directed surgery in children with obstructive sleep apnoea. A literature search was conducted for the period from January 2000 to December 2019 by using a number of medical literature data bases including Scopus, PubMed and Embase. The following search words were used either individually or in combination: drug-induced sleep endoscopy, sleep endoscopy directed surgery, paediatrics sleep apnoea. The search was conducted over a month period (December 2019). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed when possible. Seven clinical research articles were selected based on our objective and selection criteria. Seven studies were of level III evidence: retrospective, case-control and prospective series. Altogether, there were 996 patients with male predominance; 61%. Over 10% of patients (133 patients) were found to have comorbidities or were syndromic. The mean age of patient was 6 years and majority (87.6%) of our patients were found to be surgically naïve, that is, no previous surgical procedures were performed for OSA. Surgical decision was changed in 295 patients (30%) following DISE. Post intervention outcomes were objectively revealed in 4 studies. Most of our patients underwent a multilevel surgery based on DISE (86%). Complications were documented in 3 studies. Analysis of the results indicated that DISE directed surgery was an effective, safe therapeutic approach to treating paediatrics obstructive sleep apnoea. DISE directed surgery has shown to have changed surgical management in most studies.

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Bronchopulmonary dysplasia requiring tracheostomy: A review of management and outcomes

Adam Ahmad Karkoutli, Michael R. Brumund, Adele K. Evans

Publicatie 07-11-2020


Bronchopulmonary Dysplasia (BPD) is a pulmonary disease affecting newborns, commonly those with prematurity or low birth weight. Its pathogenesis involves underdevelopment of lung tissue with subsequent limitations in ventilation and oxygenation, resulting in impaired postnatal alveolarization. Despite advances in care with improved survival, BPD remains a prevalent comorbidity of prematurity. In severe cases, management may involve mechanical ventilation via tracheostomy. BPD's demand for multidisciplinary care compounds the challenges in management of this condition. Here, we review existing literature: the history of disease, criteria for diagnosis, pathogenesis, and modes of treatment with a focus on the severe subtype: that which is associated with pulmonary hypertension (PAH) for which tracheostomy is often required to facilitate long-term mechanical ventilation. We review the current recommendations for tracheostomy and decannulation.

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Dysphonia and reflux in children: A systematic review

Jeyasakthy Saniasiaya, Jeyanthi Kulasegarah

Publicatie 03-11-2020


Aim of this review is to evaluate the relation between reflux (either laryngopharyngeal or gastroesophageal) and dysphonia in children. PubMed, Scopus, Embase. A literature search was conducted over a period from January 1990 to March 2020. The following search words were used either individually or in combination: voice disorders, laryngopharyngeal reflux, and gastroesophageal reflux. The search was conducted over a period of a month: April 2020. Five clinical research were selected based on our objectives and selection criteria. Four studies were of level III evidence. Altogether, a total of 606 patients were pooled with male predominance of 63%. In all studies, reflux was suggested to have strong relation with dysphonia. Majority of cases used 24-h pH monitoring to confirm reflux which yielded positive results in 69%. The top three most common endoscopic findings include: interarytenoid erythema and edema (32/38), vocal cord erythema and edema (160/231) and postglottic edema (141/337). Vocal cord nodules were found in 28% of our patients. Acoustic analysis and perceptual assessment of voice was performed in only 1 study. No complication from any procedure was mentioned in any of the studies. Outcome of treatment was mentioned in 1 study, whereby after 4.5 months of follow-up, 68% of children showed improvement in symptoms. Current evidence shows that there is strong relation between reflux and dysphonia in children. Most common laryngoscopic findings suggestive of reflux includes interarytenoid erythema and edema, vocal cord erythema and edema and postglottic edema.

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Olfactory bulb magnetic resonance imaging in SARS-CoV-2-induced anosmia in pediatric cases

Nevin Hatipoglu, Zahide Mine Yazici, Figen Palabiyik, Filiz Gulustan, Ibrahim Sayin

Publicatie 30-10-2020


In this paper, we report three cases of pediatric patients with COVID-19 infection who presented with different symptoms and also anosmia and/or ageusia. The common feature of these 3 patients is that the smell and / or taste disorder developed without nasal symptoms such as nasal congestion, nasal obstruction or rhinorrhea. Although 40% of anosmies contains viral etiologies, COVID- 19 differs from other viral anosmies by the lack of nasal congestion and runny nose. Coronaviruses could invade the brain via the cribriform plate close to the olfactory bulb and the olfactory epithelium. We may expect some structural changes in the olfactory bulb so we evaluated our patient with cranial imaging.

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Anesthetic management of children undergoing drug-induced sleep endoscopy: A retrospective review

Katie A. Liu, Christopher C. Liu, Gijo Alex, Peter Szmuk, Ron B. Mitchell

Publicatie 21-10-2020


To determine the best anesthetic technique for DISE based on a retrospective review of the current literature and to highlight research gaps that should be addressed in future studies. A comprehensive retrospective review of the literature on anesthetic regimens for pediatric DISE through March 2020 was performed. Specific medical subject heading (MesH) terms included: drug-induced sleep endoscopy and anesthesia, DISE, child, obstructive sleep apnea, sleep disordered breathing. Twelve articles were included. One study was a retrospective comparative study while the remaining 11 were case series. Five studies described anesthetic technique for DISE pre-T&A, two post-T&A, and four both pre- and post-T&A. The heterogeneity of the studies did not allow for a meta-analysis. A total of 1110 children ages 2 months to 19 years were included. Sedation depth and anesthetic outcomes with DISE were infrequently described. Eleven studies used a sevoflurane inhalational induction and mostly transitioned to a total IV anesthetic for maintenance. Propofol was the most commonly used sole anesthetic. A total of three studies used a combination of remifentanil and propofol, one used dexmedetomidine alone, one used sevoflurane alone, and one compared different regimens. Dexmedetomidine and ketamine have the most favorable profile for pediatric DISE but are not universally used. DISE completion, as reported in two studies, was 93% and 100%. There are several anesthetic regimens for DISE that achieve good sedation and outcomes. The combination of ketamine and dexmedetomidine may be the ideal regimen. Limited data and lack of protocols/high-quality studies exist on anesthetic regimens for pediatric DISE.

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Strategies for restarting Pediatric Otolaryngology outpatient clinics after a pandemic-related shutdown such as from COVID-19

Katharina Leitmeyer, Mark Felton, Neil K. Chadha

Publicatie 19-10-2020


The novel coronavirus 19 SARS-CoV2 caused a change in the practice of Otolaryngology around the globe. The high viral load in the nasal cavity, nasopharynx and airway subjects Otolaryngologists to a high risk of catching the virus during aerosol generating procedures. After the first outbreak wave has subsided, many teams are now discussing how our 'new normal' practice will look. We share our guidelines on restarting elective clinical work in order to create a safe environment for patients and staff in a Pediatric Otolaryngology outpatient clinic.

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Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist

Arvind Chandrakantan, Deepak Mehta, Adam C. Adler

Publicatie 10-10-2020


Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.

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The role of bioresorbable intraluminal airway stents in pediatric tracheobronchial obstruction: A systematic review

Joshua A. Stramiello, Amir Mohammadzadeh, Justin Ryan, Matthew T. Brigger

Publicatie 06-10-2020


Tracheal stenosis and tracheobronchomalacia are complicated, patient-specific diseases that can be treated with intraluminal stenting. Most commonly, silicone and metal stents are utilized, however, they pose significant early and late morbidity and are further complicated by growth of the airway in the pediatric population. Given recent improvements in materials science, there is a growing body of evidence suggesting a strong role for bioresorbable intraluminal stents in treating pediatric tracheobronchial obstruction. A PubMed.gov literature search was performed on December 3, 2019 and May 15, 2020, and a 2-researcher systematic review was performed following the PRISMA criteria. The following search query was utilized: (((((((bioresorbable) OR bioabsorbable) OR resorbable) OR absorbable) OR biodegradable AND airway) OR trachea) AND stent. A pooled statistical analysis was performed on all reported pediatric patients using SPSS software. 1369 publications were screened and 26 articles with original data were identified. Materials used included polydioxanone (PDO), poly-l-lactic acid (PLLA), polyglycolic acid/poly-l-lactide co-polymer with Proglactin 910 (Vicryl®-PDS®), polycaprolactone (PCL), magnesium alloys, and co-polymers in varying proportions. Twelve articles presented data on human subjects, 8 of which were case series and case reports on pediatric populations using polydioxanone (PDO) stents. Pooled statistical analysis demonstrated an average age of 19 months (range 0.25-144), 56.5% associated with a cardiovascular anomaly, and overall complication rate of 21.7%, with a stent fragment foreign body being the most common (8.7%), followed by significant granulation tissue (4.3%), stent migration (4.3%), and local stenosis (4.3%). Comparative analysis demonstrated short-term improvement (up to 1 month) has a statistically significant association with tracheobronchomalacia versus tracheal stenosis on chi-squared test (p = 0.001). The remaining analyses did not yield statistical significance. The reported application of bioresorbable materials as intraluminal airway stents is positive. All comparative animal studies report biocompatibility and fewer morbidities compared to metal and silicone stents, however, in human studies there are concerns over the short interval of degradation and the potential for obstructive foreign bodies in poorly seated stents. Overall, there are clear, reproducible advantages to bioresorbable intraluminal stents in pediatric airway obstruction, as well as common pitfalls, that warrant further research.

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Bipolar loop device versus bipolar diathermy for tonsillectomy: A pilot randomized controlled trial

Fatemeh Fakhrealizadeh, Amir Human Hoveidaei, Jamshid Eslami, Seyed Basir Hashemi, Armin Hoveidaei, Tayebeh Kazemi, Zohre Nazarpour

Publicatie 27-11-2020


Tonsillectomy is one of the most common surgeries performed in the pediatric population. Although different forms of instruments and various methods are used to perform tonsillectomy, none of them is still recognized as the best global technique. This study aimed to compare the outcomes of the new Bipolar Loop tonsillectomy versus bipolar diathermy technique. This study is a pilot randomized clinical trial and was conducted on 40 pediatric patients who were the candidate of tonsillectomy. Patients were divided into two groups of Bipolar Loop or bipolar diathermy. Operation time, intraoperative bleeding, tonsillar fossa wound, postoperative complications, and duration of return to normal diet were evaluated in the current study. In both of the Bipolar Loop and bipolar diathermy groups, no significant difference was found in terms of sex, age, and weight. The average amount of the operative time, intra-operative blood loss, and postoperative pain loss were significantly less in the Bipolar Loop group (P < .001). In addition, the tonsillar fossa wound healing scores were significantly better (on the 14th day, P = 0.009). However, there was no significant difference between the two groups in terms of postoperative bleeding, duration of return to a normal diet, and postoperative symptoms of fever, otalgia, or voice change between the groups. The study showed that blood loss and postoperative pain through day 7 were significantly less in the Bipolar Loop group. Tonsillectomy with Bipolar Loop can be recommended as one of the methods for tonsillectomy, especially in pediatric patients.

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Monopolar tonsillotomy versus cold dissection tonsillectomy in children: Prospective study on postoperative recovery

Anniina J. Sakki, Laura K. Mäkinen, Mervi Kanerva, Johanna Nokso-Koivisto

Publicatie 26-11-2020


To compare postoperative self-reported recovery results with monopolar tonsillotomy and cold dissection tonsillectomy in children. To evaluate the feasibility of the monopolar technique in tonsillotomy. Children <12 years undergoing tonsillotomy or tonsillectomy between April 2018 and March 2020 who (with a caregiver) were willing to participate in a two-week follow-up formed the study group. They filled in a questionnaire about pain-related outcomes, return to normal activities, weight changes, complications, and length of home care. Altogether 166 patients were recruited; 103 (62%) returned the questionnaire. The first pain-free day with tonsillotomy was day 5 and with tonsillectomy day 11. After tonsillotomy, patients returned to normal activities faster, e.g. they were able to eat normally 6.5 days earlier than tonsillectomy patients. During the first postoperative week weight dropped after tonsillectomy, but not after tonsillotomy. The length of home care was 6 days with tonsillotomy and 10 days with tonsillectomy. The incidence of postoperative hemorrhage (including minor bleedings at home) was 14% after tonsillotomy and 32% after tonsillectomy. Hemorrhages needing interventions were 0% with tonsillotomy and 2% with tonsillectomy. Children operated on with monopolar tonsillotomy recovered faster and had less postoperative hemorrhage than those undergoing tonsillectomy. They were able to return earlier to daycare/school and their caregivers back to work. Recovery results with monopolar tonsillotomy were equal to other tonsillotomy techniques reported in the literature, hence the monopolar technique can be considered an alternative method to perform tonsillotomy.

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The Swedish hearing in noise test for children, HINT-C

Heléne Hjertman, Mathias Hällgren, Elina Mäki-Torkko, Stefan Stenfelt

Publicatie 26-11-2020


The aim of this study was to develop and evaluate a Swedish version of the Hearing In Noise Test for Children (HINT-C). In the first part, the Swedish HINT lists for adults was evaluated by children at three signal to noise ratios (SNRs), -4, -1 and +2 dB. Lists including sentences not reaching 50% recognition at +2 dB SNR were excluded and the rest constituted the HINT-C. In the second part, HINT-C was evaluated in children and adults using an adaptive procedure to determine the SNR for 50% correctly repeated sentences. Study Sample In the first part, 112 children aged 6-11 years participated while another 28 children and 9 adults participated in the second part. Eight out of 24 tested adult HINT lists did not reach the inclusion criteria. The remaining 16 lists formed the Swedish HINT-C which was evaluated in children 6-11 years old. A regression analysis showed that the predicted SNR threshold (dB) was 0.495-0.365*age (years + months/12) and the children reached the mean adult score at an age of 10.5 years. A Swedish version of HINT-C was developed and evaluated in children six years and older.

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Acute mastoiditis complicated by cerebral venous sinus thrombosis in children

Eleni Vergadi, Stylianos Velegrakis, Maria Raissaki, Maria Bitsori, Alexander Karatzanis, Emmanouil Galanakis

Publicatie 26-11-2020


Diagnosis and management of complicated mastoiditis in childhood are still controversial. We investigated the clinical manifestations, evaluation and management of children with mastoiditis complicated with cerebral venous sinus thrombosis. Retrospective cohort study that included all children admitted for acute mastoiditis over the last 5 years. Children were divided in two groups based on the presence or not of venous sinus thrombosis. Clinical, laboratory, imaging and management data were retrieved and compared. Overall, 20 children with acute mastoiditis were included, of whom 5 had magnetic resonance imaging-confirmed cerebral venous sinus thrombosis and elevated intracranial pressure (ICP). In all complicated cases, neurological signs rather than mastoiditis signs, prevailed. The more prominent neurologic signs observed were lethargy (60%), nuchal rigidity (60%), abducens nerve palsy (60%) and ataxic gait (20%). Treatment consisted of intravenous antibiotics combined with anticoagulation. Surgery was performed in four children (4/5). Complicated cases had prolonged symptoms prior to admission (p 0.002), presented with neurologic signs and symptoms (p < 0.001), underwent more often lumbar puncture (p < 0.001) and brain imaging (p < 0.001), and were treated with prolonged courses of antibiotics and surgery (<0.001), compared to children with uncomplicated mastoiditis. Neurological signs and symptoms and elevated ICP dominate in children with mastoiditis complicated with thrombosis. Brain imaging is essential for early diagnosis of cerebral venous sinus complications and appropriate management.

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Iatrogenic orbital cerebrospinal fluid leak in a young pediatric patient: Factors to consider

Weston L. Niermeyer, David Z. Allen, Charlemagne Kern, Charles Elmaraghy

Publicatie 22-11-2020


Orbital abscess and subperiosteal abscess are pathologies which may require surgical treatment in the pediatric patient. Though rare, orbital cerebrospinal fluid (CSF) leak is a serious complication of abscess drainage. This paper presents a unique 5-month-old male with transorbital abscess drainage complicated by CSF leak. An endoscope was used to repair the defect through the orbitotomy incision. There was no evidence of persistent leak at follow-up. The surgical approach likely contributed to the complication, and the otolaryngologist played a key role in the leak repair. This case should serve to raise the awareness regarding considerations to avoid orbital CSF leak.

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Self-concept of children and adolescents with cochlear implants

Merle Boerrigter, Anneke Vermeulen, Henri Marres, Emmanuel Mylanus, Margreet Langereis

Publicatie 28-11-2020


Communicative disorders can complicate social interactions and may be detrimental for one's self-concept. This study aims to assess the self-concept of children with Cochlear Implants (CI). Results of educational peer groups (special needs or typical) were compared. Correlations amongst speech perception, language comprehension, self-concept and other study variables are determined. This retrospectively patient file study contained 53 CI participants with a mean age of 14.2 (SD = 2.8). Self-concept was measured with the Dutch language version of the Self-Perception Profile for Children and Adolescents. Proportions of low, normal and high competence scores were compared to a normative sample. Outcomes were analyzed for the total CI group and for the two educational peer groups. In the Scholastic Competence, Athletic Competence, Physical Appearance and Behavioral Conduct domains larger proportions of high perceived competence levels were found in the CI Total group compared to the hearing normative sample. Children with CIs in the Mainstream educational subgroup were found to have larger proportions of high levels on these domains. Remarkably, children with CI in the Special hearing impaired educational subgroup reported comparable self-concept scores as their hearing peers. Speech perception and language comprehension were positively correlated to Scholastic Competence. This study has shown that self-concept levels of profoundly hearing impaired children with CI are comparable to those of hearing peers. They are generally satisfied with their functioning in various domains. Better speech perception and language comprehension levels are related to higher outcomes in the Scholastic Competence domain.

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The influence of tonsillectomy on allergic diseases in pediatric patients

Urara Funakoshi, Syuji Yonekura, Tomohisa Iinuma, Yukiko Arimoto, Atsuko Nakano, Akiko Yamaide, Minako Tomiita, Akira Hoshioka, Daiju Sakurai, Yoshitaka Okamoto

Publicatie 24-11-2020


The influence of tonsillectomy on allergic airway diseases is not well known. In the present study, the influence of tonsillectomy on perennial allergic rhinitis (PAR) and bronchial asthma (BA) among pediatric subjects was prospectively investigated. The tonsillectomy (surgery group) and the age-matched non-surgical subjects (control group) were examined and followed prospectively. In addition, immunological analysis was conducted. After in vitro allergen stimulation, the production of a small number of allergen-specific Th2 cells was induced in the tonsillar cells, even in sensitized subjects. Flow cytometry analysis detected more effector regulatory T cells (Tregs) in the tonsils than in peripheral blood. Clinically, after surgery, the PAR and BA symptoms improved in the surgery group but not in the control group. The total IgE in the surgery group was significantly lower than in the control group; after surgery, IgE levels slightly increased but remained lower. The postoperative Dermatophagoides farina (Der f)-specific IgE level increased in the sensitized subjects but not in the non-sensitized subjects. Tonsillectomy did not improve the underlying mechanisms of the allergy, however the decreased risk of infection and upper airway obstruction could lead to improved symptoms of allergic airway diseases.

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Clinical practice guidelines on newborn hearing screening: A systematic quality appraisal using the AGREE II instrument

Kevin Chorath, Luis Garza, Aina Tarriela, Neil Luu, Karthik Rajasekaran, Alvaro Moreira

Publicatie 25-11-2020


Several guidelines and consensus statements have been produced and disseminated for the detection and management of newborn hearing loss. However, to date, the quality and methodologic rigor of these screening and management protocols have not been appraised. To identify and evaluate existing guidelines and consensus statements for the detection and management of neonatal hearing loss. A comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources was conducted until August 2020. The quality of these guidelines was assessed by four independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered satisfactory quality if they scored >60%, and intraclass correlation coefficients (ICC) were calculated to assess agreement among the appraisers. Twelve guidelines were assessed for critical evaluation. Only two guidelines were classified as 'high quality', and the remaining were 'average' or 'low quality'. The 'Scope and Purpose' domain achieved the highest mean score (91.3% ± 5.8%), and lowest was 'Rigor of Development' (35.8% ± 19.1%). ICC analysis showed good to very good agreement across all domains (0.63-0.95). These findings highlight the variability in methodologic quality of guidelines and consensus statement for the detection and management of neonatal hearing loss. These results may help to improve the reporting of future guidelines and guide the selection and use of these guidelines in clinical practice.

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Characteristics of the wideband absorbance of acoustic energy in children (3–7 years old) with otitis media with effusion

Jia Liang, Lin Xiao, Xue Yao Sun, Bin Zou

Publicatie 25-11-2020


This study aimed to investigate the characteristics of the wideband absorbance (WBA) of acoustic energy in children (3-7 years old) with otitis media with effusion (OME) under environmental ear-canal air pressure and tympanometric peak pressure and to determine the diagnostic value of the acoustic energy absorption rate (AR) in OME at different frequencies. A total of 178 children aged 3-7 years were enrolled in the study between April and October 2018. They were separated into two groups: those with middle ear effusion were placed in the OME group (n = 80; 136 ears), while those without OME (n = 98; 182 ears) were placed in the control group. A WBA test was performed on the children in both groups under environmental ear-canal pressure and tympanometric peak pressure to analyze the changing characteristics of the AR value within the 0.226-8 kHz range. Under ambient ear-canal air pressure, the AR of the OME group in each frequency band was significantly lower than that of the control group (P < 0.01). Under tympanometric peak pressure, the AR of the OME group in most frequencies was also significantly lower than those of the control group (P < 0.01) except in the 2-2.5 kHz range. The area under the receiver operating characteristic curve (AUROC) was highest at 0.47-1.03 kHz: 0.96 and 0.94 at ambient ear-canal pressure and tympanometric peak pressure, respectively. Of the single frequency points, those at 0.65, 0.67, 0.69, 0.71, and 0.73 kHz had a higher AUROC value (0.96-0.97) under both ambient ear-canal air pressure and tympanometric peak pressure. The difference in the AUROC values of the two pressure conditions was not statistically significant (P < 0.01). Overall, WBA is an effective method of diagnosing OME in children. The frequency band with the most predictive value of AR for OME is 0.47-1.03 kHz. Middle ear effusion can be quickly identified by observing AR values in this frequency range, which provides a diagnostic basis for OME.

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Ethosuximide induced macroglossia and oropharyngeal edema

Hanqing Shang, Mica Glaun, Julina Ongkasuwan

Publicatie 22-11-2020


Acute macroglossia and laryngeal edema are rare adverse side effects that can cause life-threatening airway obstruction. We report a case of acute macroglossia that began after initiation of ethosuximide in a 15-year-old female with severe medically refractory epilepsy. Macroglossia worsened over the next two weeks of ethosuximide administration, preventing extubation. Macroglossia and laryngeal edema improved upon ethosuximide wean, and completely resolved after discontinuation. The patient was extubated successfully, with precautionary nasal trumpet placement and dexamethasone administration prior to extubation. In medically complex patients on multiple pharmacologic agents, anti-epileptic drugs should be suspected as a possible cause of acute macroglossia.

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Effects of allergic rhinitis on the progression and recovery of acute otitis media in a mouse model

Chang Gun Cho, Hee-Bok Kim, Chul-Kyu Kim, Bo Hae Kim, Yun-Sung Lim, Seok-Won Park, Joo Hyun Park

Publicatie 22-11-2020


The objective of this study was to evaluate the effects of allergic rhinitis (AR) on the development, progression, and recovery of acute otitis media (OM) in an animal model and investigate the secondary effects of bacterial infection. BALB/c mice were divided into four groups: AR + OM, AR, OM, and control groups. AR + OM and AR groups were sensitized with ovalbumin (OVA) and alum and then challenged intranasally with OVA. Phosphate-buffered saline (PBS) was administered to the OM and control groups the same number of times. After AR induction, OM was induced by surgical inoculation of non-typeable Haemophilus influenza (NTHi) into the middle ear (ME) cavity of the mice in the AR + OM and OM groups. PBS was injected into the bulla in the AR and control groups. Each group was subdivided into sets of six mice, one for each of the four time points (0, 2, 7, and 10 days post-bacterial inoculation), at which point the mice were euthanized and ME and nasal cavity mucosa were obtained and evaluated. The occurrence of OM and the ME mucosa thickness were evaluated and compared among the four groups. Tissue expression of interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) in infected ME mucosa was assessed by immunohistochemical staining. We also investigated IgE, IL-4, and IL-5 in the nasal mucosa. Most of the ears showed OM on post-inoculation day 2 in both AR + OM and OM groups. In the AR + OM group, 58.3% of ears still had OM on post-inoculation day 10, while only 16.7% of the OM group had OM. The ME mucosa of all groups increased, and the AR + OM group exhibited the thickest mucosa. The OM group showed peak thickness on post-inoculation day 2 and then decreased, whereas the ME mucosa thickness of the AR + OM group continued to increase to day 7. In the OM group, the expression of IL-1β, IL-6, and TNF-α in the ME also increased significantly, peaking on post-inoculation day 2, and then gradually decreased. In the AR + OM group, the expression of these proteins increased until day 7 and then decreased. The IgE and Th2 response (IL-4 and IL-5) cytokines were expressed at higher levels in the AR + OM and AR groups than in the OM and control groups. The inflammatory reaction to NTHi was more intense and lasted longer in the allergic group, which indicates that AR affects the progression and subsequent recovery of acute bacterial OM.

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Novel variants in EDNRB gene in Waardenburg syndrome type II and SOX10 gene in PCWH syndrome

Lukas Varga, Daniel Danis, Jakub Drsata, Ivica Masindova, Martina Skopkova, Zuzana Slobodova, Viktor Chrobok, Milan Profant, Daniela Gasperikova

Publicatie 26-11-2020


Waardenburg syndrome (WS) is a clinically and genetically heterogeneous group of inherited disorders manifesting with sensorineural hearing loss and pigmentary anomalies. Here we present two Caucasian families with novel variants in EDNRB and SOX10 representing both sides of phenotype spectrum in WS. The c.521G>A variant in EDNRB identified in Family 1 leads to disruption of the cysteine disulfide bridge between extracellular segments of endothelin receptor type B and causes relatively mild phenotype of WS type II with low penetrance. The novel nonsense variant c.900C>A in SOX10 detected in Family 2 leads to PCWH syndrome and was found to be lethal.

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