International Journal of Pediatric Otorhinolaryngology 2021-07-30

Round window anatomy predicts ease of cochlear implantation in children

Timothy Shim, Habib Zalzal, Nankee Kumar, Samuel Tercyak, Matthew T. Whitehead, Brian Reilly, Diego Preciado

Publication date 27-07-2021


We aim to evaluate the utility of the Round Window Angle (RWA) as a predictor of difficulty and operative time in cochlear implantation. A retrospective study of pediatric patients that underwent cochlear implantation and CT temporal bone imaging from January 2008 to November 2019. Correlation, univariate, and multivariate analysis were conducted. 347 implantations met inclusion criteria. We found a difference in RWA for difficult (median: 101°, n = 5) and non-difficult (median: 74, n = 317) implantations (p < 0.0001). There was also a difference in RWA in patients with round windows visualized intra-operatively (p < 0.0197). When controlling for age and intraoperative round window visualization, logistic regression showed RWA was significantly associated with difficult insertion (OR: 1.687; p = 0.0246). Further, there was positive correlation between RWA and operative time (r = 0.1779, p = 0.0013) with patients with acute RWAs having shorter operative times (mean 115.7 ± 32.1 min) than those with obtuse RWA (mean 183.5 ± 97.0 min) (p = 0.0035). When accounting for surgeon and patient age, multivariate linear regression showed round window visualization (β = 3.456, p = 0.0006) and obtuse RWA (β = 6.172, p < 0.0001) was associated with an increase in operative time. Further research is needed to identify difficult cochlear implantations to increase the success and reduce risks associated with the surgery. Our study reports the possibility that an obtuse RWA both significantly increases difficulty and time of operation due to decreased round window visualization.

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Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses

Louis-Xavier Barrette, Carrie Z. Morales, Edward R. Oliver, Juliana S. Gebb, Tamara Feygin, Janet Lioy, Lori J. Howell, Holly L. Hedrick, Oksana A. Jackson, N. Scott Adzick, Luv R. Javia

Publication date 27-07-2021


To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.

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Readmission and reoperation after laryngeal dilation in children: NSQIP-P analysis

Nicole M. Favre, Afreen A. Siddiqui, Adam R. Szymanowski, Michele M. Carr

Publication date 27-07-2021


To identify specific comorbidities and their relationship to complications in children who underwent laryngeal dilation, specifically comparing children with tracheostomy versus no tracheostomy as well as differences in outcomes between age groups. Retrospective study analyzing data collected in the American College of Surgeons National Surgical Improvement - Pediatric Database (2015-2018). Patients were selected using Current Procedural Terminology code 31528. Variables analyzed include demographics, comorbidities, readmission, reoperation, reintubation and total length of stay. 982 cases were identified. Comorbidities significantly higher (p < .001) in age group 1 (Age ≤ 1 year, N = 245) versus age groups 2 (Age >1 but ≤ 3 years, N = 151) and 3 (Age > 3 years, N = 270) include premature birth, ventilator dependent, oxygen support, cardiac risk factors, steroid use, nutritional support, and hematologic disorders. Comorbidities significantly higher (p < .001) in children without a tracheostomy include premature birth, history of asthma, bronchopulmonary dysplasia/chronic lung disease, oxygen support, structural pulmonary/airway abnormality, esophageal/gastric/intestinal disease, history of previous cardiac surgery, developmental delay/impaired cognitive status, cerebral palsy, neuromuscular disorder, steroid use, and nutritional support. Younger children were significantly more likely (p < .001) to require reintubation and remain in the hospital longer. Children without a tracheostomy were significantly more likely (p < .001) to return to the operating room and remain in the hospital longer. Younger children and those without a tracheostomy are more likely to have adverse outcomes after laryngeal dilation. Awareness of these associations and outcomes is helpful in establishing benchmarks for outcomes in this group.

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Nasopharyngeal cultures in children with AOM – A retrospective study on bacteriological findings and impact on management

Malin Jinhage, Ann Hermansson, Marie Gisselsson-Solén

Publication date 26-07-2021


Despite a far from perfect correlation with middle ear growth, nasopharyngeal cultures are sometimes used in children with acute otitis media (AOM) in order to have some idea of the causative pathogen. How these cultures are used in clinical practice and to what extent they influence clinical management has not previously been studied. The objective with this study was to investigate in what circumstances nasopharyngeal cultures are performed in children with AOM, what the bacteriological results are and to what extent cultures influence clinical management. All nasopharyngeal cultures taken in clinical practice from children with AOM in the county of Skåne, Sweden, during 2017-2018 were retrieved together with details from the medical charts two months prior to and one month after the culture. Information about the reason for culturing, the bacteriological result, and whether this result changed the management of the child, was retrieved from the charts. During the 2 years, 978 nasopharyngeal cultures were taken in children with AOM. The most common reasons for obtaining a culture was a recurrence of AOM (40%) or treatment failure (22%). Many of the children had ongoing or recent antibiotic treatment. M. catarrhalis was the most commonly identified pathogen (53%), followed by H. influenzae (30%) and S. pneumoniae (14%). Resistance rates were low, and the most commonly identified resistant pathogen was betalactamase-negative ampicillin-resistant H. influenzae. One in five cultures led to a change in management, such as a change of antibiotics or an additional check-up. This was most commonly seen in association with H. influenzae, reflecting clinical practice in Sweden, where AOM is primarily treated with penicillin V. Despite not having a perfect correlation with middle ear growth, nasopharyngeal cultures can provide clues about suitable alternative antibiotics in cases of treatment failure, and they can help monitoring nasopharyngeal carriage and resistance rates.

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The effect of harmonic training on speech perception in noise in hearing-impaired children

Abdollah Moossavi, Saeideh Mehrkian, Nasrin Gohari, Mohammad Ali Nazari, Enayatollah Bakhshi, Claude Alain

Publication date 23-07-2021


Speech perception in noise is a highly challenging situation experienced by hearing-impaired children (HIC). Despite advances in hearing aid technologies, speech perception in noise still poses challenges. Pitch-based training improves pitch discrimination and speech perception and may facilitate concurrent sound segregation. Considering the role of harmonics in the analysis of concurrent sounds, we performed a harmonic assessment, examined the role of harmonic training in the rehabilitation of moderate-to-severe HIC, and investigated its effect on their speech perception in noise. The participants were 57 normally hearing children (NHC) with a mean age of 7.73 ± 1.57 years and 18 HIC with a mean age of 7.94 ± 1.47 years. The two groups were compared in terms of harmonic assessment, the Pitch Pattern Sequence Test (PPST), the Consonant-Vowel in Noise (CV in noise) test, and the Bamford-Kowal Bench (BKB) test. Subsequently, the HIC underwent harmonic training, and the results of the pre- and post-harmonic training assessments were compared. HIC displayed poorer harmonic discrimination than NHC at all harmonics (P < 0.05). They also showed lower scores in PPST, CV in noise, and BKB tests compared to NHC (P < 0.05). Harmonic training led to HIC's better performance in harmonic assessment, PPST, and CV in noise test (P < 0.05). However, the BKB test results pre- and post-training did not significantly differ (P > 0.05). Harmonic training plays a significant role in improving the HIC's temporal processing of the PPST and CV in noise test; therefore, it can serve as a rehabilitation method to enhance temporal processing and auditory scene analysis.

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Investigation of the hearing levels of siblings affected by a single GJB2 variant: Possibility of genetic modifiers

Makoto Hosoya, Masato Fujioka, Kiyomitsu Nara, Noriko Morimoto, Sawako Masuda, Tomoko Sugiuchi, Sayaka Katsunuma, Akira Takagi, Noriko Morita, Kaoru Ogawa, Kimitaka Kaga, Tatsuo Matsunaga

Publication date 23-07-2021


Variants in GJB2 can cause autosomal recessive deafness (DFNB1). There is evidence for genotype-phenotype correlations of GJB2 variants; however, several genotypes can cause varying levels of hearing loss likely attributable to differences in genetic or environmental background. As siblings share approximately 50% of their genetic background and usually have a common environmental background, analysis of phenotypes of siblings with a specific GJB2 variant may reveal factors relevant to phenotypic variation. There have been no previous analyses of differences in hearing among siblings carrying a single GJB2 genotype. Here, we investigated hearing differences between siblings with a single GJB2 variant, which can cause various levels of hearing loss. We examined hearing levels in 16 pairs of siblings homozygous for the c.235delC variant of GJB2. Differences in hearing acuity between sibling pairs were detected by auditory evaluation. Average differences in acoustic threshold >30 dB were observed between five pairs of siblings, whereas the remaining 11 pairs had average threshold values within approximately 10 dB of one another. Hearing loss varied from moderate to profound. Our results indicate that auditory acuity associated with homozygosity for GJB2 c.235delC can vary in degree; however, in approximately 70% of younger siblings, it was approximately the same as that in the first child, despite a diverse spectrum of hearing loss among different families. These results suggest that differences in genetic background may modify the phenotype associated with homozygous GJB2 c.235delC.

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Paediatric velopharyngeal insufficiency following adenotonsillar surgery

Sevasti Konstantinidou, Andrew Hall, Marie Pinkstone, Lesley Cochrane

Publication date 23-07-2021


Paediatric velopharyngeal insufficiency (VPI) is a known but rare complication following adenotonsillar surgery that can have significant adverse effects on the communication as well as psychological well-being of the patient and their family. We sought to assess risk factors, aetiology, assessment and management of these patients through a dedicated multidisciplinary clinic. Retrospective data collection was performed for patients seen in the Great Ormond Street Hospital for Children multidisciplinary VPI clinic from the 1 29 patients met the inclusion criteria, with 16 having previous adenotonsillectomy and 13 isolated adenoidectomy. In our VPI clinic, patients were seen on average for 4.9 occasions over a 38.3-month period. Clinical assessment was conducted using GOS.
SP.
ASS '98 speech assessment tool, speech videofluoroscopy and nasoendoscopy, as per individual needs. The main cause of post-adenoidectomy VPI was identified in 72.5% of the cases. Speech videofluoroscopy was performed in 27 cases. Associated anatomic features identified included deep pharynx (37%), long palate (22.2%) and variable levator position. Severe hypernasality was noted in 3 patients, while in 20 cases moderate or mild hypernasality was found. There were no patients with normal speech. Ten patients were treated with speech therapy alone, whereas surgical intervention was required in seventeen cases. In the population who received treatment and had adequately recorded follow-up, improvement in speech was noted in 86.9%, with 30.4% having oral resonance on last review. Of the patients with severe hypernasality, all improved but had some persistent hyper nasality on last clinic review. We present our multidisciplinary management of post adenoidectomy VPI. Through the investigations in our dedicated specialist VPI clinic, the cause of VPI was found more frequently than in previous reports in the literature. Intense treatment is usually required with lengthy follow-up and multiple attendances in VPI clinic. Main modalities of management include SLT, surgery and speech prostheses. Most patients' speech will improve with intervention. We highlight the importance of early recognition, referral and a multi-disciplinary approach in treating this condition. We advise ENT surgeons to ensure patients are adequately aware of this complication given its potential impact.

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Outcomes of adenoidectomy with and without tonsillectomy in patients younger than 2 years with moderate to severe upper airway obstruction

Kenshiro Taniguchi, Ai Yoshitomi, Asako Kanemaru, Shintaro Baba

Publication date 25-07-2021


The effectiveness of adenotonsillectomy for obstructive sleep disorder breathing (OSDB) in children under age 2 years is unclear. The present study aimed to identify the perioperative symptoms and clinical outcomes of adenoidectomy and tonsillectomy in very young children. The present, single-center, retrospective cohort study, conducted from January 2010 to April 2020, enrolled patients under age 2 years with moderate to severe upper airway obstruction who underwent an adenoidectomy or tonsillectomy. The patients were divided according to The Brodsky grading scale into group 1 (Grade 0 to 1 tonsils) or group 2 (Grade 2 or higher tonsils), who received only an adenoidectomy. Group 3 comprised patients with a concomitant adenoidectomy and tonsillectomy. Perioperative symptoms among the groups and the cumulative revision-free status and recurrence-free status rates in groups 1 and 2 were analyzed. Fifty-three patients were enrolled. The median standard deviation score (SDS) for height and weight was -0.79 and -0.31, respectively. No postoperative complications, such as bleeding, were observed. However, two patients underwent intubation preoperatively due to severe obstruction. Seven patients underwent revision surgery. The cumulative revision-free and recurrence-free rates at week 60 were 81% and 100% for Group 1 and 42% and 48.5% for Group 2, respectively. The cumulative revision-free rate and cumulative recurrence-free rate were significantly higher in Group 1 (P < 0.0001; HR: 47.9; 95% CI: 1.12-2050 and P < 0.007; HR: 4.62; 95% CI: 1.37-15.6, respectively). None of the patients in Group 3 had revision surgery or symptom recurrence. Simple adenoidectomy in children with large tonsils carries a high risk of revision surgery. However, given the high risk of severe obstruction in very young children with OSDB, timely surgery is recommended. 3.

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Segmental congenital deficiency of tracheal rings in cervical trachea managed by tracheal resection: A case report and literature review

Caroline Gahm, Anders Näsman, Georgios Papatziamos

Publication date 23-07-2021


Congenital deficiency of tracheal rings in the cervical trachea is a rare anomaly and only one case has previously been reported in the literature (Wineland et al., 2017) [1]. Here we report a case in a newborn female transferred to our department at 11 weeks of age for management of stridor. The patent was successfully treated with a tracheal resection with an end to end anastomosis. Presentation of symptoms, endoscopic findings, surgical approach, histological findings, and literature review are described.

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Postoperative respiratory complications after adenotonsillectomy in children with obstructive sleep apnea

Alfonso Caetta, Alisa Timashpolsky, Stephanie M. Tominaga, Neeta DSouza, Nira A. Goldstein

Publication date 20-07-2021


Children with obstructive sleep apnea are considered high risk for postoperative respiratory complications, but opinions differ regarding the polysomnography (PSG) criteria that suggest the need for postoperative admission. Our objective was to determine if otherwise healthy children age ≥3 years with an apnea-hypopnea index (AHI) < 24 on overnight PSG can be safely discharged on the same day of surgery. Case series with chart review of children age <18 years with positive PSG (AHI > 2) who underwent adenotonsillectomy (T&A) between January 2013 and August 2019. Data collected included patient demographics, medical history, comorbidities, PSG results, operative details, length of stay, intraoperative and postoperative respiratory complications and management. Potential predictors of respiratory complications were evaluated using chi-square/Fisher's exact test and 2-tailed unpaired t tests with the Bonferroni adjustment for multiple comparison artifact. The percentages of healthy children age ≥3 years who were discharged on the day of surgery at various PSG cutoffs were calculated. Of the 560 children, mean (SD) age was 6.4 (3.7) years, 318 (56.8%) were male, 438 (78.2%) were African American, 243 (43.4%) were obese, 16 (2.9%) had Down Syndrome and 12 (2.1%) had sickle cell disease. Median (range) AHI was 12.3 (2-145). Fifteen children (2.7% [95% CI 1.3, 4.0]) had an intraoperative or postoperative respiratory complication. Minor complications including mild desaturation, stridor, croupy cough, and laryngospasm occurred in 9 patients and did not prolong the planned ambulatory or hospital stay. Of the 6 children with more severe complications including prolonged desaturation, tachypnea, atelectasis, intercostal retraction and obstructive apnea requiring continuous positive airway pressure, all were planned admissions based on age, severe sleep study indices (AHI ≥ 24 or oxygen saturation nadir < 80%) or underlying medical condition. Of the 165 children age ≥3 without medical comorbidities known to be predictive of postoperative complications with an AHI ≥10 but <24, 113 (68.5%) were discharged home on the same day of surgery without additional respiratory sequelae. This study demonstrates a low risk of respiratory complications after T&A. Otherwise healthy children age ≥3 years with AHI <24 may be considered for ambulatory discharge.

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Outcomes of a universal neonatal hearing screening program of 9941 newborns over a one-year period in Campinas, Brazil

Laura Franco Chiriboga, Karolina Pessote Sideri, Sthefany Nathaly Ferraresi Rodrigues Figueiredo, Elaine Soares Monteiro Pinto, Luis Miguel Chiriboga Arteta

Publication date 19-07-2021


To characterize the outcomes of a universal neonatal hearing screening program in Brazil. Retrospective documentary analysis of the hearing screening of the neonates born in the hospital from August 2019 to July 2020. The universal neonatal hearing screening program performed the examination of TEOAE in newborn without risk factors for hearing loss and TEOAE and aABR in neonates with risk factors for hearing loss. 9941 neonatal records were studied, 9088 newborns (91,42%) with no risk factors for hearing loss and 849 newborns (8.54%) with risk factors for hearing loss. 4 newborns (0.04%) had hearing loss in the group without risk factors and 16 newborns (1.88%) in the group with risk factors. In retesting those newborns who failed the UNHS test stage, we had 4 newborns (0.04%) without risk factors and 2 newborns (0,24%) with risk factors who evaded and did not return to service. It was possible to survey the outcomes of one year of the UNHS service and observe that the coverage rate of the service was 99.96%. The use of the combined methodology guaranteed a number of forwardings for less returns. Through this study, it was possible to observe that this service complies with the quality indicators recommended by the guidelines.

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Efficacy of endoscopic sinus surgery alone versus in combination with neurosurgical intervention for the treatment of pediatric subdural empyema

Danielle M. Gillard, Yi Cai, Pinar Karakas Rothey, Nicolaus Coleman, Jordan M. Virbalas, Josephine A. Czechowicz, Jacqueline E. Weinstein

Publication date 17-07-2021


To compare treatment outcomes for sinogenic subdural empyema (SE) between those managed with initial endoscopic sinus surgery (ESS) alone versus those treated with a combination of ESS and craniotomy over the last decade at our institution. To better characterize subdural empyema with regard to presentation, causative pathogens, and treatment course. Retrospective single-center chart review to identify and evaluate pediatric SE patients between 2009 and 2019.
Patients meeting inclusion criteria were classified in one of two groups: those who initially underwent ESS or frontal trephination without concurrent neurosurgical procedure and those who underwent craniotomy or burr hole in addition to a sinus procedure. Presenting characteristics and treatment outcomes were compared between the two groups. Eighteen patients met inclusion criteria. The ESS alone and the ESS + craniotomy subgroups each had 9 patients with similar baseline characteristics. The ESS + craniotomy group was more likely to present with neurological symptoms (p = 0.039) and have multiple intracranial fluid collections (p = 0.046). 74.1% of patients presented to the Emergency Department (ED) or to their primary medical doctor and were treated with outpatient management prior to hospitalization with definitive surgical management. The most common presenting symptoms were fever, headache and nausea/vomiting. There were no differences between treatment groups in rate of return to the operating room (OR) (p = 1.00), length of stay (LOS) (p = 0.553), or adverse neurological outcomes (p = 0.456). 44.4% of patients in the ESS alone group eventually required neurosurgical intervention. Surgical SE patients often present to medical professionals in the primary care setting or ED and are managed with outpatient treatment before admission with definitive treatment. In this small retrospective cohort patients who underwent sinus intervention alone had similar rates of return to OR, LOS and adverse neurological outcomes use as those who underwent a sinus procedure in coordination with a neurosurgical intervention. There may be a group of patients with SE who may be managed with endoscopic procedures alone and further studies should seek to determine the characteristics of this population.

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Modified Sistrunk procedure in a pediatric population: Infected thyroglossal duct cysts as a risk factor for recurrence and review of the literature

Murat Gumussoy, Ibrahim Cukurova

Publication date 18-07-2021


To analyze the rate of recurrence and possible risk factors after surgical treatment in pediatric patients with thyroglossal ductus cyst (TGDC), who underwent the Modified Sistrunk Procedure (MSP). Retrospective study. The pediatric otorhinolaryngology clinic of a university. The study included a total of 251 pediatric patients aged between 2 and 17 years, whose histopathological diagnosis was confirmed and who underwent MSP due to TGDC over a period of 10 years from January 2009 to December 2019. The chi-square test was used to determine the relationship between the independent variables and the dependent variables.
Parameters used in the study: The parameters were age, gender, the history of infected TGDC before surgery (cellulitis, abscess), incision and drainage in patients with abscess, number of cysts detected in ultrasonographic imaging, postoperative histopathology, and the number of recurrences. The study included a total of 251 pediatric patients. The mean age of the children was 6.2 years (2-17 years), the mean follow-up period was 4.8 years (2-6 years), and 38 (15.13%) recurrences were observed after 251 MSP applications. Five risk factors were found to be statistically significant in terms of recurrence rates (p<0.05). These risk factors were surgery during the school period (6-10 years), history of infected TGDC, abscess formation, incision/drainage before MSP, and multicystic cyst in ultrasonographic evaluation. The main determinant for the five significant risk factors among the causes of MSP recurrence is a history of infected TGDC before surgery. When there is no history of TGDC infection in pediatric patients before surgery, surgery should be planned under appropriate conditions before infection occurs. The risk of infected TGDC, cellulitis, and abscess formation increases at school age in particular due to frequent upper respiratory tract infections. When there is a cyst infection, antibiotic treatment should be applied, and incision and drainage should be avoided as much as possible in the presence of an abscess.

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Whole exome sequencing of six Chinese families with hereditary non-syndromic hearing loss

Pengfei Liang, Fengping Chen, Shujuan Wang, Qiong Li, Wei Li, Jian Wang, Jun Chen, Dingjun Zha

Publication date 16-07-2021


Hereditary non-syndromic hearing loss (NSHL) has a high genetic heterogeneity with about 152 genes identified as associated molecular causes. The present study aimed to detect the possible damaging variants of the deaf probands from six unrelated Chinese families. After excluding the pathogenic/likely pathogenic variants in the most common genes, GJB2 and SLC26A4, 12 probands with prelingual deafness and autosomal recessive inheritance were evaluated by whole-exome sequencing (WES). All the candidate variants were verified by Sanger sequencing in all patients and their parents. Biallelic variants were identified in all deaf patients. Among these six families, 10 potentially causative variants, including 3 reported and 7 novel variants, in 3 different deafness-associated autosomal recessive (DFNB) genes (MYO15A, COL11A2, and CDH23) were identified. These novel variants are thought to be pathogenic or likely pathogenic for theirs predicted damage function upon the protein as while as cosegregated with the deafness phenotype. The variants in MYO15A were frequent with 7/10 candidate ones. Next-generation sequencing (NGS) approach becomes more cost-effective and efficient when analyzing large-scale genes compared to the conventional polymerase chain reaction-based Sanger sequencing, which is often used to screen common deafness-related genes. The current findings further extend the pathogenic/likely pathogenic variants spectrum of hearing loss in the Chinese population, which has a positive significance for genetic counseling.

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The utility of handheld ultrasound as a point-of-care screening tool to assess vocal fold impairment following congenital heart surgery

Anita Deshpande, Ching Siong Tey, Nikhil Chanani, April Landry, Mallory Raymond, Merry Sebelik, Subhadra Shashidharan, Michael Wolf, Nikhila Raol

Publication date 13-07-2021


Vocal fold motion impairment (VFMI) is a known potential complication of congenital heart surgery (CHS). Flexible nasolaryngoscopy (FNL) is the gold standard for evaluation of vocal fold movement but has risks, including epistaxis, desaturation, and changes in heart rate. Laryngeal ultrasound (LUS) has begun to emerge as a diagnostic tool and has been shown to have high accuracy in the evaluation of VFMI. We sought to assess the utility of hand-held LUS as a point-of-care screening tool to assess VFMI in pediatric patients following congenital heart surgery. Using a prospective cohort design, children under 18 years who were undergoing congenital heart surgery at a tertiary care pediatric hospital were enrolled. All patients underwent postoperative LUS and FNL. All studies were reviewed by two otolaryngology reviewers blinded to the clinical diagnosis. Higher quality studies were reviewed by two cardiology reviewers also blinded to the clinical diagnosis. Accuracy and inter-rater reliability were calculated. Sixty-two children were screened. Fourteen children with VFMI were identified via FNL. When comparing LUS and FNL, both individual accuracy (90.3% and 75.8%) and interrater agreement (79% overall, 96% for high quality videos) were high for the otolaryngology reviewers. The cardiology reviewers were able to obtain 100% accuracy for high quality videos. Handheld LUS has utility as a point-of-care screening tool to assess VFMI. This may have benefit in low-resource settings, for universal screening in cardiac intensive care units, or in settings where otolaryngology consultation may be difficult to obtain.

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Auditory Event Related Potentials in children with autism spectrum disorder

Mariana K. Kamita, Liliane.A.F. Silva, Fernanda.C.L. Magliaro, Fernanda D. Fernandes, Carla G. Matas

Publication date 11-07-2021


To analyze auditory cortical processing in high functioning ASD individuals. Thirty individuals were included in the study (15 with Autism Spectrum Disorder and 15 with typical development), and their Auditory Event Related Potentials evaluation, elicited with tone burst and speech stimuli, were analyzed. There were no significant differences between individuals with high-functioning Autism Spectrum Disorder without intellectual disability and those with typical development in the auditory Event-related Potentials elicited with tone bursts or speech stimuli. The results of Auditory Event Related Potentials did not show any change at the cortical level in individuals with Autism Spectrum Disorder.

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Ranula in children: Retrospective study of 25 years and literature review of the plunging variable

Andressa Bolognesi Bachesk, Luiza Roberta Bin, Isabela Vessoni Iwaki, Liogi Iwaki Filho

Publication date 10-07-2021


The aim of this article was to conduct a 25-year retrospective study within an oral surgery department, on the incidence of the ranula in children and its ideal treatment, associated with a literature review on the plunging ranula in pediatrics. A retrospective review of the medical records of pediatric patients (0-12 years) from 1995 to 2020 was performed in an oral surgery department in Maringá/Brazil. The examined data included age of the patients, sex, clinical signs, time of evolution and follow-up, complementary exams, type of ranula, diagnostic hypothesis, surgical procedures and accesses, complications and recurrence. In addition, a literature review was carried out on the plunging ranula in children, using the MEDLINE database, from 1995 to 2020, with the search terms: "PLUNGING RANULA" OR "CERVICAL RANULA. A PICOS was established and PRISMA standards were followed. In the retrospective study, of the 11 patients found, 10 were with simple ranulas and only 1 with plunging ranula. All patients were approached by intraoral access, and conservative treatments had higher recurrence rates. The case of plunging ranula was treated by intraoral resection of the sublingual gland and saliva drainage, and obtained good results with 15 years of follow-up. In the literature review, 372 articles were found, which 10 were qualitatively selected after inclusion and exclusion criteria. Excision of the sublingual gland was the most prevalent procedure, and intraoral and extraoral accesses had the same incidence, despite the fact that the last one had higher percentages of complications. The treatment of ranulas is variable; however, it is proven that conservative methods have higher rates of recurrence. As for the plunging ranula, resection of the sublingual gland through intraoral access, associated with mucus leakage, is considered a safe and effective treatment.

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Dysphonia and dysphagia consequences of paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS)

Rhiannon Halfpenny, Alexandra Stewart, Alison Carter, Michelle Wyatt, Christopher Jephson, Emma ODwyer, Lesley Cavalli

Publication date 09-07-2021


Paediatric inflammatory multisystem syndrome, temporally associated with SARS-CoV-2 (PIMS-TS) is a novel disease first identified in 2020. Recent cohort studies have described the complex presentation and symptomatology. This paper provides detailed description of the dysphagia and dysphonia symptoms, management, and outcome. To describe dysphagia and dysphonia in PIMS-TS. Retrospective cohort study. Single tertiary and quaternary children's hospital. All 50 children treated for paediatric multisystem inflammatory disease between April and June 2020 were included in this study.
Dysphonia: GRBAS Perceptual Severity Scores, Vocal Handicap Index scores and the Vocal Tract Discomfort Scale.
Dysphagia: Functional Oral Intake Scale. Fifty children met the diagnostic criteria for PIMS-TS. 33 (66%) were male. Median age was 10 years (range: 1-17). 36 (72%) were of Black, Asian or minority ethnic background. Nine (18%) required specialist assessment and management of dysphagia and/or dysphonia. Five (55%) were male with a median age of 9 years 7 months (range: 1-15 years). Symptoms typically resolved within three months. Two children presented with persisting dysphonia three months post-presentation. Neurological, inflammatory, and iatrogenic causes of dysphagia and dysphonia were identified. Dysphonia and dysphagia are present in children with PIMS-TS. Further data is required to understand pathophysiology, estimate incidence, and determine prognostic factors. This preliminary data highlights the need for dysphagia and dysphonia screening and timely referral for specialist, multidisciplinary assessment and treatment to ensure short-term aspiration risk is managed and long-term, functional outcomes are optimised.

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"Decision-making following identification of an infants unilateral hearing loss: Parent and professional perspectives"

Ann Porter, Nicola Sheeran, Michelle Hood, Peter Creed

Publication date 06-07-2021


Parents of infants identified with unilateral hearing loss (UHL) make decisions about managing their infant's hearing loss based on limited evidence and before knowing whether their infant will require additional support. The decision-making processes of parents and clinicians regarding the management of UHL following newborn hearing screening were examined.
Two convenience samples were recruited: 15 parents of children with permanent UHL aged under 4 years, and 14 clinicians. Applied thematic analysis of the semi-structured interviews elicited insight into the complexities surrounding decision-making from a parent and clinician perspective. Three main themes captured the decision-making process: motivation for decision-making, limited evidence creates uncertainty, and available evidence builds certainty. The diverse experiences and opinions of parents and clinicians highlight the complexity of decision-making when there are contested opinions and no clear best management option. The choices parents make about the management of their child's UHL can have lifelong implications for their child. Many questions need answering before parents can effectively evaluate the short- and long-term consequences of their options and whether the advantages outweigh the disadvantages in the long-term. This uncertainty is challenging for professionals and parents and risks cognitive biases influencing clinical and parental decision-making.

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Electrically evoked auditory brainstem responses to electrical stimulation at round window membrane in congenitally deaf children at different ages

Li Chen, Jun-Ge Zhang, Jing-Wu Sun, Xiao-Tao Guo, Jia-Qiang Sun

Publication date 06-07-2021


To investigate the usefulness of measuring the electrically evoked auditory brainstem responses (eABRs) to electrical stimulation at the round window niche (RWN) and round window membrane (RWM) and the effect of deafness duration on functions of the auditory pathway to the level of the brainstem. According to the age at cochlear implantation (CI), 99 children with profound sensorineural hearing loss were divided into four groups: ≤12 months (group A), 13-36 months (group B), 37-60 months (group C) and >60 months (group D). The eABRs were evoked by electrical stimulation at RWN and RWM during the operation of CI. The higher eABR extraction rate and lower threshold for RWM stimulation was found than those for RWN stimulation. The eⅢ latencies and eⅢ-eⅤ latency intervals for RWM stimulation were similar among four groups. However, children with earlier CI (group A) showed a significantly shorter eⅤ latency than others. The eABR evoked by the electrical stimulation at RWM is more stable and sensitive compared with that at RWN for evaluating functions of the auditory conduction pathway. Development in the upper brainstem pathway may be more vulnerable to long-term deafness as revealed by the eⅤ latency.

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Does ibuprofen, prednisolone, or amoxicillin reduce post-tonsillectomy pain in children? A prospective randomized controlled trial

Carolina B. de Azevedo, Fabiana C.P. Valera, Lucas R. Carenzi, Daniel S. Küpper, João Vitor B. Caetano, Danielle L.C. Queiroz, Wilma T. Anselmo-Lima, Edwin Tamashiro

Publication date 07-07-2021


To evaluate whether the use of anti-inflammatory or antibiotic in the postoperative period modifies pain in children undergoing tonsillectomy. 225 children who underwent cold knife tonsillectomy ± adenoidectomy were randomized into five groups, receiving #1 metamizole/acetaminophen, #2 amoxicillin, #3 ibuprofen, #4 prednisolone, or #5 amoxicillin plus prednisolone. All groups received oral analgesics (metamizole/acetaminophen) to use as needed. Pain was monitored during the 7 days following surgery using the Parents' Postoperative Pain Measurement (PPPM) and the Faces Pain Scale - Revised (FPS-R). Pain was also indirectly evaluated by the dose of analgesics administered on each day and by the time needed to return to a solid diet. After losses (24%), 170 individuals were submitted for analysis. Multiple comparisons demonstrated that the evolution of pain between the different groups, as matched day-per-day, was not significantly different by either PPPM or FPS-R (p > 0.05). The instances of analgesic intake were also similar in all the groups (p > 0.05), as was the return to solid food ingestion (p = 0.41). All groups presented a similar standard of clinical improvement at intervals of 2 days (p < 0.01). Independent of postoperative pain management, patients developed significant pain up to the day 4 following surgery. The addition of amoxicillin, ibuprofen, prednisolone, or amoxicillin and prednisolone does not modify postoperative pain in children undergoing cold-knife tonsillectomy. Special pain control should be performed on the first 4 days following tonsillectomy in children.

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Exploring the relationship between conductive hearing loss and cleft speech characteristics in children born with cleft palate

Sharon Baker, Yvonne Wren, Fei Zhao, Francesca Cooper

Publication date 05-07-2021


Children with cleft palate are at high risk of both conductive hearing loss and cleft speech characteristics (CSCs) yet there is limited research to understand whether hearing loss impacts speech development in this population by contributing to the development of CSCs. This study used data from a large national cohort study in the UK (The Cleft Collective) to explore the relationship between those with a history of diagnosed hearing loss and presence of CSCs in children with cleft palate (+/- cleft lip) aged between 18 and 24 months. Speech and Language Therapists (SLTs) provided uniformed information from assessment for 123 participants who had been recruited to the Cleft Collective study. History of diagnosed hearing loss, intervention for hearing loss, and presence of CSCs were reported. A consonant inventory for each participant was completed. Statistical analysis of relationships between hearing loss and CSCs and analysis of consonant inventories was undertaken to provide information related to speech acquisition and its relationship with hearing. There was a statistically significant relationship between history of diagnosed hearing loss and presence of CSCs (p < 0.05). Analysis of the consonant inventories highlighted that children with diagnosed hearing loss used fewer oral consonants compared to those with normal hearing (p < 0.05) CONCLUSION: This study provides some evidence that a conductive hearing loss can affect speech in children with cleft palate resulting in CSCs developing. Therefore, children with cleft palate should be closely monitored by audiology from birth to ensure that hearing is optimised for speech and language development. SLT services should also closely monitor the speech development of those children where a hearing loss has been identified, so that early intervention can be provided if appropriate. Continued data collection, with a large sample of children, will provide additional evidence regarding how this hearing loss is best managed. It will also allow increased knowledge of the long term impact of conductive hearing loss on speech development in children with cleft palate.

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A study on the association of functional hearing behaviors with semantics, morphology and syntax in cochlear-implanted preschool children

Sevgi Kutlu, Hilal Burcu Ozkan, Esra Yucel

Publication date 03-07-2021


Monitoring children's development of auditory perception, speech and language after implant programming is critical to post-implantation success. Most of the time, it is not possible to perform an evaluation in clinical conditions, and the tests administered may not provide adequate data on children's everyday functional hearing skills. Therefore, administration of functional hearing measures alongside clinical tests will present supplementary data as to both language development and functional hearing performance of children. In addition, determining demographic and environmental variables affecting functional hearing skills and language development will facilitate the implementation of countermeasures. The main objective of this study was to investigate the relationship of functional hearing behaviors in cochlear-implanted children with semantics, morphology and syntax, and to determine how various variables affect functional hearing and language development. The study was conducted with 48 cochlear implant users (24 female and 24 male) aged between 3 years and 5 years 11 months with no additional disability. The Test of Early Language Development -Third Edition (TELD-3) was administered to the children participating in the study, and the Functioning after Pediatric Cochlear Implantation (FAPCI) and the demographic information form was completed pursuant to the information provided by the parents. Data analysis in accordance with our hypotheses revealed a significant relationship between semantics, morphology, syntax and functional hearing skill (p < 0.05). The results indicated that language development and functional hearing skill were positively affected by duration of implant use, duration of auditory rehabilitation and kindergarten attendance, and a negative relationship between screen time and functional hearing skill. In conclusion, the FAPCI is a suitable measure for early listening development and language assessment after cochlear implantation surgery, providing supplementary data on functional hearing and language development when administered in conjunction with other tests. Many factors are affecting functional hearing and language development that determine cochlear implant success. It is important to identify these factors.

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Investigating the cepstral acoustic characteristics of voice in healthy children

Ayşe Nur Demirci, Ayşen Köse, Fatma Esen Aydinli, Önal İncebay, Taner Yilmaz

Publication date 04-07-2021


This study aimed to determine the cepstral acoustic parameters that vary depending on age and gender in vocally healthy children, and to establish normative data for cepstral analysis. Cepstral measurements are among the strongest predictors of auditory-perceptual evaluation of voice and differentiate between healthy and dysphonic voices. More spesificially, ceptral peak prominence is accepted to be as a strong acoustic predictor of breathiness and overall severity of dysphonia. Cepstral measures determine voice quality reliably not only in sustained vowel samples but also in running speech samples. Determining the parameters related to the acoustic profile of children with normal voices can lead us to a better understanding of the effect of changes in the larynx and vocal fold structure during growth and development. There is a limited number of norm studies examining the cepstral acoustic properties of pediatric voice. Determining norm-specific values and clinical guidelines of cepstral acoustics according to the age and gender in vocally healthy children are utmost important.
A total of 160 vocally healthy children were divided into the following four age groups: Group-I included children within the age range of 4-7 years, Group-II included 7-11 years, Group-III 11-14 years, and Group-IV included children within the age range of 14-18 years. An equal number of male and female participants were assigned to each group. PENTAX Medical CSL Model 4500 was used for recording all tasks. For acoustic analysis, Multi-Dimensional Voice Program and Analysis of Dysphonia in Speech and Voice were used. Cepstral Peak Prominence (CPP), Cepstral Peak Prominence Standard Deviation (CPP SD), and Low-To-High Spectral Ratio (L/H Ratio) increased with age. It is found that the CPP parameter of all-voiced sentences and nasal-weighted sentences increased with age in boys, while no significant pattern was observed in any sample for girls. For L/H ratio, it can be said that there is a general increase with age in all speech samples, except for the vowel-weighted and voiceless plosive sentence samples, evident especially in the group above the age of 15 years. This study concluded that the CPP SD parameter in the vowel-weighted sentences increased with age in boys. It was also noticed in this study that CPP F0 standard deviation (SD) intervals were narrower in vowel-weighted, easy onset, and voiceless plosive sentence samples than in all-voiced, hard glottal attack and nasal-weighted sentence samples. This study established cepstral acoustic normative values for a wide age range of the pediatric population. It is thought that age and gender specific cepstral acoustic findings presented in this study contributed to the related literature. In addition, to our knowledge, this is the first study that provides a normative cepstral acoustic database of the CAPE-V/Turkish sentences in the pediatric population.

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Perception of temporally enhanced and hearing aid processed speech in children with late-onset Auditory Neuropathy Spectrum Disorder

Srikar Vijayasarathy, Hemanth Narayan Shetty

Publication date 02-07-2021


To investigate phrase perception and subjective quality preference of temporal enhancement-based speech processing strategies: Deep-band modulation and Stretching, and hearing aid processed speech in adolescents with late-onset Auditory Neuropathy. 15 participants with Auditory Neuropathy Spectrum Disorder were involved. Speech perception was assessed using unprocessed, deep-band modulated, stretched, and hearing aid processed conditions. Subjective preference was also assessed using the pair-wise comparison technique. Gap detection test was done using broadband noise to investigate the possible correlation with benefit from processing strategies. As a group, no significant benefits were found with processed speech. Clinically relevant trends emerged on subdividing the group into good and poor performers. Deep-band modulation processing was significantly better than unprocessed speech in those with poorer speech recognition abilities. There was a trend for those with poorer temporal processing abilities to benefit more with deep-band modulation processing. In those with relatively better speech recognition abilities, processing showed no benefit, and hearing aid processed speech was inferior to unprocessed speech. Quality-wise, the unprocessed speech was preferred by all the participants. Among the processed conditions, deep-band modulation was preferred by most, followed by stretching and hearing aid processed speech. Results indicate that temporal enhancement strategies may be beneficial for a subset of individuals with ANSD with poorer temporal processing and speech perception abilities. However, processing strategies need to take into account the quality aspect and not just intelligibility.

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Loss to follow up of failed hearing screen and missed opportunities to detect congenital cytomegalovirus are better identified with the implementation of a new electronic health record system protocol

Eileen Raynor, Christine Holmes, Matthew Crowson, Sarah Peskoe, Arrianna Planey, Paul M. Lantos

Publication date 02-07-2021


Congenital CMV (cCMV) is the leading cause of non-genetic sensorineural hearing loss. Babies with cCMV can present with hearing loss any time but failing the initial hearing screen should trigger cCMV testing. cCMV must be identified within 3 weeks after birth to differentiate congenital from acquired CMV, yet follow-up hearing screens may not occur until after 21 days. A new electronic health record protocol to test cCMV in babies who fail their initial hearing screen was established at our institution in 2013. The purpose of this study is to evaluate adherence and deviations from this protocol. All term infants born in 2013-2016 who failed initial hearing screen were included. The records were reviewed retrospectively. Demographic data, dates of hearing screens, CMV testing results and follow-up hearing test results were collected. A total of 19,069 newborn babies were screened between 2013 and 2016. Babies who were in the neonatal intensive care unit whether premature or not were excluded as these infants are often in the hospital longer than 3 weeks so audiologic diagnostic testing may be delayed. Among term newborns screened, 1358 failed initial screen and 444 failed subsequent hearing testing prior to discharge. We identified 60 babies who did not follow up and 59 underwent additional audiologic testing. Overall 38 babies were tested for cCMV with 2 positives. We found an increase in cCMV testing over time and a significant decrease between physical distance from birth hospital and outpatient audiologic follow-up testing within 21 days of birth. Our results are consistent with a 0.4% rate of cCMV in full-term babies who failed their newborn hearing screen. From 2013 to 2016, more babies received CMV tests, but post-screening follow up was still delayed. Further research is necessary to address factors affecting follow up. Use of electronic health record eased identification of results and improved tracking.

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Morphological classification of crista fenestra of round window corridor during pediatric cochlear implantation

Saad Elzayat, Hitham H. Elfarargy, Islam Soltan, Mona A. Abdel-Kareem, Maurizio Barbara, Ashraf Fayed, Fathi Baki

Publication date 02-07-2021


This study aimed to document the observation of the Crista Fenestra's morphological types (CF) of the round window and to detect its impact during cochlear implant operation. A prospective descriptive cohort study. We conducted this study at tertiary referral institutions in Egypt. This study included 140 children who underwent cochlear implantation. We observed the CF's morphological type during the operation according to (Baki-Elzayat) novel classification of CF anatomy, and the need for drilling in each CI operation. CF has two main types. Type A, in which CF was present at the same level of round window membrane and attached to it. Type B, in which CF was medial to the Round window membrane. Type (A) CF was detected in 125 cases (89.28%), while 25 cases (10.71%) showed type (B) CF. Drilling was needed in 10 cases (7.14%), including CF types A.3 and B2. Drilling was not needed in 130 cases (92.85%), including CF type A.1, A.2, and B.1. There was a statistically significant difference in the need for drilling (P-value <0.001). According to this prospective study, CF had complicated anatomy. Baki-Elzayat classified the CF into two main types. In type A, CF was at the same level of RWM and attached to it. In type B, CF was medial to RWM. We recommended drilling for partial removal of massive CF types (A.3 and B.2) for atraumatic safe insertion of the electrode without deflection. This classification can offer an easy language system for CI surgeons to describe and register CF during their operations and in the surgical files.

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Repeat tympanostomy tubes in children with Down syndrome

Mahmoud Omar, Jennifer L. McCoy, Andrew A. McCormick, Kishore Vellody, David H. Chi

Publication date 02-07-2021


Children with Down syndrome (DS) have a higher incidence of tympanostomy tube insertion (TTI) than children in the general population. As there were no studies investigating factors that are associated with multiple TTIs in children with DS, we sought to determine what factors increase or decrease the likelihood of repeat TTI in children with DS. A retrospective case-control study was performed on consecutive children with DS from 2007 to 2018 with first TTI at a large tertiary children's hospital and follow-up duration at least 27 months since first TTI. 277 patients met the inclusion criteria. Repeat TTI rate was 61.4%. Having an indication of chronic otitis media with effusion (COME) at first TTI was an adjusted risk factor for increased rate of repeat TTI (OR: 2.01, 95%CI: 1.15-3.51, p = .014), while being older at first TTI was an adjusted protective factor for decreased rate of repeat TTI (OR: 0.84, 95%CI: 0.74-0.95, p = .004). Adenotonsillectomy at or before first TTI was not an adjusted protective factor for decreased rate of repeat TTI (OR: 0.915, 95%CI: 0.448-1.872, p = .809) and bilateral intra-operative fluid was not an adjusted risk factor for repeat TTI (OR: 1.97, 95%CI: 0.99-3.90, p = .054). Children with DS were more likely to undergo repeat TTI if they were of younger age and if the indication for surgery was COME. The repeat TTI rate for children with DS was high at 61.4%. Prospective studies are warranted to more precisely investigate factors associated with repeat TTIs in this unique patient population.

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Traumatic perforations are associated with previous tympanostomy tube placement

Glenn Isaacson, Brian Reilly

Publication date 03-07-2021


Recognized late complications of tympanostomy tube placement include persistent tympanic perforation, tympanosclerosis, and focal atrophy. Based on clinical experience, we suspected that atrophy at healed tympanostomy tube sites might predispose to re-perforation following trauma. Computerized record review of children seen in an academic pediatric otolaryngology practice from January 2001 to December 2020. 33 children with confirmed traumatic tympanic perforations and complete follow-up were identified. All perforations were unilateral. 19 of 33 (58%) perforations were in children with tympanostomy tube placement in the past and 14/33 (42%) had never had tubes. 17/19 (90%) traumatic perforations in the tube group were due to blunt or barotrauma rather than penetrating trauma as compared with 6/13 (46%) in the non-tube group (p = 0.0147 by Fisher's exact test). One patient in the non-tube group had an unknown mechanism of injury. 15/19 perforations in the tube groups were in the antero-inferior or antero-superior quadrants (old tube sites) compared to 4/14 in the non-tube group (p = 0.0152). Perforations tended to be larger in the non-tube group (non-tube mean perforation size = 27%/tube group mean = 18%) The median time to re-perforation was 8 years (range 3-15 years). Boys predominated in both perforation groups. Traumatic perforations in this series occurred more often in the antero-inferior quadrant (old tube site) in children with previous tympanostomy tube placement. These perforations tended to be smaller and less often resulted from penetrating injuries than in children who had never undergone tube placement. 3B - individual case-control study.

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Congenital cytomegalovirus (CMV) for the pediatric otolaryngologist

J. Drew Prosser, Thomas W. Holmes, Mohammad Seyyedi, Daniel I. Choo

Publication date 02-07-2021


Cytomegalovirus (CMV) is a double-stranded DNA virus and a member of the herpesvirus family. It is the most common congenital viral infection. For symptomatic infections, symptoms can vary widely but tends to have a predilection for the central nervous system and for the reticuloendothelial system. Sensorineural hearing loss (SNHL) is by far the most common sequelae of congenital CMV infection. For this reason, it is imperative to understand the screening, diagnosis, and possible treatment options for congenital CMV induced SNHL. This literature review explores the association of CMV with hearing loss, screening for congenital CMV infections, possible treatments options, and the development of a possible vaccine.

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"Authors response to a letter to the editor IJPORL-D-20-01778: Response to a Letter to the Editor"

Ana Concheiro-Guisan, Isabel González-Guijarro

Publication date 08-02-2021


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