A Novel Articulating Chip-on-Tip Endoscope for Dynamic Middle Ear Surgical Visualization

OBJECTIVE

To enhance visualization in pediatric Otolaryngology middle ear surgeries and reduce mastoidectomy instances, we introduce a novel Articulating Chip-on-Tip Endoscope (ACoT Endo).

METHODS

The ACoT Endo incorporates a cable-driven distal end camera and off-the-shelf Chip-on-Tip camera to improve visualization. We compared its capabilities with standard endoscopes, evaluating its bending capacity (70 ° ± 2 °) and center axis rotation (360 °). To test the overall functionality of this device, a Mock Ear was created to simulate the anatomy of the human ear, and the ACoT Endo's ability to be used in this cavity is compared to a standard 0 ° Karl Storz endoscope through tests with the Mock Ear and respective endoscopes.

RESULTS

The ACoT Endo accurately captured surgical details similar to standard endoscopes in the ENT field. Compared to the 0 ° Karl Storz endoscope, the ACoT Endo demonstrated an increased field of view by approximately 69% and captured area by approximately 249%. ACot Endo allowed the surgeon to effortlessly articulate the camera with the rotation of a finger, while an excision tool was inserted in the middle ear, a procedure that is currently extremely difficult with standard endoscopes.

CONCLUSION

The ACoT Endo's dynamic viewing angle and Chip-on-Tip camera enable unparalleled surgical visualization within the middle ear using a single endoscope, offering potential benefits in Otolaryngology procedures.

SIGNIFICANCE

By reducing the need for invasive mastoidectomies and providing better visualization tools, the ACoT Endo has significant potential to improve outcomes and safety in pediatric middle ear surgeries.

Olfactory dysfunction and training in children with COVID-19 infection: A prospective study Post-COVID pediatric olfactory training

OBJECTIVE

Postviral olfactory dysfunction (OD) including corona 2019 viral disease (COVID-19) OD occurs in both adults and children. Despite limited reports of efficacy in treating adult postviral including COVID-19 OD with olfactory training (OT), its effects on children in general, and post-COVID-19 in specific, is unknown. The study aimed at evaluating the effects of OT in a COVID-19 OD pediatric cohort.

METHODS

A single-arm prospective study of pediatric COVID-19 OD subjects confirmed by the University of Pennsylvania Smell Identification Test (UPSIT), was conducted. All subjects underwent OT by sniffing 4 odorants (lavender, orange, peppermint, and eucalyptus) for 1 min twice a day for 3 months. Subjects underwent an odorant identification test (OIT) of the 4 odorants each visit. A repeat UPSIT was administered at the 4th visit.

RESULTS

The study enrolled a total of 37 subjects [11 males/26 females with mean age/standard deviation (std) of 15.6(2.1) years]. The time interval between COVID-19 and entry was 5.3(2.4) months. The mean pre/post study UPSIT score improvement was 2.3(4.7), p = .09. OIT scores between entry and 3 subsequent visits showed a mean improvement of 1.8(1.5), 1.8(1.9) and 2.3(1.9) odorants, respectively, with P < .001 for all 3 comparisons.

CONCLUSIONS

OT subjects were predominantly female teens with substantial OD lasting greater than 5 months. OT did not affect OD as measured by UPSIT but OIT scores improved during OT. We postulate that OT likely has a role in pediatric post-COVID OD recovery, but UPSIT likely is too rigid to detect disparate odorant improvement.

Postmeningitic pediatric hearing loss from non-type b Haemophilus influenzae

BACKGROUND

Postmeningitic hearing loss from Haemophilus influenzae (H. influenzae) is increasingly due to encapsulated serotypes other than type b (Hib) and nontypeable strains (collectively, nHiB H. influenzae). Pediatric hearing loss after nHib H. influenzae meningitis remains poorly described.

METHODS

Retrospecive case series of nHiB H. influenzae meningitis cases identified from a microbiologic database at Children's Hospital Colorado from 2000 to 2020. Literature regarding nHiB H. influenzae and H. influenzae postmeningitic hearing loss was also reviewed.

RESULTS

Eleven cases of nHib H. influenzae meningitis (median age 15.9 months) were identified due to serotype f (36 %), serotype a (27 %), and nontypable strains (36 %). Seven (64 %) patients were male, 55 % were white and 18 % were Hispanic or Latino. Hearing loss was initially identified in 4 children (40 %), with two patients with moderate conductive hearing loss (CHL) and one child with unilateral moderate sensorineural (SNHL) hearing loss patients recovering normal hearing. One patient with bilateral profound sensorineural hearing loss and associated labyrinthitis ossificans required cochlear implantation. All children (4) with identified hearing loss were noted to have additional intracranial sequelae, which included empyema (2), sinus thrombosis (2), and seizures (2). Of patients receiving steroids, 25 % had hearing loss on initial testing, compared to 66 % of those who did not receive steroids.

CONCLUSIONS

nHib H. influenzae can cause both transient and permanent postmeningitic hearing loss. Steroids may offer otoprotection in nHib H. influenzae meningitis similar to Hib meningitis. Given the limited literature, further study is needed to better characterize hearing outcomes after nHib H. influenzae meningitis.

Pediatric head and neck manifestations associated with multiple endocrine neoplasia syndromes

INTRODUCTION

Multiple endocrine neoplasia (MEN) syndromes are a group of hereditary cancer syndromes that can predispose children to endocrine neoplasms developing within the head and neck.

OBJECTIVE

To examine the neoplastic manifestations of MEN type 1 (MEN1) and MEN type 2 (MEN2) in the pediatric head and neck.

METHODS

Single-institution, retrospective review of pediatric MEN between 2005 and 2022.

RESULTS

Fifty-three children were genetically confirmed with MEN (15 MEN1, 34 MEN2A, and 4 MEN2B), while three patients received clinical diagnoses of MEN1. The male to female ratio was essentially equal (1.15:1), and a documented family history of cancer was present in 89% (50/56). After multidisciplinary evaluation, a familial MEN diagnosis was confirmed in 91% (51/56). The mean ages of initial presentation and surgical intervention were 8.9 years (SD 5) and 9.8 years (SD 4.8), respectively. Although patients with MEN2 received surgery earlier than patients with MEN1 (8.7 vs 12.7 years), surgical patients with MEN2 in this cohort were older relative to current American Thyroid Association (ATA) guidelines primarily due to late presentation. Thyroid malignancies were identified in 36% (9/25) of thyroidectomy specimens (21 MEN2A, 4 MEN2B), with medullary thyroid carcinoma (MTC) present in five MEN2A patients and three MEN2B patients (89%), and papillary thyroid carcinoma (PTC) present in one MEN2A patient (11%). Nearly 90% (8/9) of thyroid malignancies were occult, with some occurring earlier than predicted by current guidelines (ATA-MOD and ATA-H). Central neck dissections were performed in 24% (2 MEN1, 2 MEN2A, and 4 MEN2B), with two MEN2B (50%) demonstrating cervical lymph node (LN) metastases. Additional histopathologic findings included C-cell hyperplasia in 57% (12/21) of MEN2A thyroidectomy patients. Of the eight MEN1 parathyroidectomy patients, four demonstrated parathyroid hyperplasia and four presented with parathyroid adenoma.

CONCLUSION

Nearly 60% required head and neck procedures. While MEN1 guidelines were appropriate for our cohort, we identified patients with MEN2 that developed MTC earlier than expected based on current ATA guidelines, including children in categories considered lower risk. In conjunction with a multidisciplinary approach, pediatric head and neck surgeons should be aware of the potential need for earlier surgical intervention in the pediatric MEN2 population.

Pediatric primary salivary gland tumors

OBJECTIVES

To characterize the presentation and treatment of children presenting with primary salivary gland neoplasms.

METHODS

A retrospective review of primary salivary tumor patients presenting to Children's Hospital Colorado between January 2000 and August 2020.

RESULTS

Fifty children were identified with primary salivary gland tumors, comprising of 39 (78 %) benign and 11 (22 %) malignant lesions. Pleomorphic adenoma was the most common benign tumor (36/39, 92 %), while acinic cell carcinoma was the most common malignancy (7/11, 64 %). The parotid gland was the most common site, followed by the submandibular gland (66 % vs. 34 %). No tumors were found in the sublingual glands. Benign neoplasms accounted for 70 % of parotid lesions and 94 % of submandibular tumors. No significant differences in age (13.6 years, SD 4 vs. 13.0 years, SD 4.3) were noted between patients with benign and malignant disease, but tumors in females were more frequently malignant (M:F 1:1.3 vs. 1:2.7 for benign and malignant tumors, respectively). Neck dissection and/or facial nerve sacrifice were required in 27 % (3/11) and 9.1 % (1/11) of malignancies, respectively. Local recurrence was observed in 7.7 % (3/39) of benign cases and 9.1 % (1/11) of malignant cases. No salivary malignancies required chemotherapy, though one patient with neurofibromatosis received imatinib prior to resection. Two patients with locoregional malignancy received adjunctive radiation. The average duration of follow up for benign and malignant disease were 12.6 ± 25 and 45.1 ± 32 months, respectively.

CONCLUSIONS

This study presents one of the larger single institutional experiences of pediatric primary salivary neoplasms in the past 20 years, identifying pleomorphic adenoma and acinic cell carcinoma as the most common benign and malignant etiologies, respectively. While this review found most neoplasms presented as a localized mass effectively managed with conservative surgical resection, aggressive tumors required multidisciplinary care.

Rosai-Dorfman-Destombes Disease in the Pediatric Head and Neck

BACKGROUND

Rosai-Dorfman-Destombes disease (RDD), or sinus histiocytosis with massive lymphadenopathy, is a rare form of non-Langerhans cells histiocytosis. It has a wide-ranging variability in presentation since first described in 1969 but much of its characteristics in children remain unknown.

METHODS

A retrospective chart review of children diagnosed with RDD at a tertiary care children's hospital was conducted from 2000 to 2021.

RESULTS

Twelve RDD patients were identified, with an average age of 7 years (SD 4.3). Males comprised 58% of the cohort, and African American ethnicity was most common (42%). Nodal RDD was found in 7 patients (58%). Nine patients (75%) presented RDD within the head and neck, 6 of whom had nodal RDD. The most common presentation was cervical lymphadenopathy, which most often involved levels V (67%), II (56%), III (44%), and I (11%), in order of frequency. Recurrence and persistence of disease after initial treatment was common, with 5 (42%) being disease free at the time of the last follow up. Fifty-eight percent (7/12) developed recurrence or had persistent disease and 4 required adjuvant systemic treatment with corticosteroids and/or chemotherapy. One patient succumbed after developing treatment related acute myelodysplastic leukemia (t-AML) from chemotherapy used to treat recurrent RDD.

CONCLUSION

Pediatric RDD presents at a young age and most commonly involving cervical lymphadenopathy. Ongoing surveillance in the setting of persistence or recurrence without clearly defined prognostic risk factors is important.

Otitis Media in Children with Down Syndrome Is Associated with Shifts in the Nasopharyngeal and Middle Ear Microbiotas

Background: Otitis media (OM) is defined as middle ear (ME) inflammation that is usually due to infection. Globally, OM is a leading cause of hearing loss and is the most frequently diagnosed disease in young children. For OM, pediatric patients with Down syndrome (DS) demonstrate higher incidence rates, greater severity, and poorer outcomes. However, to date, no studies have investigated the bacterial profiles of children with DS and OM. Method: We aimed to determine if there are differences in composition of bacterial profiles or the relative abundance of individual taxa within the ME and nasopharyngeal (NP) microbiotas of pediatric OM patients with DS (n = 11) compared with those without DS (n = 84). We sequenced the 16S rRNA genes and analyzed the sequence data for diversity indices and relative abundance of individual taxa. Results: Individuals with DS demonstrated increased biodiversity in their ME and NP microbiotas. In children with OM, DS was associated with increased biodiversity and higher relative abundance of specific taxa in the ME. Conclusion: Our findings suggest that dysbioses in the NP of DS children contributes to their increased susceptibility to OM compared with controls. These findings suggest that DS influences regulation of the mucosal microbiota and contributes to OM pathology.

Concurrent Pediatric Lingual and Submental Dermoid Cysts: Case Report and Literature Review

This pediatric case report describes the novel finding of concurrent submental and lingual dermoid cysts, which to our knowledge, has not been previously reported in the literature. The etiology of cysts involving the tongue, floor of the mouth, and submental neck is varied, representing congenital, inflammatory, and neoplastic sources. Dermoid cysts involving these regions are uncommon and are most frequently reported in the submental, sublingual, and lingual spaces. Presenting symptoms vary with cyst size and position relative to the mylohyoid muscle. MRI is the preferred modality to differentiate dermoid cysts from other etiologies. While interventional techniques have been utilized to treat dermoid cysts in other head and neck locations, surgical excision remains the preferred treatment for those involving oral and floor-of-mouth structures.

Hearing outcomes in children with pneumococcal meningitis in the PCV13 era

INTRODUCTION

Streptococcus pneumoniae, is associated with the highest incidence of post-meningitic SNHL. The exact impact of 13-valent pneumococcal conjugate vaccine (PCV) on pediatric SNHL from pneumococcal meningitis is unknown. We aimed to identify clinical factors associated with post-meningitic SNHL (pmSNHL) from pneumococcal meningitis and describe its rates based on three time periods: pre-PCV, PCV-7 and PCV13 eras.

METHODS

A retrospective case-control study was performed for patients 18 years and younger diagnosed with pneumococcal meningitis from January 1, 2010 to December 31, 2020 at Children's Hospital Colorado. Demographic and clinical risk factors between those with or without SNHL were compared. Detailed hearing outcomes of those with resulting SNHL are described.

RESULTS

23 patients with CSF cultures or Meningitis/Encephalitis Panel positive for pneumococcal meningitis were identified. Twenty patients both survived the infection and had audiologic evaluation. Six patients had pmSNHL, with 50 % affected bilaterally. The rate of pmSNHL from S. pneumoniae in the PCV-13 era at our institution was similar to historical rates from the pre-PCV and PCV-7 eras. Similar proportions of patients with pmSNHL completed PCV vaccination (66.7 %) compared to those without (71.4 %). Non-PCV-13 serotypes were responsible 83 % of patients with pmSNHL versus 57 % of patients without pmSNHL.

CONCLUSIONS

Despite high rates of PCV-13 uptake in our cohort, pmSNHL was still common, severe, and commonly associated with non-PCV-13 serotypes. Non-PCV-13 serotypes may be contributing to the persistently high rate of post-meningitic SNHL and the severity of SNHL. Newer pneumococcal conjugate vaccines with expanded serotypes may help mitigate the SNHL associated with pneumococcal meningitis.

Olfactory testing as COVID-19 screening in school children; A prospective cross-sectional study

BACKGROUND

Little is known about olfactory changes in pediatric COVID-19. It is possible that children under-report chemosensory changes on questionnaires, similar to reports in adults. Here, we aim to describe COVID-19-related olfactory dysfunction in outpatient children. We hypothesized that children with COVID-19 will demonstrate abnormal olfaction on smell-identification testing at a higher rate than children with negative COVID-19 testing.

METHODS

A prospective cross-sectional study was undertaken from June 2020-June 2021 at a tertiary care pediatric hospital. A consecutive sample of 205 outpatients aged 5-21 years undergoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) PCR testing were approached for this study. Patients with prior olfactory dysfunction were excluded. Participants were given a standard COVID-19 symptom questionnaire, a Smell Identification Test (SIT) and home-odorant-based testing within 2 weeks of COVID-19 testing. Prior to study enrollment, power calculation estimated 42 patients to determine difference in rates of SIT results between groups. Data were summarized with descriptive statistics.

RESULTS

Fifty-one patients underwent smell identification testing (23 positive (45%) and 28 negative (55%) for COVID-19; mean age 12.7 years; 60% female). 92% of all patients denied subjective change in their sense of smell or taste but only 58.8% were normosmic on testing. There was no difference in screening questionnaires or SIT scores between COVID-19 positive and negative groups.

CONCLUSIONS

Unlike adults, there was no statistical difference in olfactory function between outpatient COVID-19 positive and negative children. Our findings suggest a discrepancy between objective and patient-reported olfactory function in pediatric patients, and poor performance of current screening protocols at detecting pediatric COVID-19.

Pediatric Primary Tympanoplasty Outcomes With Autologous and Non-autologous Grafts

OBJECTIVE

To compare rates of successful tympanic membrane (TM) closure in primary pediatric tympanoplasty between various autologous and non-autologous tissues.

METHODS

A retrospective chart review was performed examining all primary pediatric tympanoplasties over a 20-year period at a single institution.

RESULTS

In 564 pediatric tympanoplasties, no statistically significant difference existed between success rates of autologous and non-autologous grafts (p = 0.083). Compared with fascia, the hazard ratios (and 95% confidence intervals [CI]) for failure for each graft were as follows: human pericardial collagen (HR 0.90, CI 0.54-1.50, p = 0.680), porcine submucosal collagen (HR 1.07, CI 0.56-2.05, p = 0.830), human acellular dermal collagen (HR 1.66, CI 0.95-2.87, p = 0.073), and "multiple grafts" (HR 0.72, CI 0.26-1.98, p = 0.520). Survival curves demonstrated that 75% of graft failures occurred by 6 months after surgery, the rest occurring between 6 and 12 months postoperatively. Larger perforations encompassing more than or equal to 50% of the TM had lower success rates (HR 1.50, CI 1.02-2.21, p = 0.041) than smaller perforations encompassing less than 50% of the TM. Age was not correlated with success (HR 0.98, CI 0.93-1.03, p = 0.390).

CONCLUSION

This study found that non-autologous collagen grafts provide equivalent rates of healing when compared with autologous tissue in primary pediatric tympanoplasty. In addition to the potential for reduced operative time and donor site morbidity, these materials provide a viable graft alternative in fascia-depleted ears.Level of Evidence: Level 4.

Growth After Adenotonsillectomy for Obstructive Sleep Apnea: Revisited

OBJECTIVES/HYPOTHESIS

To reanalyze the growth trajectory and assess longitudinal changes of children undergoing adenotonsillectomy (AT) versus watchful waiting (WW) enrolled in the Childhood Adenotonsillectomy Trial (CHAT) study and to determine if an AT increases the risk of obesity in children.

STUDY DESIGN

Reanalysis of prospective cohort investigation.

METHODS

The study analyzed publicly available data from CHAT, including 3 months visit data not previously included in a prior publication. Statistical comparisons and mixed-effects modeling were done using age- and sex-specific BMI expressed as a percentage of the 95th percentile (%BMIp95). P < .05 was considered significant.

RESULTS

Children in the AT group, especially if underweight at baseline, had an increased rate of weight gain, with 100% of underweight children in the AT group becoming normal weight compared to 20% for WW. However, the rate of weight gain, as measured by the %BMIp95 trajectory for both AT and WW groups, was not significantly different when baseline weight status and obstructive sleep apnea (OSA) resolution were accounted for. Comparisons of %BMIp95 between treatment groups at baseline, 3- and 7-month follow-up visits also failed to identify statistically significant differences (P > .05). Overall for the entire cohort, resolution of OSA was associated with a decreased weight trajectory (P < .001).

CONCLUSIONS

AT compared to WW is not associated with an increased risk of excessive weight gain. Otolaryngologists should be aware of this updated analysis when discussing AT surgical outcomes with families.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

Pediatric Head and Neck Tumors Associated with Li-Fraumeni Syndrome

INTRODUCTION

Cancer predisposition syndromes are germline pathogenic variants in genes that greatly raise the risk of developing neoplastic diseases. One of the most well-known is Li-Fraumeni syndrome (LFS), which is due to pathogenic variants in the TP53 gene. Children with LFS have higher risks for multiple malignancies before adulthood, often with rare and aggressive subtypes.

OBJECTIVE

To examine head and neck manifestations of LFS in children treated at a tertiary children's hospital over a 20-year period.

METHODS

A retrospective review of LFS children with neoplastic disease presenting in traditional Otolaryngologic head and neck subsites from 2000 to 2019, with patient charts reviewed for relevant clinical, imaging, and operative data.

RESULTS

Of the 40 LFS patients initially identified, 27 neoplastic tumors were identified in 20 children within this cohort (20 primary, 7 second primary). Head and neck subsites aside from the brain or orbit were involved in 22% (6/27) of these tumors, representing 20% (4/20) of primary tumors and 29% (2/7) of second primary tumors. Both second primaries within the head and neck were within the radiation fields of the first primary tumor. The mean ages at primary and second primary diagnosis were 4.6 years (SD 3.5) and 12 years (SD 1.4), respectively. The male/female ratio was 1:6 among all patients with head and neck tumors. All 6 head and neck tumors were sarcomas. Rhabdomyosarcoma (N = 3, 50%) was the most common pathology, and the other 3 demonstrated rare tumor pathological subtypes (synovial cell sarcoma, pleomorphic myxoid liposarcoma, mandibular osteosarcoma). The neck was the most common subsite (75%) within this group for primary tumor presentation.

CONCLUSION

This study identifies a high potential for head and neck involvement in children with LFS, which has not been previously described in the literature. Otolaryngological care should be included in a multidisciplinary care team surveilling these patients.

Parental Perception of Weight Status for Adenotonsillectomy Patients

OBJECTIVE

Weight status can affect outcomes in pediatric adenotonsillectomy performed for obstructive sleep disordered breathing. Parents frequently underestimate their child's weight and are unaware weight status may affect adenotonsillectomy success. Accurate understanding of a child's weight status is important for shared decision making with the family and perioperative care. The purpose of this study is to analyze the accuracy of the parent's perception of their child's weight status.

METHODS

A retrospective analysis was performed of prospective data collected from families of children undergoing adenotonsillectomy from June 2018 through June 2019.

RESULTS

A total of 522 children met the inclusion criteria. Two hundred and thirty-two children were either overweight (n = 46, 9%) or obese (n = 186, 36%). Among parents of this cohort whose children were overweight or obese, 74 (32%) erroneously reported that their child was normal weight. For the 290 nonoverweight children, 99% of parents accurately reported weight status. After adjusting for ethnicity, race, BMI%, and sex, for every 1-year increase in age of the child, the odds of the parent correctly identifying their child as overweight increased by a factor of 1.18 (95% CI: 1.09, 1.27).

CONCLUSION

One-third of families with children who were overweight or obese undergoing adenotonsillectomy for obstructive sleep disordered breathing underestimated their child's weight. This study highlights the need to facilitate family understanding of weight status' potential impact on both obstructive sleep disordered breathing severity and adenotonsillectomy success, especially for younger children.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2121-2125, 2021.

Pediatric sublingual dermoid and epidermoid cysts: A 20-year institutional review

INTRODUCTION

Pediatric cystic sublingual masses often present a diagnostic dilemma for practitioners. Though uncommon, dermoid or epidermoid cysts can present in the sublingual space at any age and are often misdiagnosed as an inflammatory pseudocyst (ranula) or lymphatic malformation. Imaging may not always identify the underlying etiology, requiring physicians to maintain a high index of suspicion for these relatively rare oral cysts.

OBJECTIVES

To describe the presentation and treatment of sublingual dermoid and epidermoid cysts presenting to a tertiary children's hospital over 20 years.

METHODS

A retrospective review of all pathology specimens identified as dermoid or epidermoid cysts within the sublingual space from 1999 to 2019. Patient charts were then reviewed for relevant clinical, imaging, and operative data.

RESULTS

Twelve pediatric patients were identified (8 female, 4 male) with a mean age of 7.2 years (SD 5.6). Eighty six percent (6/7) of dermoid cysts were found in female patients, while 60% (3/5) of epidermoid cysts were in male patients. Multiple dermoid and epidermoid cysts were each found in one patient (8%). Two epidermoid cysts presented in the neonatal period. Preoperative diagnosis included nondiagnostic "cystic mass" (33%), ranula (25%), lymphatic malformation (LM) (17%), and dermoid/epidermoid cyst (17%). Two thirds of patients (8/12) underwent imaging, with all receiving either MRI or CT. Although MRI was the most likely to suggest the possibility of a dermoid/epidermoid cyst (2/4), ranula was the most common primary radiographic diagnosis (5/8). One patient underwent sclerotherapy for presumed LM one year prior to surgical excision of the cyst. Eleven patients (92%) underwent intraoral excision, one (8.3%) underwent a combined intraoral/extraoral approach.

CONCLUSIONS

To our knowledge, this review represents the largest case series of pediatric sublingual dermoid and epidermoid cysts to date. This series contained higher levels of epidermoid cysts and female patients than previously reported in the literature. Identifying more dermoid cysts in females and epidermoid cysts in males is also a new finding. MRI was superior to CT and US regarding the presence of a dermoid/epidermoid cyst. Frequently misdiagnosed, it is important to consider these relatively rare pathologies when treating children presenting with sublingual masses in order to avoid delayed and/or inappropriate treatment.

Head and neck pleomorphic myxoid liposarcoma in a child with Li-Fraumeni syndrome

INTRODUCTION

Pleomorphic myxoid liposarcoma is a rare and aggressive cancer seen in the pediatric population that has been previously associated with hereditable cancer disorders like Li Fraumeni syndrome. We present a case report and review of the relevant literature.

CASE PRESENTATION

Pleomorphic myxoid liposarcoma presenting as a second primary tumor in a child with a strong family history for cancer led to diagnosis of Li-Fraumeni syndrome, which is associated with TP53 tumor suppressor gene inactivation.

MANAGEMENT AND OUTCOME

The tumor was fully excised, but postoperative radiation was deferred to limit future radiation-induced tumorgenesis.

DISCUSSION

Pleomorphic myxoid liposarcoma is rare but aggressive, and should prompt caregivers to test for potential hereditable cancer disorders. Li-Fraumeni syndrome is associated with early onset neoplasia and development of recurrent primary tumors. Its presence affects treatment decisions and methods of surveillance. Chemoradiation should be used judiciously in this population.

Intracranial Complications of Pediatric Frontal Rhinosinusitis

Background

The aim of this study was to review the presentation and management of children admitted for intracranial complications arising from frontal rhinosinusitis. We performed a retrospective case series review at two academic tertiary care children's hospitals.

Methods

This study consisted of children <18 years old who presented with intracranial complications from frontal rhinosinusitis between January 1, 1990 and December 31, 2002. Relevant literature was reviewed with the assistance of Medline. Presentation, type of intracranial complication, radiographic evaluations, response to treatment, and prognosis were evaluated.

Results

Sixteen patients were identified with intracranial complications due to frontal rhinosinusitis. Patients were usually older (mean age, 14 years and 3 months), of male gender (M/F, 4.3:1.0), and African American (AA/W, 3.0:1.0). Headache, nasal congestion, and visual changes were the most common early symptoms and neurological findings indicated advanced disease. Subdural (56%), epidural (44%), and cerebral abscesses (19%) were the most common complications. Meningitis alone was identified in 13% and was associated with another intracranial complication in 6%. Multiple intracranial complications were noted in 31%. Polymicrobial cultures were obtained in 50% of patients. Although CT was excellent in identifying orbital pathology, MRI was superior for characterization of intracranial disease.

Conclusion

Intracranial complications of frontal rhinosinusitis are rare in children. Early symptoms often are nonspecific, with neurological findings more commonly seen in advanced disease. Adolescent African American male patients were found to be at highest risk for intracranial complications from frontal rhinosinusitis. Headache and orbital complaints associated with rhinosinusitis in older children failing to respond to initial therapy should prompt an aggressive evaluation including MRI.

A Preliminary Report on the Effects of Paclitaxel-Impregnated Stents on Sheep Nasal Mucosa

Introduction

Traditional frontal sinus stents serve only as mechanical devices. It has been proposed that stents also may serve as drug-delivery systems for the topical application of drugs that minimize postoperative scarring. Paclitaxel (Taxol), which has recognized antiscarring effects, may be incorporated via a polymeric formulation into standard rubber stents. The impact of topically applied paclitaxel on the morphology of the nasal mucosa is unknown.

Methods

An adult sheep model was used for this study. A modified rubber T-tube stent (incorporating paclitaxel at varying dosages) was secured to each side of the septum in four animals (eight sides). An unmodified T-tube was placed on each side of one animal, a T-tube with the drug carrier (but no paclitaxel) was placed on each side of the second animal, and T-tubes with varying paclitaxel were placed on each side of the final two animals. After 4 weeks, animals were killed and the nasal mucosa was harvested. The nasal mucosa was sectioned and stained with hematoxylin and eosin. A pathologist then assessed the nasal mucosa for vascular congestion, glandular atrophy, chronic inflammation, mucosal metaplasia, and mucosal ulceration.

Results

No consistent histopathological differences were noted in the specimens. All specimens showed varying degrees of vascular congestion, glandular atrophy, chronic inflammation, and mucosal metaplasia; the paclitaxel-impregnated stents were not consistently associated with more severe mucosal injury. Finally, mucosal ulceration was noted to be very rare in all specimens.

Conclusion

This preliminary report describes the impact of paclitaxel-impregnated stents on sheep nasal mucosa, which tolerated these stents very well. Because paclitaxel minimizes scarring reactions at very low concentrations, paclitaxel-impregnated stents may prove useful in clinical situations in which frontal sinus stenting is deemed necessary. Additional investigations with animal models, as well as clinical trials, may be warranted.

Sinonasal Posttransplant Lymphoproliferative Disorder in Pediatric Lung Transplant Patients

OBJECTIVE: To evaluate sinonasal manifestations of posttransplant lymphoproliferative disorder (PTLD) in the pediatric lung transplant population.

STUDY DESIGN AND METHODS: Case series of children less than 18 years presenting with PTLD after pulmonary transplantation at St Louis Children's Hospital between Jan 1, 1990 and Dec 31, 2003.

RESULTS: Two hundred eighty-two lung transplants were performed in 246 children. Thirty-two cases of histopathologically confirmed PTLD were identified with 8 (25%) presenting in the head and neck. Sinonasal PTLD was the most common site of head and neck involvement (63%), with 40% of patients presenting with occult disease. All patients with sinonasal PTLD had longstanding nasal polyposis related to cystic fibrosis ( P = 0.07).

CONCLUSIONS: This is, to our knowledge, the first report identifying an increased frequency of sinonasal PTLD after pediatric pulmonary transplantation, particularly in children with cystic fibrosis and associated nasal polyposis. Because sinonasal PTLD may be asymptomatic, this region should receive close scrutiny on surveillance evaluations.

Otolaryngological manifestations of posttransplant lymphoproliferative disorder in pediatric thoracic transplant patients

OBJECTIVE

To identify the otolaryngological manifestations of posttransplant lymphoproliferative disorder (PTLD) in pediatric heart and lung transplant recipients.

METHODS

A 14-year retrospective case series review (1990-2003) of children less than 18 years of age presenting with PTLD after receiving orthotopic heart and lung transplants at St. Louis Children's hospital (St. Louis, MO, USA).

RESULTS

One hundred ninety seven cardiac and 246 pulmonary transplant patients were included in this review. Thirteen heart transplant patients developed PTLD with 39% (5/13) presenting in the head and neck. Thirty-two lung transplant patients developed PTLD with 25% (8/32) presenting in the head and neck. PTLD in cardiac transplants most often presented as adenotonsillar hypertrophy or cervical lymphadenopathy. The sinonasal cavity was the most common site of head and neck PTLD in pulmonary transplants patients.

CONCLUSIONS

This study suggests that head and neck involvement is more common than currently reported in the literature. As thoracic organ transplants become more frequent in children, otolaryngologists caring for this population should maintain a high index of suspicion for any suggestive findings. Evaluation must include tissue biopsy, as histopathologic examination is required for diagnosis.

Otologic and audiologic features of Nager acrofacial dysostosis

OBJECTIVE

To describe the otologic and audiologic characteristics of pediatric patients with Nager acrofacial dysostosis.

DESIGN

Retrospective case series.

SETTING

Multidisciplinary clinic in a tertiary care children's hospital.

SUBJECTS

Patients less than 18 years of age with Nager acrofacial dysostosis.

METHODS

Nager syndrome is a mandibulofacial dysostosis associated with preaxial limb abnormalities and multiple craniofacial anomalies. Ten patients with Nager syndrome were reviewed. Relevant literature, 1966 to the present, was reviewed with the assistance of Medline.

RESULTS

External and middle ear abnormalities are common in Nager syndrome. All non-atretic ears had significant difficulty with otitis media, requiring an average of two sets of tympanostomy tubes. Cholesteatoma was diagnosed in one patient. Pure conductive hearing loss was identified in eight patients with mixed hearing loss noted in two patients. Conductive hearing loss greater than 30 dB HL was noted in 90% (9/10) of patients, with 40% (4/10) having 55-70 dB HL loss. Although amplification was effective, results of surgical interventions to correct conductive hearing loss were inconsistent. Two patients with mixed hearing loss developed the sensorineural component in later childhood, indicating that progressive or fluctuating sensorineural hearing loss is also possible in this population.

CONCLUSIONS

Pediatric patients with Nager acrofacial dysostosis exhibit conductive hearing loss due to middle and external ear pathology. Prolonged ventilation of the middle ear via tympanostomy tubes and amplification with hearing aids are often required. Some patients also demonstrate mixed hearing loss that may be progressive and should be monitored carefully. Early and aggressive management in a multidisciplinary team approach is recommended.

Congenital salivary gland anlage tumor: a case series and review of the literature

OBJECTIVE

To understand the clinical presentation and management of salivary gland anlage tumor (SGAT).

DESIGN AND METHODS

This case series includes a report of a newborn male who presented with acute airway obstruction secondary to a nasopharyngeal mass which was discovered in the course of the clinical evaluation. Six additional cases of SGAT from the pathology consultation files of one of the authors (LPD) presenting in similar fashion are also included. The relevant literature from 1966 to the present has been reviewed through a Medline keyword search utilizing terms "salivary gland anlage tumor", "neonatal", and "nasopharynx."

RESULTS

Endoscopic evaluation identified a nasopharyngeal mass tethered to the posterior septum. Although CT and MRI were helpful in identifying the mass and excluding involvement of the surrounding structures, the imaging characteristics of the mass itself were nonspecific. The patient was taken to the operating room and the polypoid mass was removed transorally after lysis of its septal attachment. Pathologic examination revealed a SGAT, a recently described entity in neonates and young infants, who present with early onset respiratory distress. Since the initial report of nine cases by one of the co-authors (LPD), seven additional cases including the present one have been seen in consultation.

CONCLUSIONS

Salivary gland anlage tumor of the nasopharynx is a rare cause of neonatal airway obstruction. Endoscopic evaluation and imaging studies are helpful in the exclusion of other etiologies, some of which may have intracranial extension. Simple excision has been curative to date. There have been no reported recurrences in any of the previously studied cases with clinical follow-up dating more than 5 years.

Lipofibromatosis presenting as a pediatric neck mass

Lipofibromatosis is a recently described, benign neoplasm that presents in the pediatric population [J.F. Fetsch, M. Miettinen, W.B. Laskin, M. Michal, F.M. Enzinger, A clinicopathologic study of 45 pediatric soft tissue tumors with an admixture of adipose tissue and fibroblastic elements, and a proposal for classification as lipofibromatosis, Am. J. Surg. Pathol. 24 (2000) 1491-1500]. It is a rare soft tissue tumor histologically distinct from other fibromatoses such as juvenile fibromatosis, fibrous hamartoma of infancy, calcifying aponeurotic fibroma, and lipoblastoma. Distinguishing histopathologic features of lipofibromatosis include abundant and disorganized adipose lobules traversed by bundles of spindled fibroblast-like cells. It most commonly presents in the extremities. We present a case involving a young girl, which we believe represents the first report of lipofibromatosis involving the neck.

Simultaneous intracranial and orbital complications of acute rhinosinusitis in children

OBJECTIVE

To evaluate the frequency of intracranial and orbital complications occurring as simultaneous but separate complications of acute rhinosinusitis in the pediatric population.

METHODS

Records of children admitted to St. Louis Children's Hospital between 1 January 1990 and 31 December 2002 were reviewed. Relevant literature was reviewed with the assistance of Medline.

RESULTS

We identified 74 patients with orbital complications related to acute rhinosinusitis. A bimodal age distribution was identified with one group above and one group below the age of 7 years. The frequency of intracranial complications in pediatric patients already admitted for orbital complications of acute rhinosinusitis was 0% for those less than 7 years of age and 9.3% (4/43) for patients 7 years and older. If surgery was required for orbital disease, these risks were 0 and 24% (4/17), respectively. The review found that patients with dual complications had a mean age of 15 years, 11 months, were male (100%), had subperiosteal abscesses located superiorly or superolaterally within the orbit, and presented with significant frontal sinus disease. All intraoperative cultures were polymicrobial. MRI was superior to CT for identification of intracranial extension.

CONCLUSIONS

Simultaneous intracranial and orbital complications are rare but significant occurrences in acute pediatric rhinosinusitis. Because of the high incidence of intracranial findings, we recommend MRI in addition to CT scan along with aggressive management in children older than 7 years of age admitted with orbital complications of acute rhinosinusitis who also demonstrate risk factors for intracranial disease. These risk factors are discussed.

Areolar connective tissue grafts in pediatric tympanoplasty: a pilot study

PURPOSE

To compare the surgical and audiologic success rates of areolar connective tissue with temporalis fascia in pediatric tympanoplasty.

METHODS

Retrospective case series review of 10 patients younger than 18 years who underwent primary tympanoplasty between December 1997 and December 2000 using areolar connective tissue grafts. Tympanoplasty patients receiving temporalis fascia grafts during this period were used as a control group. Surgical and audiometric results were gathered after a minimum follow-up of 1 year.

RESULTS

Both groups were similar in their clinical characteristics (P <.05). The surgical success rates for areolar and temporalis fascial groups were 90% and 91%, respectively. Closure of the air bone gap to within 25 dB was achieved in 90% and 91% of the areolar and temporalis fascial groups, respectively.

CONCLUSIONS

This study showed equivalent surgical and audiometric success rates between areolar connective tissue and temporalis fascia. Both are excellent sources of graft material in pediatric patients.

A preliminary report on the effects of paclitaxel-impregnated stents on sheep nasal mucosa

INTRODUCTION

Traditional frontal sinus stents serve only as mechanical devices. It has been proposed that stents also may serve as drug-delivery systems for the topical application of drugs that minimize postoperative scarring. Paclitaxel (Taxol), which has recognized antiscarring effects, may be incorporated via a polymeric formulation into standard rubber stents. The impact of topically applied paclitaxel on the morphology of the nasal mucosa is unknown.

METHODS

An adult sheep model was used for this study. A modified rubber T-tube stent (incorporating paclitaxel at varying dosages) was secured to each side of the septum in four animals (eight sides). An unmodified T-tube was placed on each side of one animal, a T-tube with the drug carrier (but no paclitaxel) was placed on each side of the second animal, and T-tubes with varying paclitaxel were placed on each side of the final two animals. After 4 weeks, animals were killed and the nasal mucosa was harvested. The nasal mucosa was sectioned and stained with hematoxylin and eosin. A pathologist then assessed the nasal mucosa for vascular congestion, glandular atrophy, chronic inflammation, mucosal metaplasia, and mucosal ulceration.

RESULTS

No consistent histopathological differences were noted in the specimens. All specimens showed varying degrees of vascular congestion, glandular atrophy, chronic inflammation, and mucosal metaplasia; the paclitaxel-impregnated stents were not consistently associated with more severe mucosal injury. Finally, mucosal ulceration was noted to be very rare in all specimens.

CONCLUSION

This preliminary report describes the impact of paclitaxel-impregnated stents on sheep nasal mucosa, which tolerated these stents very well. Because paclitaxel minimizes scarring reactions at very low concentrations, paclitaxel-impregnated stents may prove useful in clinical situations in which frontal sinus stenting is deemed necessary. Additional investigations with animal models, as well as clinical trials, may be warranted.

Pediatric sinonasal rhabdomyosarcoma: three cases and a review of the literature

OBJECTIVE

To understand the clinical presentation, management, and natural history of paranasal rhabdomyosarcoma.

DESIGN

Retrospective case series review.

METHODS

Retrospective medical record review of patients less than 20 years of age who presented to our facility with rhabdomyosarcoma of the nasal cavity or paranasal sinuses.

RESULTS

Medical records of all pediatric patients seen in our pediatric otolaryngology clinic were reviewed from January 1, 1995, through December 31, 2000. Three patients were identified with sinonasal rhabdomyosarcoma. Their presentation, evaluation, and treatment were evaluated. Relevant literature 1966 to the present was reviewed with the assistance of Medline.

CONCLUSIONS

Rhabdomyosarcoma is an aggressive pediatric malignancy, requiring a high index of suspicion to detect it in its earliest stages. Patients with suggestive symptoms should undergo a full evaluation including nasal endoscopy and imaging. Because the current chemotherapy protocols are more effective on localized disease, early diagnosis is crucial to patient survival.

The effect of peroxynitrite on sphincter of Oddi motility

BACKGROUND

Nitric oxide (NO*) is an inhibitory neurotransmitter that induces sphincter of Oddi relaxation. Superoxide (O*-2)-scavenging enzymes are present in enteric plexuses of the sphincter of Oddi and O*-2 alters sphincter of Oddi motor function. O*-2 rapidly oxidizes nitric oxide (NO*) to form peroxynitrite (ONOO-), thus terminating the biological activity of NO*. The aim of our study was to determine the effects of ONOO- on sphincter of Oddi motility in vitro.

MATERIALS AND METHODS

Adult opossums were sacrificed and the sphincter of Oddi was removed and placed in a tissue bath containing oxygenated Krebs solution at 37 degreesC. In the first series of experiments, force transducers recorded tension in a transverse orientation at two sites along the spontaneously contracting sphincter of Oddi. In a second series of experiments, circular muscle strips were precontracted with carbachol and stimulated by an electrical field.

RESULTS

ONOO-, superoxide dismutase (SOD), Nomega-nitro-l-arginine (l-NNA), or oxyhemoglobin were added to the tissue baths. ONOO- decreased the frequency of contractions in the spontaneously contracting sphincter of Oddi. Adding hemoglobin increased the frequency of contractions. ONOO- also increased the stimulation-induced relaxation compared to controls. The increase in relaxation induced by ONOO- was inhibited by oxyhemoglobin and l-NNA but not SOD. Pretreatment with oxyhemoglobin prevented the increase in the stimulation-induced relaxation caused by ONOO-.

CONCLUSION

These results suggest that hemoglobin binds ONOO- or that ONOO- generates NO.