Large Nasopharyngeal Hairy Polyp Causing Immediate Respiratory Distress at Birth

This article presents a rare case of a large hairy polyp, a developmental malformation causing a benign tumor, within the nasopharynx. The patient, born with the polyp obstructing the airway, required immediate intubation and a combined transnasal-transoral surgical approach for excision. The case underscores the challenges in diagnosing and managing such polyps, emphasizing the importance of imaging for surgical planning, and the consideration of multiple approaches to ensure complete resection and prevent recurrence. Laryngoscope, 2024.

Surgical procedure of intratympanic injection and inner ear pharmacokinetics simulation in domestic pigs

Introduction: One major obstacle in validating drugs for the treatment or prevention of hearing loss is the limited data available on the distribution and concentration of drugs in the human inner ear. Although small animal models offer some insights into inner ear pharmacokinetics, their smaller organ size and different barrier (round window membrane) permeabilities compared to humans can complicate study interpretation. Therefore, developing a reliable large animal model for inner ear drug delivery is crucial. The inner and middle ear anatomy of domestic pigs closely resembles that of humans, making them promising candidates for studying inner ear pharmacokinetics. However, unlike humans, the anatomical orientation and tortuosity of the porcine external ear canal frustrates local drug delivery to the inner ear. Methods: In this study, we developed a surgical technique to access the tympanic membrane of pigs. To assess hearing pre- and post-surgery, auditory brainstem responses to click and pure tones were measured. Additionally, we performed 3D segmentation of the porcine inner ear images and used this data to simulate the diffusion of dexamethasone within the inner ear through fluid simulation software (FluidSim). Results: We have successfully delivered dexamethasone and dexamethasone sodium phosphate to the porcine inner ear via the intratympanic injection. The recorded auditory brainstem measurements revealed no adverse effects on hearing thresholds attributable to the surgery. We have also simulated the diffusion rates for dexamethasone and dexamethasone sodium phosphate into the porcine inner ear and confirmed the accuracy of the simulations using in-vivo data. Discussion: We have developed and characterized a method for conducting pharmacokinetic studies of the inner ear using pigs. This animal model closely mirrors the size of the human cochlea and the thickness of its barriers. The diffusion time and drug concentrations we reported align closely with the limited data available from human studies. Therefore, we have demonstrated the potential of using pigs as a large animal model for studying inner ear pharmacokinetics.

Interarytenoid injection outcomes in pediatric feeding disorders

Objectives

Type 1 laryngeal clefts (LC1) and deep interarytenoid grooves contribute to pediatric feeding disorders. Management of these defects remains heterogeneous among surgeons and interarytenoid injection augmentation (IIA) is not always offered as a treatment option. This study evaluated IIA outcomes among a pediatric patient cohort comprised mostly of those with deep interarytenoid grooves.

Methods

A single-institution retrospective chart review featured children under the age of 5 years presenting for aspiration, dysphagia, or choking. Over the period of 7 years (January 2014-October 2021), 39 met inclusion criteria and had sufficient follow-up data. Descriptive statistics and subgroup analyses were performed.

Results

Of the 39 included patients, 76.92% had clinical improvement post-injection, with the mean time to follow-up being 47 days. Within the deep interarytenoid groove group, improvement rates were 82.76%. Bronchoscopy findings revealed 29 (74.36%) patients with a DIG, 3 (7.69%) with LC1, 3 (7.69%) with no anatomic abnormality, and 4 (10.26%) with vocal cord paralysis. There were no adverse events. There were no associations with the outcomes based on subgroup analysis and logistic regression.

Conclusions

IIA is an effective and safe treatment for pediatric feeding disorders. No covariates were associated with symptom improvement. Within the deep interarytenoid groove diagnosis subgroup, IIA effectively improved symptoms. Further investigations are needed to explore predictors of success with IIA in this population.

Level of Evidence

VI.

Assessment of drug permeability through an ex vivo porcine round window membrane model

Delivery of pharmaceutical therapeutics to the inner ear to treat and prevent hearing loss is challenging. Systemic delivery is not effective as only a small fraction of the therapeutic agent reaches the inner ear. Invasive surgeries to inject through the round window membrane (RWM) or cochleostomy may cause damage to the inner ear. An alternative approach is to administer drugs into the middle ear using an intratympanic injection, with the drugs primarily passing through the RWM to the inner ear. However, the RWM is a barrier, only permeable to a small number of molecules. To study and enhance the RWM permeability, we developed an ex vivo porcine RWM model, similar in structure and thickness to the human RWM. The model is viable for days, and drug passage can be measured at multiple time points. This model provides a straightforward approach to developing effective and non-invasive delivery methods to the inner ear.

Accuracy and Reliability of 4D-CT and Flexible Laryngoscopy in Upper Airway Evaluation in Robin Sequence

OBJECTIVES

To evaluate the performance of 4-dimensional computed tomography (4D-CT) in assessing upper airway obstruction (UAO) in patients with Robin sequence (RS) and compare the accuracy and reliability of 4D-CT and flexible fiber-optic laryngoscopy (FFL).

STUDY DESIGN

Prospective survey of retrospective clinical data.

SETTING

Single, tertiary care pediatric hospital.

METHODS

At initial and 30-day time points, a multidisciplinary group of 11 clinicians who treat RS rated UAO severity in 32 sets of 4D-CT visualizations and FFL videos (dynamic modalities) and static CT images. Raters assessed UAO at the velopharynx and oropharynx (1 = none to 5 = complete) and noted confidence levels of each rating. Intraclass correlation and Krippendorff alpha were used to assess intra- and interrater reliability, respectively. Accuracy was assessed by comparing clinician ratings with quantitative percentage constriction (QPC) ratings, calculated based on 4D-CT airway cross-sectional area. Results were compared using Wilcoxon rank-sum and signed-rank tests.

RESULTS

There was similar intrarater agreement (moderate to substantial) with 4D-CT and FFL, and both demonstrated fair interrater agreement. Both modalities underestimated UAO severity, although 4D-CT ratings were significantly more accurate, as determined by QPC similarity, than FFL (-1.06 and -1.46 vs QPC ratings, P = .004). Overall confidence levels were similar for 4D-CT and FFL, but other specialists were significantly less confident in FFL ratings than were otolaryngologists (2.25 and 3.92, P < .0001).

CONCLUSION

Although 4D-CT may be more accurate in assessing the degree of UAO in patients with RS, 4D-CT and FFL assessments demonstrate similar reliability. Additionally, 4D-CT may be interpreted with greater confidence by nonotolaryngologists who care for these patients.

Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review

STUDY OBJECTIVES

Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as step towards evidence based clinical decision making for RS.

METHODS

A literature search was performed in Pubmed and Embase databases (1990-2020) following PRISMA-guidelines. Articles reporting on RS and UAO-treatment were included if the following objective measures were studied: oximetry, polysomnography and blood gas. Quality was appraised by methodological index for non-randomized studies (MINORS, range:0-24).

RESULTS

A total of 91 articles met inclusion criteria. Mean MINORS-score was 7.1 (range:3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings in more than half. Of 71 studies that evaluated UAO-interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive-apnea-hypopnea index (27%), and oxygen-desaturation-index (16%). Only 42 studies reported indications for UAO-intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified.

CONCLUSIONS

This systematic review demonstrates a lack of standardization, interpretation and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS.

4D Computed Tomography for Dynamic Upper Airway Evaluation in Robin Sequence

Thorough assessment of dynamic upper airway obstruction (UAO) in Robin sequence (RS) is critical, but traditional evaluation modalities have significant limitations. Four-dimensional computed tomography (4D-CT) is promising in that it enables objective and quantitative evaluation throughout all phases of respiration. However, there exist few protocols or analysis tools to assist in obtaining and interpreting the vast amounts of obtained data. A protocol and set of data analysis tools were developed to enable quantification and visualization of dynamic 4D-CT data. This methodology was applied to a sample case at 2 time points. In the patient with RS, overall increases in normalized airway caliber were observed from 5 weeks to 1 year. There was, however, continued dynamic obstruction at all airway levels, though objective measures of UAO did improve at the nasopharynx and oropharynx. Use of 4D-CT and novel analyses provide additional quantitative information to evaluate UAO in patients with RS.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement

OBJECTIVES/HYPOTHESIS

The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.

STUDY DESIGN

Delphi method-based survey series.

METHODS

A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.

RESULTS

The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).

CONCLUSION

This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E1941-E1949, 2021.

Readability analysis of pediatric otolaryngology patient-reported outcome measures

OBJECTIVE

(s): Patient-reported outcome measures (PROMs) are tools that allow patients to directly share information about their health with their healthcare provider. Health literacy experts recommend that health information, such as PROMs, be written at a 6th grade level to ensure patients can read and comprehend it. As the readability of PROMs used in pediatric otolaryngology has yet to be studied, our goal was to analyze the readability of these PROMs and assess their compliance with readability recommendations.

METHODS

The Gunning Fog, the Simple Measure of Gobbledygook (SMOG), and the FORCAST readability formulas were used to determine the readability of disease-specific PROMs for pediatric otolaryngology.

RESULTS

Fourteen PROMs were reviewed in the study. Most were intended for caregiver completion (n = 13, 92.9%). Ten PROMs when measured by Gunning Fog (71.4%), 2 PROMs when measured by SMOG (14.3%), and 0 PROMs when measured by FORCAST (0.0%) were at or below the 6th grade reading level.

CONCLUSION

Most PROMs available for use in pediatric otolaryngology are above the recommended 6th grade reading level when measured by FORCAST, the most appropriate metric for assessing questionnaires. The high reading grade level needed to complete these PROMs can contribute to health disparities among underserved and vulnerable populations, such as children. Pediatric otolaryngology PROMs developed in the future should take readability into account in order to ensure equity in the delivery of care.

International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction

OBJECTIVE

To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery.

METHODS

Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses.

RESULTS

Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure.

CONCLUSIONS

Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus

OBJECTIVES/HYPOTHESIS

Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal.

STUDY DESIGN

Blinded modified Delphi consensus process.

SETTING

Tertiary care center.

METHODS

A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items.

RESULTS

The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus.

CONCLUSIONS

It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated.

LEVEL OF EVIDENCE

5. Laryngoscope, 131:1168-1174, 2021.

IVORY Guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS): A Consensus on Surgical Videos in Ear, Nose, and Throat

Objectives/Hypothesis

Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology.

Study Design

DELPHI survey.

Methods

Twenty‐seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained.

Results

The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high‐definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ‐specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre‐ and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery.

Conclusions

International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery.

Level of Evidence

5 Laryngoscope, 131:E732–E737, 2021

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus

OBJECTIVES/HYPOTHESIS

Create a competency-based assessment tool for pediatric tracheotomy.

STUDY DESIGN

Blinded, modified, Delphi consensus process.

METHODS

Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.

RESULTS

The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.

CONCLUSIONS

It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:2700-2707, 2020.

Idiopathic, Refractory Sweet's Syndrome Associated with Common Variable Immunodeficiency: a Case Report and Literature Review

PURPOSE OF REVIEW

Sweet's syndrome (SS) is classically considered a hypersensitivity reaction often associated with autoimmune disorders and malignancy. SS has also been increasingly reported to occur with immunodeficiencies. We present a case of treatment-refractory, systemic SS as the initial manifestation in a young child with common variable immunodeficiency (CVID). We also review current literature about SS and concurrent immunodeficiencies and autoimmunity in CVID patients.

RECENT FINDINGS

Few case reports exist regarding the co-occurrence of Sweet's syndrome and primary immunodeficiencies. SS is characterized by a pro-inflammatory state with a neutrophil predominance resulting in a spectrum of clinical manifestations. CVID is a multifactorial antibody deficiency that can be associated with autoimmunity, which some studies have proposed to be secondary to altered CD21 expression. SS occurring in patients with CVID has been infrequently reported, and one case study demonstrated improvement of Sweet's associated skin lesions with immunoglobulin replacement. In our case, the patient had multi-system SS refractory to multiple immunomodulatory therapies. To our knowledge, this is the first report of the effective and safe use of intravenous tocilizumab and oral lenalidomide to treat SS in a child with CVID. Immunoglobulin replacement reduced the frequency of infections and may have contributed to the opportunity to wean the immunosuppressive therapies for Sweet's syndrome. Sweet's syndrome as an initial manifestation of co-occurring immunodeficiencies is rare, and providers need a high index of suspicion. In addition, treatment of SS associated with an immunodeficiency can be a challenge. Treatment with immunoglobulin replacement reduces the frequency of infections, and in some patients with concurrent SS may improve skin lesions and reduce the need for immunomodulator therapy. Further study is necessary to better understand the pathogenesis of CVID in patients with SS and to identify possible biomarkers that predict who with SS are at risk for developing hypogammaglobulinemia.

Considering a Weight Criterion for Neonatal Tracheostomy: An Analysis of the ACS NSQIP-P

OBJECTIVES

Neonates weighing < 2.5 kg have known higher rates of surgical mortality and morbidity, but this remains unexamined specifically for tracheostomy. We present outcomes of neonates undergoing tracheostomy stratified by weight.

METHODS

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric from 2012 to 2014. Patients undergoing tracheostomy were included. Thirty-day mortality and major/minor complication rates were stratified by weight (group 1: < 2.5 kg; group 2: ≥ 2.5 kg and < 4 kg; group 3: ≥ 4 kg). Patient comorbidities were assessed for independent risk factors of morbidity and mortality.

RESULTS

Of 183,233 patients, 543 underwent tracheostomy. Forty-four patients were group 1 (mean: 2.2 kg ± 0.25); 170 patients were group 2 (mean: 3.31 kg ± 0.42); and 329 patients were group 3 (mean: 6.4 kg ± 2.7). Between groups 1 and 2, there were no significant differences in mortality (P = 0.47), major complication rates (P = 0.99), or minor complication rates (P = 0.64). In comparing all three groups, there were no significant differences in mortality (P = 0.47), major complication rates (P = 0.80), or minor complication rates (P = 0.77). The overall 30-day mortality for all patients was 4.24%. In a multivariate logistical regression model, weight group did not change the odds of all negative outcomes (group 1: odds ratio [OR] of 0.71; 95% confidence interval [CI], 0.33-1.53 and group 2: OR of 0.78; 95% CI, 0.50-1.22). Bronchopulmonary dysplasia was the only independent significant predictor of major complications (OR, 1.69; 95% CI, 1.02-2.79) (P = 0.04).

CONCLUSION

Our data indicate that 30-day mortality and morbidity outcomes for neonatal tracheostomy are not affected by weight. Overall 30-day mortality should be discussed with caregivers preoperatively.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:500-505, 2019.

Relationship between degree of obstruction and airflow limitation in subglottic stenosis

OBJECTIVES

Subglottic stenosis (SGS) is one of the most common airway disorders in pediatric patients. Currently, treatment decisions rely primarily on the Cotton-Myer scale, which classifies SGS severity based on percentage reduction in airspace cross-sectional area (CSA). However, the precise relationship between upper airway resistance and subglottic CSA is unknown. We hypothesize that airway resistance can be described by the Bernoulli Obstruction Theory, which predicts that airway resistance is inversely proportional to airspace CSA ( R∝A-1) in cases of severe constriction.

METHODS

Computed tomography (CT) scans of six healthy subjects and five SGS patients were used to create three-dimensional models of the respiratory tract from nostrils to carina. Cylindrical segments of varying lengths and varying diameters were digitally inserted in the subglottis of the healthy subjects to create simulated SGS models. Computational fluid dynamics simulations were run, and airway resistance was computed in the simulated SGS models and actual SGS models.

RESULTS

Constriction diameter had a greater impact in airway resistance than constriction length. In agreement with the Bernoulli Obstruction Theory, airway resistance in the simulated SGS models was well represented by the power law R=aAb, where a is a constant and the exponent b ranged from -0.85 to -1.07. The percentage reduction in airflow (QOBSTRUCTIONQHEALTHY) at a constant pressure drop was found to be directly proportional to the percentage reduction in CSA (AOBSTRUCTIONAHEALTHY) in the limit of severe constrictions, namely QOBSTRUCTIONQHEALTHY=kAOBSTRUCTIONAHEALTHY, where k=2.25 ± 0.15. Airway resistances in the simulated SGS models were similar to resistances in models based on CT scans of actual SGS patients, suggesting that our simulated SGS models were representative of airway resistance in actual SGS patients.

CONCLUSION

Our computer simulations suggest that the degree of airflow limitation in SGS patients may be estimated based on anatomic measurements alone. Future studies are recommended to test these predictions in larger cohorts.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1551-1557, 2018.

Electrocardiogram Screening in Children with Congenital Sensorineural Hearing Loss: Prevalence and Follow-up of Abnormalities

Objective The purpose is to determine the prevalence of electrocardiogram (ECG) abnormalities, including borderline and prolonged QT, among screened children with sensorineural hearing loss (SNHL) and to analyze their subsequent medical workup. Study Design Institutional Review Board-approved case series with chart review. Setting Tertiary academic center. Subjects and Methods Cases from 1996 to 2014 involving pediatric patients (N = 1994) with SNHL were analyzed. Abnormal ECGs were categorized as borderline/prolonged QT or other. A board-certified pediatric cardiologist retrospectively determined the clinical significance of ECG changes. For follow-up analysis, children with heart disease, known syndromes, or inaccessible records were excluded. Results Among 772 children who had ECGs, 215 (27.8%) had abnormal results: 35 (4.5%) with QT abnormalities and 180 (23.3%) with other abnormalities. For children with QT abnormalities meeting inclusion criteria (n = 30), follow-up measures included cardiology referral (46.6%), repeat ECG by ear, nose, and throat (ENT) specialist (20%), clearance by ENT specialist with clinical correlation and/or comparison with old ECGs (20%), and pediatrician follow-up (6.7%). Documentation of further workup by ENT or referral was absent for 6.7%. For children with other ECG changes meeting inclusion criteria (n = 136), abnormalities were documented for 57 (41.9%); normal QT without other abnormality was documented for 18 (13.2%). The most common follow-up referrals were to pediatricians (16.9%) and cardiologists (10.3%). Among patients with clinically significant non-QT abnormalities mandating further evaluation (n = 122), 38 (31.1%) had documented follow-up in medical records. Conclusion There is a high prevalence of ECG abnormalities among children with congenital SNHL. If findings are confirmed by future studies, screening should be considered for congenital unilateral or bilateral SNHL, regardless of severity. We describe a standardized protocol for ECG screening/follow-up.

Comprehensive quality of life outcomes for pediatric patients undergoing endoscopic sinus surgery

BACKGROUND

Limited quality of life data exist for pediatric chronic rhinosinusitis (CRS) patients undergoing endoscopic sinus surgery (ESS). Further exploration of the following areas will enhance understanding and support clinical decision-making: baseline and post-ESS general and disease-specific quality of life, parent vs. child report, and correlation of nasal endoscopy to sinus CT scores.

METHODOLOGY

A prospective cohort study evaluated CRS patients age 5-18 undergoing ESS. Surveys were completed at two timepoints: (1) pre-ESS and (2) 30-90 days post-ESS, with parents completing general (PedsQLTM) and CRS-specific (SNOT-16 and SN-5) quality of life surveys and children completing PedsQLTM and SNOT-16 surveys. Preoperative Lund-Kennedy nasal endoscopy and Lund-Mackay sinus CT scores were calculated. Where appropriate, outcomes were stratified by cystic fibrosis status.

RESULTS

Impaired preoperative general quality of life was evidenced by parent proxy-report of PedsQLTM scores in 10 cystic fibrosis and 11 non-CF patients. ESS was associated with decreased sinus symptoms at 1-3 months postoperatively with SN-5 change scores of -1.85 and -2.2, in CF and non-CF patients, respectively. Parents reported worse CRS symptoms via higher preoperative SNOT-16 scores than their children did. Nasal endoscopy and sinus CT scores correlated with a Spearman correlation coefficient of 0.51. Scores not reaching statistical significance included CF-related CRS SNOT-16 change scores and PedsQLTM general quality of life change scores.

CONCLUSION

In pediatric patients with CRS electing ESS, general quality of life is impaired preoperatively and sinus symptoms improve significantly 1-3 months after sinus surgery. Parents report statistically worse CRS symptom scores than their children do. Nasal endoscopy scores in this cohort correlated with sinus CT scores.

Emergent airway management in the labor and delivery suite

INTRODUCTION

Congenital airway obstruction is of varied etiology and uncommonly encountered. Prenatal care and imaging have enhanced detection of these abnormalities and allow for multi-disciplinary care planning for airway management at delivery. Despite the availability and advances in prenatal imaging, unanticipated airway obstruction may not be identified until the time of delivery.

METHODS

Case series.

RESULTS

Four airway emergencies were encountered in the labor and delivery suite over an eight-month period. Clinical history is correlated with autopsy findings. Congenital upper airway and laryngotracheal anomalies are reviewed. Recommendations to improve timely and efficient airway management in the labor and delivery suite are discussed and a protocol for a multi-disciplinary neonatal emergency airway response team is offered for consideration.

CONCLUSIONS

The development and implementation of a multi-disciplinary emergency newborn airway protocol is both realistic and feasible. While it did not improve survivability in our small group, it did reduce response time. It, or a protocol like it, is recommended for institutions caring for high-risk pregnancies and with Neonatal Intensive Care Units with high acuity patients.

Transoral robotic surgery for upper airway pathology in the pediatric population

OBJECTIVES/HYPOTHESIS

The purpose of this study is to present one of the largest case series of pediatric transoral robotic surgery (TORS) in the upper airway demonstrating a wide range of ages and indications.

STUDY DESIGN

A retrospective case series at an academic tertiary referral center from August 2010 to September 2014.

METHODS

The da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) was used on 16 pediatric patients for 18 procedures. A variety of upper airway pathologies and reconstructions in children with a wide range of ages and weights were treated. No lingual tonsillectomies or base-of-tongue reductions were included.

RESULTS

Sixteen children (6 males) underwent 18 TORS procedures, including resection of hamartoma (n = 1), repair of laryngeal cleft (n = 7), removal of saccular cyst (n = 2), release of pharyngeal or esophageal strictures (n = 2), and excision of lymphatic malformations (n = 4). Patient ages ranged from 14 days to 15 years. There were no intraoperative complications. All patients had successful robotic access, and no patients had conversions to open or traditional endoscopic surgery. Hospital courses varied with duration ranging from 1 to 20 days. The median follow up was 22 months.

CONCLUSION

Applying TORS to the pediatric population can be feasible and safe for appropriate airway pathologies. Because many patients are small in size, there is inherent risk in using robotic instruments and scopes transorally. Pearls in this series include a standardized two-robot experienced attending team and longitudinal airway follow-up.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:247-251, 2017.

A Multidisciplinary Children's Airway Center: Impact on the Care of Patients With Tracheostomy

BACKGROUND

Children with complex airway problems see multiple specialists. To improve outcomes and coordinate care, we developed a multidisciplinary Children's Airway Center. For children with tracheostomies, aspects of care targeted for improvement included optimizing initial hospital discharge, promoting effective communication between providers and caregivers, and avoiding tracheostomy complications.

METHODS

The population includes children up to 21 years old with tracheostomies. The airway center team includes providers from pediatric pulmonology, pediatric otolaryngology/head and neck surgery, and pediatric gastroenterology. Improvement initiatives included enhanced educational strategies, weekly care conferences, institutional consensus guidelines and care plans, personalized clinic schedules, and standardized intervals between airway examinations. A patient database allowed for tracking outcomes over time.

RESULTS

We initially identified 173 airway center patients including 123 with tracheostomies. The median number of new patients evaluated by the center team each year was 172. Median hospitalization after tracheostomy decreased from 37 days to 26 days for new tracheostomy patients <1 year old discharged from the hospital. A median of 24 care plans was evaluated at weekly conferences. Consensus protocol adherence increased likelihood of successful decannulation from 68% to 86% of attempts. The median interval of 8 months between airway examinations aligned with published recommendations.

CONCLUSIONS

For children with tracheostomies, our Children's Airway Center met and sustained goals of optimizing hospitalization, promoting communication, and avoiding tracheostomy complications by initiating targeted improvements in a multidisciplinary team setting. A multidisciplinary approach to management of these patients can yield measurable improvements in important outcomes.

Volumetric nasal cavity analysis in children with unilateral and bilateral cleft lip and palate

OBJECTIVES/HYPOTHESIS

Children with cleft lip and palate (CLP) often suffer from nasal obstruction that may be related to effects on nasal volume. The objective of this study was to compare side:side volume ratios and nasal volume in patients with unilateral (UCLP) and bilateral (BCLP) clefts with age-matched controls.

STUDY DESIGN

Retrospective case-control study using three-dimensional (3D) nasal airway reconstructions.

METHODS

We analyzed 20 subjects (age range = 7-12 years) with UCLP and BCLP from a regional craniofacial center who underwent cone beam computed tomography (CT) prior to alveolar grafting. Ten multislice CT images from age-matched controls were also analyzed. Mimics software (Materialise, Plymouth, MI) was used to create 3D reconstructions of the main nasal cavity and compute total and side-specific nasal volumes. Subjects imaged during active nasal cycling phases were excluded.

RESULTS

There was no statistically significant difference in affected:unaffected side volume ratios in UCLP (P = .48) or left:right ratios in BCLP (P = .25) when compared to left:right ratios in controls. Mean overall nasal volumes were 9,932 ± 1,807, 7,097 ± 2,596, and 6,715 ± 2,115 mm(3) for control, UCLP, and BCLP patients, respectively, with statistically significant volume decreases for both UCLP and BCLP subjects from controls (P < .05).

CONCLUSIONS

This is the first study to analyze total nasal volumes in BCLP patients. Overall nasal volume is compromised in UCLP and BCLP by approximately 30%. Additionally, our finding of no major difference in side:side ratios in UCLP and BCLP compared to controls conflicts with pre-existing literature, likely due to exclusion of actively cycling scans and our measurement of the functional nasal cavity.

LEVEL OF EVIDENCE

3b. Laryngoscope, 126:1475-1480, 2016.

Connexin-Related (DFNB1) Hearing Loss

Objectives

Determine if routine computed tomography (CT) imaging is necessary in the workup for children with connexin-related (DFNB1) sensorineural hearing loss (SNHL).

Study Design

Case-control retrospective chart and imaging review.

Setting

Tertiary care otolaryngology practice.

Subjects and Methods

High-resolution temporal bone CT scans of children (n = 21) with DFNB1 SNHL were compared to age-matched controls with either conductive hearing loss (CHL, n = 33) or a nonsyndromic, non-DFNB1 SNHL (n = 33). Sixteen measurements of cochleo-vestibular structures were recorded. Statistical analysis was performed using a repeated analysis of variance model that controlled for both age and gender. Area under the curve (AUC) and multidimensional AUC (MAUC) analyses were also performed.

Results

Overall, no statistically significant differences were found between the 3 experimental groups. In addition, comparisons between the DFNB1 and CHL groups, DFNB1 and non-DFNB1 SNHL groups, and CHL and non-DFNB1 SNHL groups failed to demonstrate any statistically significant differences. AUC and MAUC analyses also failed to detect any significant differences between the 3 groups.

Conclusions

Patients with DFNB1 SNHL do not have significant anatomic differences on temporal bone CT scans when compared to non-DFNB1 SNHL and CHL control groups. Based on the above analysis, it is reasonable to avoid routine CT imaging of the temporal bones in children with known DFNB1 SNHL unless otherwise clinically indicated.

New Concepts in Pediatric Otolaryngology: A Video Forum

Program Description:

In this state-of-the-art miniseminar, 7 experts will share video-based examples of new ideas in pediatric otolaryngology. New knowledge, techniques, and outcomes for emerging concepts will be discussed while ample opportunity for audience questions and answers will be provided. Steven L. Goudy: endoscopic-assisted pharyngeal surgery. Christopher J. Hartnick: optical coherence tomography in the operating room; differentiating cysts from nodules. Sanjay R. Parikh: drug-induced sleep endoscopy: technique and findings. Soham Roy: mechanical models of operating room airway fires. Michael J. Rutter: slide tracheoplasty for difficult tracheoesophageal fistula. David R. White: a new understanding of congenital nasal stenosis. Carlton J. Zdanski: transoral robotic surgery: pearls and pitfalls.

Educational Objectives:

(1) Characterize novel ideas for pediatric airway surgery techniques and concepts. (2) Prevent airway fires during surgery. (3) Practice novel techniques for understanding pediatric sleep apnea evaluation.

Statistical atlas construction via weighted functional boxplots

Atlas-building from population data is widely used in medical imaging. However, the emphasis of atlas-building approaches is typically to estimate a spatial alignment to compute a mean/median shape or image based on population data. In this work, we focus on the statistical characterization of the population data, once spatial alignment has been achieved. We introduce and propose the use of the weighted functional boxplot. This allows the generalization of concepts such as the median, percentiles, or outliers to spaces where the data objects are functions, shapes, or images, and allows spatio-temporal atlas-building based on kernel regression. In our experiments, we demonstrate the utility of the approach to construct statistical atlases for pediatric upper airways and corpora callosa revealing their growth patterns. We also define a score system based on the pediatric airway atlas to quantitatively measure the severity of subglottic stenosis (SGS) in the airway. This scoring allows the classification of pre- and post-surgery SGS subjects and radiographically normal controls. Experimental results show the utility of atlas information to assess the effect of airway surgery in children.

Comparison of endoscopic versus 3D CT derived airway measurements

OBJECTIVES/HYPOTHESIS

To understand: 1) how endoscopic airway measurements compare to three-dimensional (3D) CT derived measurements; 2) where each technique is potentially useful; and 3) where each has limitations.

STUDY DESIGN

Compare airway diameters and cross-sectional areas from endoscopic images and CT derived 3D reconstructions.

METHODS

Videobronchoscopy was performed and recorded on an adult-sized commercially available airway mannequin. At various levels, cross-sectional areas were measured from still video frames using a referent placed via the biopsy port. A 3D reconstruction was generated from a high resolution CT of the mannequin; planar sections were cut at similar cross-sectional levels; and cross-sectional areas were obtained.

RESULTS

At three levels of mechanically generated tracheal stricture, the differences between the endoscopic measurement and CT-derived cross-sectional area were 1%, 0%, and 7% (1.8, 0.8, and 14 mm²). At the vocal folds, the difference was 9% (7.8 mm²). The tip of the epiglottis and width of the epiglottis differed by 27% and 10% (18.73 mm², 0.40 mm). The airway measurements at the base of tongue, minimal cross-sectional area of the pharynx, and choana differed by 26%, 36%, and 30% (101.40 mm², 36.67 mm², 122.71 mm²).

CONCLUSIONS

Endoscopy is an effective tool for obtaining airway measurements compared with 3D reconstructions derived from CT. Concordance is best in geometrically simple areas where the entire cross-section measured is visible within one field of view (trachea, round; vocal folds, triangular) versus geometrically complex areas that encompass more than one field of view (i.e. pharynx, choana).

A PEDIATRIC AIRWAY ATLAS AND ITS APPLICATION IN SUBGLOTTIC STENOSIS

Young children with upper airway problems are at risk for hypoxia, respiratory insufficiency and long term morbidity. Computational models and quantitative analysis would reveal airway growth patterns and benefit clinical care. To capture expected growth patterns we propose a method to build a pediatric airway atlas as a function of age. The atlas is based on a simplified airway model in combination with kernel regression. We show experimental results on children with subglottic stenosis to demonstrate that our method is able to track and measure the stenosis in pediatric airways.

Congenital Oral and Pharyngeal Masses: Diagnosis, Management, and Prognosis

Objective: Understand the complex management and prognosis of patients with congenital oral and pharyngeal masses that cause cleft palate. To understand the multifaceted role of the pediatric otolaryngologist in the care of these patients.

Method: Retrospective study of all patients with oral or pharyngeal masses and cleft palate or velopharyngeal insufficiency treated in one year at a tertiary care institution. Charts were reviewed for age; gender; comorbidities; birth history; location and pathology of the mass; surgical treatment; and follow-up care.

Results: There were 5 patients, 21-months to 24-years-old, 3 of whom had other congenital anomalies. Three patients had large oral masses (2 hamartomas and 1 teratoma). Two patients had pharyngeal masses (teratomas). Four patients had cleft palate, all repaired by 1 year, 2 with later pharyngeal flaps. One patient with an intact but short palate underwent a pharyngeal flap at 6 year. One patient with a large oral mass had significant airway compromise at birth. Two patients underwent tracheotomy, and one was decannulated at 18 months. Additional surgeries were performed in all patients, including tympanostomy (2 patients), tonsillectomy (2 patients), maxillary and mandibular advancement (1 patient), and gastrostomy (1 patient).

Conclusion: Congenital oral or pharyngeal masses may cause cleft palate. Otolaryngologists are involved in care from initial airway management and excision to reconstruction and rehabilitation of speech and swallow. After excision, most patients will have a stable airway and tolerate an oral diet. Additional surgeries are often performed for associated comorbidities.

Rigid Laryngoscopy Is Necessary to Diagnose Laryngeal Cleft

Objective: 1) Identify the signs and symptoms of a laryngeal cleft in children. 2) Compare diagnostic methods available for identifying laryngeal cleft and determine their utility.

Method: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, symptoms, bedside swallow evaluation, and results of imaging studies. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared.

Results: Six patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy, performed for cough and signs of aspiration. In 3 cases the pattern on a barium video swallow examination heightened suspicion of laryngeal cleft. Flexible laryngoscopy was performed on all patients by a pulmonologist. Laryngeal cleft was suspected in four cases but could not be confirmed. Direct laryngoscopy was performed by an otolaryngologist. Direct laryngoscopy, in which the arytenoids could be physically separated, allowed for definitive diagnosis of the cleft and identification of its type and severity in all 6 cases.

Conclusion: Video swallow and flexible laryngoscopy can raise suspicion of a rare laryngeal cleft in patients with otherwise common symptoms. A laryngeal cleft and its type can be definitively diagnosed by a direct laryngoscopy in which the inter-arytenoid space is palpated.

Transpalatal greater palatine canal injection: Radioanatomic analysis of where to bend the needle for pediatric sinus surgery

BACKGROUND

The greater palatine canal (GPC) local injection is used to limit posterior bleeding during sinus surgery in adults. Given the potential for causing iatrogenic damage to the intraorbital contents, this procedure is not commonly used in the pediatric population. No studies have described the anatomic development of the GPC during facial growth. By using age-stratified radioanatomic analysis, the dimensions of the GPC and the clinical implications are described for pediatric patients. An age-stratified radioanatomic study was performed.

METHODS

High-resolution computed tomography measurements included the thickness of the mucosal plane overlying the GPC, the length of the GPC, and the distance between the base of the pterygopalatine fossa (PPF) and the orbital floor. Mean distance and standard deviation were calculated for each age cohort and compared using the one-way ANOVA test.

RESULTS

The GPC length correlated directly with patient age. It varied from 9.14 ± 0.11 mm in the youngest age group (<2 years) to 19.36 ± 2.76 mm in adults (18-64 years). The height of the orbit relative to the hard palate approximated the adult dimensions described in the literature by 12-13 years (49.58 ± 1.72 mm).

CONCLUSION

These radioanatomic results suggest that the GPC injection described for adult patients may be safely administered to selected pediatric patients. For patients >12 years old, we recommend bending the needle 45° and inserting it 25 mm. For patients 6-12 years old, the needle should be inserted 20 mm to enter into the PPF. In patients <6 years old, the needle may safely be placed 12 mm into the GPC. Each of these descriptions is based on the minimal distance required to effectively access the PPF but with maximal safety in regard to the orbit. Further clinical correlation of these findings is necessary through future investigation.

Magnetic resonance imaging of guinea pig cochlea after vasopressin-induced or surgically induced endolymphatic hydrops

Objective: To investigate the ability to detect the in vivo cochlear changes associated with vasopressin-induced and surgically induced endolymphatic hydrops using MRI at 3 tesla (T).

Study Design: Prospective, animal model.

Setting: Animal laboratory.

Subjects and Methods: In group 1, five guinea pigs underwent post–gadolinium temporal bone MRI before and after seven and 14 days of chronic systemic administration of vasopressin by osmotic pump. In group 2, five guinea pigs underwent temporal bone MRI eight weeks after unilateral surgical ablation of the endolymphatic sac. Three-tesla high-resolution T1-weighted sequences were acquired pre- and postcontrast administration. Region of interest signal intensities of the perilymph and endolymph were analyzed manually. Quantitative evaluation of hydrops was measured histologically.

Results: Gadolinium preferentially concentrated in the perilymph, allowing for distinction of cochlear compartments on 3.0-T MRI. The T1-weighted contrast MRI of vasopressin-induced hydropic cochlea showed significant increases in signal intensity of the endolymph and perilymph. Surgically induced unilateral hydropic cochlea also showed increased signal intensity, compared with the control cochlea of the same animal, but less of an increase than the vasopressin group. The histological degree of hydrops induced in the vasopressin group was comparable to previous studies.

Conclusions: In vivo postcontrast MRI of the inner ear demonstrated cochlear changes associated with chronic systemic administration of vasopressin and surgical ablation of the endolymphatic sac. Understanding the MRI appearance of endolymphatic hydrops induced by various methods contributes to the future use of MRI as a possible tool in the diagnosis and treatment of Ménière's disease.

Experience of the school-aged child with tracheostomy

BACKGROUND

Little is known about the school experience of children with tracheostomy tubes. These children may represent a population that qualifies for special services in school. Understanding how tracheostomy affects school-aged children may provide information needed to develop programs that provide these children with invaluable experiences.

OBJECTIVE

To understand what children with tracheostomies experience in school as it relates to tracheostomy care and how their condition affects academic achievement and social adjustment.

METHODS

We identified a cohort of 38 eligible school-aged children with indwelling tracheostomy tubes for ongoing upper airway obstruction through the North Carolina Children's Airway Center. A questionnaire was developed to assess support of their medical condition throughout the school day. Twenty-three patients responded to the questionnaire.

RESULTS

School experience for a child with a tracheostomy varied. Approximately half the children attended special needs classes, the other half were in mainstream classrooms. Speech services and Passy-Muir valves were used in 43% and 57% of cases, respectively. Over half the students were excluded from physical activity because of the tracheostomy. Most students missed at least 10 days of school for medical care in an academic year. Fifty percent of the students reported attending schools where school personnel had no training in tracheostomy care. In some cases, a trained nurse accompanied the child to school to help with tracheostomy care. In other cases, the child coped with tracheostomy care alone.

CONCLUSIONS

As children with special medical needs are increasingly incorporated into mainstream schools, it is important to understand the potential hurdles they face in managing tracheostomies. In particular, school personnel should have the ability to provide basic care for students with tracheostomies. Student speech and educational outcomes require further investigation and analysis.

High-resolution ultrasound in the evaluation of pediatric recurrent respiratory papillomatosis

OBJECTIVES

To characterize the ultrasonographic appearance of laryngeal papillomatosis and to compare ultrasound with direct laryngoscopy and bronchoscopy, the criterion standard, for airway evaluation.

DESIGN

Prospective, nonrandomized analysis of preoperative and postoperative airway ultrasound images.

SETTING

Tertiary, university-based medical center.

PARTICIPANTS

Eight patients (4 females and 4 males) with recurrent respiratory papillomatosis, with a mean age of 10.25 years and a mean of 14 surgical papilloma resections (range, 3-35).

INTERVENTION

The patients underwent planned papilloma resections with ultrasound evaluation before formal endoscopic resection. Preresection ultrasound images of respiratory papillomas were evaluated.

MAIN OUTCOME MEASURES

The ultrasonographic appearance of respiratory papillomas and pediatric airway anatomy.

RESULTS

Respiratory papillomas appeared as discrete, hyperechoic lesions on the relatively hypoechoic background of the true vocal folds.

CONCLUSIONS

Recurrent respiratory papillomas have a characteristic ultrasonographic appearance that seems to correlate with endoscopic findings. It seems that this modality holds promise for identifying pedunculated papillomas. Although direct laryngoscopy and bronchoscopy are the criterion standard, airway ultrasound may have a role in the early diagnosis of, surveillance of, and operative planning for recurrent respiratory papillomatosis. To our knowledge, this is the first study to describe the ultrasonographic appearance of papillomas and the first comparison of ultrasonographic and endoscopic airway images. This modality merits further study, and further investigation is ongoing.

Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency

OBJECTIVE

To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers.

DESIGN

Multicenter blinded R (inter) and R (intra) study.

SETTING

Eight academic tertiary care centers.

PARTICIPANTS

Sixteen otolaryngologists from 8 centers.

MAIN OUTCOME MEASURES

Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated.

RESULTS

The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size.

CONCLUSIONS

In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Cricothyroidotomy vs. sternal tracheotomy for challenging airway anatomy

Although tracheotomies are the standard procedure for elective surgical airways, some patients present with challenging anatomy. In circumstances of abnormal skeletal deformities, such as kyphoscoliosis, the airway is also often tortuous and access to the trachea may be difficult. In the situation of severely distorted tracheal anatomy, where access to the trachea may require a mediansternotomy, a cricothyroidotomy may be the safer option. This article details the technique involved in approaching a substernal larynx and stomatizing a cricothyroidotomy for a patient who required a long-term surgical airway secondary to severe kyphoscoliosis from Proteus syndrome and failure to extubate.

Internal Auditory Canal Morphology in Children with Cochlear Nerve Deficiency

OBJECTIVE

To describe the internal auditory canal (IAC) and inner ear morphologic characteristics of children with cochlear nerve (CN) deficiency.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Fourteen children with small or absent (deficient) CNs have been identified by means of high-resolution magnetic resonance imaging (MRI).

INTERVENTIONS

MRI of the brain. Clinical evaluation.

MAIN OUTCOME MEASURES

Review of medical records, audiological testing results, and imaging studies. Images were evaluated for the structure of the cochlear, vestibular and facial nerves, IACs and inner ears. Audiometric thresholds were evaluated in all subjects.

METHODS

Fourteen children with small or absent (deficient) CNs have been identified by means of high-resolution MRI. A review of the medical records, audiologic testing results, and imaging studies was undertaken. The images were evaluated for the structure of the cochlear, vestibular and facial nerves, IACs, and inner ears. The audiometric thresholds were evaluated in all subjects.

RESULTS

Among the 14 patients, 5 had known syndromes. MRI allowed an exact specification of the nervous structures within all ears with normal-size IACs. Precise characterization of the nerves in ears with small IACs was more difficult, requiring a consideration of both imaging findings and functional parameters. Five children had bilateral deficient CNs, whereas the remaining 9 subjects were affected unilaterally. Thus, 19 ears had CN deficiency (absent CN, 16; small CN, 3). Eleven ears had normal-size IACs and deficient CNs. Of the 9 ears with small IACs, 8 had deficient CNs (absent, 7; small, 1) on the basis of both MRI and functional assessments. Two ears with small IACs had clear morphologic and/or functional evidence for the presence of a CN: one had a small-size CN on MRI, whereas another had a single nerve in a small IAC with present facial and auditory functions.

CONCLUSION

The findings of this study suggest that CN deficiency is not an uncommon cause of congenital hearing loss. The findings that most ears with CN deficiency had normal IAC morphology and that two ears with small IACs had CNs present indicate that IAC morphology is an unreliable surrogate marker of CN integrity. On the basis of these findings, we think that high-resolution MRI, rather than CT imaging, should be performed in all cases of pediatric hearing loss, especially in those cases where profound hearing loss has been documented. For ears with small IACs, the resolution of MRI currently remains limiting. In these cases, the determination of CN status frequently requires a variety of anatomic (CT and MRI) and functional tests (auditory brainstem response, otoacoustic emissions, behavioral audiometry, and physical examination).

Auditory Neuropathy Characteristics in Children with Cochlear Nerve Deficiency

OBJECTIVE

To describe a group of children exhibiting electrophysiologic responses characteristic of auditory neuropathy (AN) who were subsequently identified as having absent or small cochlear nerves (i.e., cochlear nerve deficiency).

DESIGN

A retrospective review of the clinical records, audiological testing results, and magnetic resonance imaging (MRI) studies. Fifty-one of 65 children with AN characteristics on auditory brain stem response (ABR) testing had MRI available for review. Nine (18%) of these 51 children with ABR characteristic of AN have been identified as having small (N = 2; 4%) or absent (N = 7; 14%) cochlear nerves on MRI.

RESULTS

Of the nine children with cochlear nerve deficiency, five (56%) were affected unilaterally and four (44%) bilaterally. Eight of nine presented after failing a newborn infant hearing screening, whereas one presented at 3 yr of age. On diagnostic ABR testing, all 9 children (9 of 13 affected ears; 69%) had evidence of a cochlear microphonic (CM) and absent neural responses in at least one ear. In the unilateral cases, AN characteristics were detected in all affected ears. In bilateral cases, at least one of the ears in each child demonstrated the AN phenotype, whereas the contralateral ear had no CM identified. Only one ear with cochlear nerve deficiency had present otoacoustic emissions as measured by distortion-product otoacoustic emissions. In children with appropriate available behavioral testing results, all ears without cochlear nerves were identified as having a profound hearing loss. Only 4 (31%) of the 13 ears with cochlear nerve deficiency had a small internal auditory canal on MRI.

CONCLUSIONS

Children with cochlear nerve deficiency can present with electrophysiologic evidence of AN. These children frequently refer on newborn screening examinations that use ABR-based testing methods. Similar to other causes of AN, diagnostic ABR testing will show a CM with absent neural responses. Given that 9 (18%) of 51 children with available MRI and electrophysiologic characteristics of AN in our program have been identified as having cochlear nerve deficiency makes this a relatively common diagnosis. These findings suggest that MRI is indicated for all children diagnosed with AN. Moreover, electrophysiologic evidence of unilateral AN in association with a profound hearing loss should make the clinician highly suspicious for this problem. Although children with cochlear nerve deficiency who have a small nerve may benefit from cochlear implantation or amplification, these interventions are obviously contraindicated in children with completely absent cochlear nerves.

Comparison of Pediatric Airway Foreign Bodies Over Fifty Years

Prevention and early recognition remain critical factors in the treatment of foreign body inhalation in children. Accidental inhalation of both organic and nonorganic foreign body material continues to be a cause of childhood morbidity and mortality. The University of North Carolina Department of Otolaryngology has collected foreign bodies acquired from the airways of young children since its inception in 1954. The authors reviewed 26 foreign bodies removed bronchoscopically from the airways of children during the years 1955 to 1960, and compared these to 27 foreign bodies collected from 1999 to 2003. Findings showed remarkable similarities in the types of foreign bodies aspirated. Organic foreign bodies were most commonly found. Differences existed in the type of organic foreign body aspirated, with popcorn being retrieved in 15% of cases during the later time period. Also, an increase in bronchoscopically removed small toy parts was found in the later group.

Revision ossicular reconstruction with the titanium Kurz prosthesis

OBJECTIVE/HYPOTHESIS

One European multicenter study has reported favorable outcomes after ossicular reconstruction with the titanium Kurz prosthesis. At the time of this study, however, no study has analyzed its outcomes when used for reconstruction after prior failure with another implant (revision reconstruction). The study reports our experience with the titanium Kurz prosthesis for revision ossicular reconstruction.

STUDY DESIGN

A retrospective review was made of all revision ossicular reconstructions at our institution from October 1998 to September 2001.

METHODS

Seventeen cases were reviewed. Patients were divided into two groups: patients who underwent revision ossicular reconstruction with the Kurz prosthesis and patients who underwent revision ossicular reconstruction with another prosthesis (the "other" group). Audiograms were reviewed and air-bone gaps were calculated for each patient.

RESULTS

The average postoperative air-bone gap after Kurz revision was 15.6 dB, a statistically significant improvement over the average postoperative air-bone gap from the "other" revision group (P =.022).

CONCLUSION

The titanium Kurz prosthesis has been an effective implant at our institution for revision ossicular reconstruction. Future research should focus on a prospective, randomized trial comparing the Kurz prosthesis with other prostheses currently in use.