Dominant negative variants in IKZF2 cause ICHAD syndrome, a new disorder characterised by immunodysregulation, craniofacial anomalies, hearing impairment, athelia and developmental delay

BACKGROUND

Helios (encoded by IKZF2), a member of the Ikaros family of transcription factors, is a zinc finger protein involved in embryogenesis and immune function. Although predominantly recognised for its role in the development and function of T lymphocytes, particularly the CD4+ regulatory T cells (Tregs), the expression and function of Helios extends beyond the immune system. During embryogenesis, Helios is expressed in a wide range of tissues, making genetic variants that disrupt the function of Helios strong candidates for causing widespread immune-related and developmental abnormalities in humans.

METHODS

We performed detailed phenotypic, genomic and functional investigations on two unrelated individuals with a phenotype of immune dysregulation combined with syndromic features including craniofacial differences, sensorineural hearing loss and congenital abnormalities.

RESULTS

Genome sequencing revealed de novo heterozygous variants that alter the critical DNA-binding zinc fingers (ZFs) of Helios. Proband 1 had a tandem duplication of ZFs 2 and 3 in the DNA-binding domain of Helios (p.Gly136_Ser191dup) and Proband 2 had a missense variant impacting one of the key residues for specific base recognition and DNA interaction in ZF2 of Helios (p.Gly153Arg). Functional studies confirmed that both these variant proteins are expressed and that they interfere with the ability of the wild-type Helios protein to perform its canonical function-repressing IL2 transcription activity-in a dominant negative manner.

CONCLUSION

This study is the first to describe dominant negative IKZF2 variants. These variants cause a novel genetic syndrome characterised by immunodysregulation, craniofacial anomalies, hearing impairment, athelia and developmental delay.

Two-Year Outcomes After Pediatric In-Office Tympanostomy Using Lidocaine/Epinephrine Iontophoresis and an Automated Tube Delivery System

OBJECTIVE

Evaluate 2-year outcomes after lidocaine/epinephrine iontophoresis and tympanostomy using an automated tube delivery system for pediatric tube placement in-office.

STUDY DESIGN

Prospective, single-arm.

SETTING

Eighteen otolaryngology practices.

METHODS

Children age 6 months to 12 years indicated for tympanostomy were enrolled between October 2017 and February 2019. Local anesthesia of the tympanic membrane was achieved via lidocaine/epinephrine iontophoresis and tympanostomy was completed using an automated tube delivery system (the Tula® System). An additional Lead-In cohort of patients underwent tube placement in the operating room (OR) under general anesthesia using only the tube delivery system. Patients were followed for 2 years or until tube extrusion, whichever occurred first. Otoscopy and tympanometry were performed at 3 weeks, and 6, 12, 18, and 24 months. Tube retention, patency, and safety were evaluated.

RESULTS

Tubes were placed in-office for 269 patients (449 ears) and in the OR for 68 patients (131 ears) (mean age, 4.5 years). The median and mean times to tube extrusion for the combined OR and In-Office cohorts were 15.82 (95% confidence interval [CI]: 15.41-19.05) and 16.79 (95% CI: 16.16-17.42) months, respectively. Sequelae included ongoing perforation for 1.9% of ears (11/580) and medial tube displacement for 0.2% (1/580) observed at 18 months. Over a mean follow-up of 14.3 months, 30.3% (176/580) of ears had otorrhea and 14.3% (83/580) had occluded tubes.

CONCLUSION

In-office pediatric tympanostomy using lidocaine/epinephrine iontophoresis and automated tube delivery results in tube retention within the ranges described for similar grommet-type tubes and complication rates consistent with traditional tube placement in the OR.

High frequency of otolaryngology/ENT encounters in Canadian primary care despite low medical undergraduate experiences

Otolaryngology involves the treatment of patients with diseases and disorders of the ear, nose, throat (ENT), and related structures of the head and neck. Many medical students in Canada have limited experiences in ENT and a vast majority of these students go on to pursue a career as primary care physicians. Physicians at a primary care facility classified patient's visits as either being "ENT" related or not, to assess the amount of ENT related concerns they typically encounter. The data was collected separately in the summer and winter months to assess any seasonal variability. One in eight patient encounters presented with an ENT related concern. The percentage of ENT related symptom presentation visits in the pediatric population for both data collection periods (29%) was more than three times that of the adult population (9%). The rate of ENT symptom presentation in both adult and pediatric populations was not affected by seasonality. Primary care physicians will encounter new patients presenting with ENT related concerns quite frequently. This is especially true in the pediatric patient population. Increased ENT medical education is both necessary and essential for undergraduate medical students, residents, and primary care physicians.

Intranasal Dexmedetomidine increases the successful sedation of children with autism for out-patient auditory brainstem response hearing tests

INTRODUCTION

The auditory brainstem response (ABR) hearing test can be challenging in children with autism spectrum disorder (ASD) due to the inherent behavioral challenges associated with this condition. To attempt to increase our success in sedating ASD patients, we added the use of intranasal Dexmedetomidine (Dexmed) to be used alone or with oral Chloral Hydrate (CH) in an ambulatory care setting, with monitoring by a specialist nurse.

OBJECTIVES

To determine the success and safety of a protocol for ABR testing performed under sedation with intranasal Dexmed and oral chloral hydrate in ASD patients. To compare the success rate, the occurrence of adverse events and time needed to initiate ABR between Dexmed-CH protocol and previous CH-alone protocol in ASD patients.

METHODS

Retrospective review. ASD patients in Dexmed-CH sedation protocol were age- and sex-matched to ASD patients who underwent CH-alone sedation protocol, for comparison.

RESULTS

74 ABR records in ASD children were included, 37 patients using Dex-CH protocol and 37 patients using CH-alone protocol. In the Dexmed-CH protocol group, Dexmed was used in 2 different ways: alone as a first choice in patients who refused to swallow CH (9/37), or combined with CH as a rescue (28/37). Under this sedation protocol, 89% of the attempted ABRs were completed successfully with no major adverse effects. In comparison, in ASD patients sedated using the protocol of CH-alone, the success rate significantly lower (69% vs. 89%). The time needed to initiate the test was not significantly different.

CONCLUSION

The use of intranasal Dexmed by itself or in combination with CH was a safe and reliable method of performing sedated ABR in ASD patients. Modifying our previous oral CH protocol to include intranasal Dexmed, substantially improved our success rate of sedation in ASD patients in an ambulatory setting. This study may be of significant value to centers worldwide exploring alternatives to general anesthesia for ABR testing in ASD patients.

A national study of choanal atresia in tertiary care centers in Canada - part II: clinical management

Background

To evaluate the clinical management of choanal atresia (CA) in tertiary centers across Canada.

Methods

Multi-centre case series involving six tertiary care pediatric hospitals across Canada. Retrospective chart review of patients born between 1980 and 2010 diagnosed with choanal atresia to a participating center.

Results

The health charts of 215 patients (59.6% female) with choanal atresia (CA) were reviewed. Mean age of initial surgical repair was 0.8 months for bilateral CA, and 48.6 months for unilateral CA. Approaches of surgical repair consisted of endoscopic transnasal (31.7%), non-endoscopic transnasal (42.6%), and transpalatal (25.2%). Stents were used on 70.7% of patients. Forty-nine percent of patients were brought back to the OR for a planned second look; stent removal being the most common reason (86.4%). Surgical success rate of initial surgeries was 54.1%. Surgical technique was not associated with rate of restenosis [χ² (2) = 1.6, p = .46].

Conclusions

The present study is the first national multi-institutional study exploring the surgical outcomes of CA over a 30-year period. The surgical repair of CA presents a challenge to otolaryngologists, as the rate of surgical failure is high. The optimal surgical approach, age at surgical repair, use of stents, surgical adjuncts, and need for planned second look warrant further investigation.

Graphical abstract

A national study of choanal atresia in tertiary care centers in Canada - part I: clinical presentation

Background

To evaluate the clinical presentation of choanal atresia (CA) in tertiary centers across Canada.

Methods

Multi-centre case series involving six tertiary care pediatric hospitals across Canada. Retrospective chart review of patients born between 1980 and 2010 diagnosed with CA at a participating center.

Results

The health charts of 215 patients (59.6% female) with CA were reviewed and included in this study. The mean age of patients at time of CA presentation was 0.4 months (range 0.1 to 7.2 months) for bilateral CA and 37.8 months (range 0.1 to 164.1 months) for unilateral cases. The most common presenting symptoms for bilateral CA in decreasing order were respiratory distress (96.4%), feeding difficulties (68.2%), and rhinorrhea (65.5%), and for unilateral cases in decreasing order were rhinorrhea (92.0%), feeding difficulties (24.7%), and respiratory distress (18.0%). For the majority of patients (73.2%), the obstruction comprised mixed bony and membranous tissue, with only 10.5% presenting with a purely membranous obstruction. Familial history of CA was confirmed in only 3.3% of cases. One half of patients with CA presented with one or more associated anomalies and 30.6% had a syndrome.

Conclusions

The present investigation is the first national multi-institutional study evaluating the clinical presentation of CA over three decades. The present cohort of CA patients presented with a breadth of co-morbidities with highly variable presentations, with bilateral cases being more severely affected than unilateral cases. Further investigation into hereditary linkages to CA development is warranted.

Graphical abstract

Mastoid pressure dressing - Current practice amongst Canadian pediatric cochlear implant surgeons

OBJECTIVES

Mastoid pressure dressing (MPD) has routinely been used following major ear surgery, such as cochlear implant (CI) surgery, to prevent postoperative wound complications. To date, controlled studies have suggested no difference in the incidence of wound complications following MPD use. However, there is a variation in the practice of MPD usage across pediatric CI surgeons. In this study, we aimed to identify the most common type of postoperative dressing management after pediatric cochlear implantation and the factors in the decision-making process for post-surgical care amongst Canadian pediatric CI surgeons.

METHODS

Canadian Otolaryngologists who perform pediatric CI surgery were identified (n = 18) and contacted via email to complete a short online questionnaire regarding current post-operative head dressing practice following CI surgery. Descriptive statistics were used to analyze the response data.

RESULTS

The participants provided an approximate number of CI's they performed in 2016. 100% of the recipients completed the survey. Approximately 376 CI's were completed in 2016 with an average of 21 CI's per surgeon. 61% of participants routinely used MPDs following surgery justified by reasons such as wound protection, institutional standard of care, and physician's original training practice.

CONCLUSION

There is no clear consensus on the use of MPDs amongst Canadian pediatric CI surgeons. Since the current evidence in the literature suggests no difference in wound complication incidence post-surgery with MPD use, a change in postoperative dressing management to non-use in those that employ this practice may be justified. Eliminating the usage of a MPD may also have potential economic benefits. Further prospective controlled studies may be warranted.

In-Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery

OBJECTIVES/HYPOTHESIS

Evaluate technical success, tolerability, and safety of lidocaine iontophoresis and tympanostomy tube placement for children in an office setting.

STUDY DESIGN

Prospective individual cohort study.

METHODS

This prospective multicenter study evaluated in-office tube placement in children ages 6 months through 12 years of age. Anesthesia was achieved via lidocaine/epinephrine iontophoresis. Tube placement was conducted using an integrated and automated myringotomy and tube delivery system. Anxiolytics, sedation, and papoose board were not used. Technical success and safety were evaluated. Patients 5 to 12 years old self-reported tube placement pain using the Faces Pain Scale-Revised (FPS-R) instrument, which ranges from 0 (no pain) to 10 (very much pain).

RESULTS

Children were enrolled into three cohorts with 68, 47, and 222 children in the Operating Room (OR) Lead-In, Office Lead-In, and Pivotal cohorts, respectively. In the Pivotal cohort, there were 120 and 102 children in the <5 and 5- to 12-year-old age groups, respectively, with a mean age of 2.3 and 7.6 years, respectively. Bilateral tube placement was indicated for 94.2% of children <5 and 88.2% of children 5 to 12 years old. Tubes were successfully placed in all indicated ears in 85.8% (103/120) of children <5 and 89.2% (91/102) of children 5 to 12 years old. Mean FPS-R score was 3.30 (standard deviation [SD] = 3.39) for tube placement and 1.69 (SD = 2.43) at 5 minutes postprocedure. There were no serious adverse events. Nonserious adverse events occurred at rates similar to standard tympanostomy procedures.

CONCLUSIONS

In-office tube placement in selected patients can be successfully achieved without requiring sedatives, anxiolytics, or papoose restraints via lidocaine iontophoresis local anesthesia and an automated myringotomy and tube delivery system.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:S1-S9, 2020.

Subjective and objective vestibular changes that occur following paediatric cochlear implantation: systematic review and meta-analysis

Objective

Cochlear implantation can result in post-operative vestibular dysfunction of unknown clinical significance. The objective of this study was to characterize the presence, magnitude, and clinical significance of vestibular dysfunction that occurs after pediatric cochlear implantation.

Data sources

The databases Embase, Medline (OvidSP), and PubMed were used. Only articles published in English were included. Grey literature and unpublished sources were also reviewed.

Study selection

Articles published from 1980 until the present which documented pre-operative and post-operative vestibular testing on children under the age of 18 were used.

Data extraction

Parameters that were assessed included number of patients, pre- and post-operative vestibular-evoked myogenic potentials (VEMPs), head impulse testing (HIT), calorics, and posturography, timing of pre- and post-operative testing, symptomatology, and other demographic data such as etiology of the hearing loss.

Data synthesis

Ten articles were included. Relative risk values evaluating the effect of cochlear implantation on vestibular function were calculated for VEMPs and caloric testing due to the availability of published data. I² values were calculated and 95% confidence intervals were reported. Separate analyses were conducted for each individual study and a pooled analysis was conducted to yield an overall relative risk. Assessment on risk of bias in individual studies and overall was performed.

Conclusion

Pediatric cochlear implantation is associated with a statistically significant decrease in VEMP responses post-operatively (RR 1.8, p < 0.001, I² 91.86, 95%CI 1.57–2.02). Similar results are not seen in caloric testing. Insufficient data is available for analysis of HIT and posturography. Further studies are necessary to determine the effect of cochlear implantation on objective vestibular measures post-operatively and whether any changes seen are clinically relevant in this population.

Improving vaccination uptake in pediatric Cochlear implant recipients

BACKGROUND

An Infectious Disease vaccine specialist joined our institution's Cochlear Implant Team in 2010 in order to address the high percentage of non-compliance to immunization prior to surgery identified previously from an internal review. The purpose of this study was to (1) review the immunization status of cochlear implant recipients in 2010-2014, (2) assess if introducing a vaccine specialist made a significant change in vaccination compliance and (3) elucidate any barriers to vaccination compliance.

METHODS

Retrospective chart review and a telephone survey. Medical records of 116 cochlear implant recipients between 2010 and 2014 were reviewed. A telephone survey was conducted to obtain the current vaccination status in children who required post-operative vaccinations with incomplete records on chart review and, if applicable, the reason for non-compliance.

RESULTS

Between 2010 and 2014, 98% of children were up-to-date at the time of surgery, compared to 67% up-to-date at the time of surgery between 2002 and 2007. 27 children were included in our post-operative immunization analysis. 29.6% (8/27) failed to receive necessary vaccinations post-surgery. Pneumovax-23, a vaccine for high-risk patients (such as cochlear implant candidates) was missed in all cases.

CONCLUSION

Pre-operative vaccination for cochlear implant recipients improved dramatically with the addition of a vaccine specialist. However, a significant proportion of patients requiring vaccinations post-surgery did not receive them. The main reason for non-compliance was due to parents being unaware that their children required this vaccine postoperatively by being "high-risk". Although improvement was demonstrated, a communication gap continued to impede the adequacy of vaccination uptake in pediatric cochlear implant recipients following surgery at age 2 when the high-risk vaccine was due.

Detection of abnormally shaped ears by a trained non-specialist allows for early non-surgical intervention

INTRODUCTION

Many children are born with abnormally-shaped ears, including protruding ears or unusually-shaped outer ears. While the majority are benign, these may cause significant issues with self-esteem and bullying in childhood. Early molding can resolve some of these abnormalities, avoiding the need for future corrective surgery. However, newborns with these abnormalities are rarely identified early, within the first few days of life, when molding is most effective. In this study, we investigate whether a trained non-specialist can correctly identify ear shape abnormalities in newborns.

METHODS

A non-specialist (medical student) was trained on normal and abnormal ear anatomy using photographs and descriptions. Newborns <72 h of age were recruited from maternity wards. Newborns' ears were photographed and these images were assessed independently by two specialists and the non-specialist. External ear shape was classified as either normal or abnormal based on pre-determined criteria.

RESULTS

A total of 661 ears of 334 newborns were photographed and assessed. High inter-rater agreement was achieved with a kappa statistic of 0.863 (SE 0.078). The non-specialist detected abnormally-shaped ears with a sensitivity and specificity of 90.9% and 91.1% respectively.

CONCLUSIONS

Our study illustrates that non-specialist can be trained to accurately detect newborn ear abnormalities, providing a cost-effective means of ensuring that these children's health care needs are met in a timely fashion. Specifically, we recommend the integration of ear shape assessment into currently established programs such as the newborn hearing screening program.

Krazy Glue® in the ear: A case report of child abuse

Krazy Glue^® or cyanoacrylate glue is an acrylic resin that polymerizes in less than a minute when in contact with moisture or water. We present a case of a one month old referred to our tertiary pediatric otolaryngology clinic from an outside emergency department with a history of application of cyanoacrylate glue in the external ear canals. This report presents the management of this case along with the medical and legal outcomes surrounding this case of child abuse.

Health care professionals' neckties as a source of transmission of bacteria to patients: a systematic review

BACKGROUND

There is growing concern that neckties worn by health care professionals may contribute to infections contracted in health care settings. We evaluated the evidence for health-care-associated infections resulting from neckties and whether the evidence is sufficient to warrant a tieless policy in Canada.

METHODS

We performed a systematic review to determine whether neckties worn by health care professionals colonize harmful pathogenic bacteria and whether they contribute to the spread of infection to patients in the inpatient or outpatient setting. We searched PubMed (1966 to 2017) and Embase (1974 to 2017). The level of evidence was appraised according to the Oxford Centre for Evidence-Based Medicine levels of evidence. We evaluated the quality of evidence and the risk of bias using the Jadad scale or the Newcastle-Ottawa Scale.

RESULTS

We screened 1675 citations, of which 6 were ultimately included in the systematic review. Only 1 study gave level 1b evidence (randomized controlled trial). Neckties were more likely than shirt pockets to colonize bacteria. There is limited evidence that neckties may be contaminated with pathogenic bacteria (e.g., methicillin-resistant Staphylococcus aureus) and very limited evidence that contaminated neckties may transmit bacteria (in a controlled experimental setting to a mannequin).

INTERPRETATION

There is no evidence of increased rates of health-care-associated infections related to the wearing of neckties by health care professionals. There is weak evidence that neckties are contaminated with pathogenic (and nonpathogenic) bacteria. The level of evidence was weak and the studies were heterogeneous. Evidence to support the need for a tieless dress code policy is lacking.

Chloral hydrate sedation for auditory brainstem response (ABR) testing in children: Safety and effectiveness

INTRODUCTION

The auditory brainstem response (ABR) test is used to identify hearing loss and measure hearing thresholds of infants and children who cannot be tested using standard behavioral hearing testing methods. In order for the ABR to yield useful data, a child must be asleep throughout the duration of the test. In many centers, this is achieved through the use of a general anesthetic, with its inherent risks and costs. Since 2004, ABRs have been routinely conducted at BC Children's Hospital in an ambulatory care setting under oral chloral hydrate sedation, with monitoring by a specialist nurse. The aim of this retrospective study was to assess the effectiveness and safety of nurse-led sedation with chloral hydrate for ABR testing at our tertiary pediatric center.

METHODS

Medical and audiology records were reviewed for children aged 6 months to 17 years who underwent ABR testing from 2004 to 2012. We reviewed the dosage of drug used, condition of the child after chloral hydrate administration, adverse effects, audiological results, patients' vital signs, and the effectiveness of the sedative in keeping the child asleep throughout the duration of the test. Frequency distributions were derived for adverse outcomes.

RESULTS

725 ABR records encompassing 635 children (multiple ABR tests in some children) were reviewed. The average dose of chloral hydrate used was 52mg/kg. The majority of sedated ABR's (80.8%) were completed without any incident. Significant events [apnea and/or bradycardia], minor complications [vomiting, hypoxemia, prolonged sedation, and/or tachypnea] and restlessness were noted in 3.4%, 6.2%, and 5.0% of the cases, respectively. The majority of these issues resolved without medical intervention, such as the need to provide supplementary oxygen. In 95.9% of ABRs, chloral hydrate was successful in sedating the child adequately to answer the audiological question.

CONCLUSIONS

This forms the largest study to date on oral sedation for ABR testing. Based on our results, the use of chloral hydrate in the presence of a sedation nurse was a safe and reliable method of performing ABR in infants and children. This may be of significant value to centres worldwide exploring alternatives to general anesthesia for ABR testing.

Type IV congenital laryngeal web: Case report and 15 year follow up

A five day old patient with mild VACTERL syndrome had repair of a type IV congenital laryngeal web with successful decannulation 76 days later. Voice and respiratory outcome is good with follow up 15 years later. This case presents a rare clinical finding of a type IV laryngeal web successfully repaired with a keel and subsequent long term follow up during an era when it was suggested that repair be delayed until 18 months of age at the earliest.

Casting a look at pediatric plastic bronchitis

OBJECTIVES

To review clinical presentations and management strategies for children with plastic bronchitis.

METHODS

Retrospective chart review.

RESULTS

Seven patients required rigid bronchoscopy to remove bronchial casts over a 17-year study period. Mean age at presentation was 60 months. Mean follow-up was 53 months. Co-morbidities included: congenital heart disease (n=3), chronic pulmonary disorders (n=2) and sickle cell disease (n=1). 4 patients required multiple bronchoscopies for recurrent casts. Adjunctive topical therapies were administered in all 7 patients, without complication. Rigid bronchoscopy for cast removal was performed in 2 patients who were on extra-corporal membrane oxygenation (ECMO), using special precautions to safeguard the ECMO catheters.

CONCLUSIONS

Bronchial casts in children may present acutely or sub-acutely. Recurrent casts are unusual; however, in combination with severe cardiac disease may lead to mortality. Adjunctive topical therapies are still under investigation. Special safeguards for ECMO catheters are imperative. This case series complements and adds to the International Plastic Bronchitis Registry.

Nocardia asteroides sinusitis in a pediatric patient: Case report with 20 year follow-up and review of the literature

Nocardia Asteroides infection in a non-immunocompromised pediatric patient is extremely rare. We present a case of ethmoid sinusitis and orbital subperiosteal abscess caused by N. asteroides with a 20 year follow up and a review of the literature. N. asteroides was grown from intraoperative cultures for mycobacteria following surgical incision and drainage of the abscess. Postoperatively, the patient received a seven month course of trimethoprim-sulfamethozaxole and had no subsequent sequelae. Nocardia infections are common in immunocompromised patients. We present what we believe to be the first case of pediatric Nocardia sinusitis with 20-year follow up.

A meta-analysis and systematic review of the prevalence of mitochondrially encoded 12S RNA in the general population: Is there a role for screening neonates requiring aminoglycosides?

BACKGROUND

This was a meta-analysis and systematic review to determine the global prevalence of the mitochondrially encoded 12S RNA (MT-RNR1) genetic mutation in order to assess the need for neonatal screening prior to aminoglycoside therapy.

MATERIALS AND METHODS

A comprehensive search of MEDLINE, EMBASE, Ovid, Database of Abstracts of Reviews of Effect, Cochrane Library, Clinical Evidence and Cochrane Central Register of Trials was performed including cross-referencing independently by 2 assessors. Selections were restricted to human studies in English. Meta-analysis was done with MetaXL 2013.

RESULTS

Forty-five papers out of 295 met the criteria. Pooled prevalence in the general population for MT-RNR1 gene mutations (A1555G, C1494T, A7445G) was 2% (1-4%) at 99%.

CONCLUSION

Routine screening for MT-RNR1 mutations in the general population prior to treatment with aminoglycosides appear desirable but poorly supported by the weak level of evidence available in the literature. Routine screening in high-risk (Chinese and Spanish) populations appear justified.

False carina: a distinct variant of tracheal bronchus

Tracheal-bronchus is an aberrant bronchus arising from the lateral tracheal wall, superior to the carina. A "False-carina" can be classified as a sub-type. This clinical entity will be defined and the clinical presentation, diagnosis and management of five patients with variations of the anatomical definition of a False-carina, identified at our institution, will be reviewed. Congenital bronchial abnormalities, including False-carina, have important implications in the overall management of the airway. Management can range from expectant in asymptomatic patients to surgical intervention in cases of recurrent respiratory infections. Awareness and understanding of this clinical entity allows for timely investigation, diagnosis and appropriate intervention.

Radiological prevalence of superior and posterior semicircular canal dehiscence in children

OBJECTIVE

Establishing the prevalence of semicircular canal dehiscence in a pediatric population using temporal bone CT imaging.

STUDY DESIGN

Retrospective analysis of all temporal bone CT scans during a 5-year period (2007-2012).

METHODS

CT scan images were reformatted in the plane of the canals and assessed by two independent reviewers with a third to resolve disagreement. Detailed chart review was performed for those found to have dehiscence. Superior and posterior canals were classified as "dehiscent", "possibly dehiscent", "thin" or "normal" for each case.

RESULTS

649 temporal bones were assessed from 334 children (under 18 years of age). The prevalence rate of superior canal dehiscence (SCD) was 1.7% (3.3% of individuals). Posterior canal dehiscence (PCD) was present in 1.2% (2.1% of individuals). There were no cases of bilateral SCD, and one case of bilateral PCD. Age under 3 years was associated with a higher prevalence of thinning but not dehiscence. Congenital inner ear malformation was not related to a higher probability of dehiscence. The superior petrosal sinus was associated with the SCD in three cases (27.3%). Retrospective chart review highlighted possible vestibular symptoms in 3/11 patients with SCD (27.3%).

CONCLUSIONS

This forms the largest pediatric study of canal dehiscence to date. This study's prevalence rate is significantly lower than previous reports. The identified association with overlying venous structures may reflect the etiological process involved. The occurrence in children supports the hypothesis of a congenital predisposition for development of canal dehiscence syndrome.

Cochlear implantation among deaf children with additional disabilities: parental perceptions of benefits, challenges, and service provision

Although increasing numbers of children with additional disabilities are receiving cochlear implants (CIs), little is known about family perspectives of the benefits and the challenges of cochlear implantation in this pediatric population. This study examines perceptions among parents of deaf children with additional disabilities regarding satisfaction with service provision, benefits, and challenges of the CI process. This was a mixed-methods study, which included a survey and interviews. Twenty-three families of deaf children with additional disabilities participated in this study, and 17 of these parents participated in in-depth interviews regarding their child's experience with the CI, including benefits and challenges. Interviews were analyzed through inductive thematic analysis. Parent-perceived benefits of cochlear implantation included children's improved sound awareness, communication skills, and greater well-being compared to preimplantation status. However, the majority of families felt that they and their children were not receiving enough services. Major challenges included managing funding; coping with limited availability of specialized services, particularly in rural areas; and continuing concerns about the child's communication, social skills, and academic performance. Results suggest that children with additional disabilities benefit from CIs, but they and their families also face unique challenges that professionals should consider when working with these families.

Publication rate of abstracts presented at the Canadian society of otolaryngology- head and neck surgery annual meetings: a five year study 2006-2010

BACKGROUND

To determine the rate of publication in a peer-reviewed journal for all oral presentations made at the Canadian Society for Otolaryngology- Head and Neck Surgery's Annual Meetings from 2006-2010.

METHODS

All abstracts were searched by keywords and authors' names in Medline via PubMed and Google Scholar. Authors of presented abstracts not found to be published were contacted directly for further information.

RESULTS

50.5% of presented abstracts (n = 198) were subsequently published with an average time to publication of 21 months. For those abstracts found not to be published 74.6% (n = 167) of authors responded with further information about their research, 66% (n = 89) of abstracts with author response that were not published were never submitted for publication. Authors' main reasons for not publishing were that the research was still in process (34%, n = 21) or that a resident or fellow working on the project "had moved on" (26%, n = 16).

CONCLUSION

The publication rate for the Canadian Society for Otolaryngology- Head and Neck Surgery's Annual Meetings from 2006-2010 is within the range reported by other conferences and specifically other Canadian conferences in different specialties; however, roughly half of presentations went on to be published. The main barrier to publication was bringing projects to the submission stage and not rejection by journals. Resources such as more time for research or personnel to coordinate projects may result in a greater rate of project completion.

Changes in pediatric tracheostomy 1982-2011: a Canadian tertiary children's hospital review

BACKGROUND

Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period.

METHODS

A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time.

RESULTS

251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed.

CONCLUSIONS

Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH.

Esophageal wishbone extraction: not for the chicken-hearted

OBJECTIVE

Ingestion of foreign bodies in the pediatric population is common and in the majority of cases involves spontaneous passage through the esophagus; however, they can become lodged in spaces of anatomical narrowing. Sharp foreign bodies are of particular concern due to a higher chance of perforation and other complications. The goal of this case report is to describe the safe removal of a chicken wishbone and 3 alternate options in the event that the initial choice was unsuccessful.

METHODS

We report the case of a 2-year-old boy who presented to our pediatric tertiary center after unsuccessful endoscopic removal of a chicken wishbone from the esophagus.

RESULTS

Radiologically, the wishbone was oriented with the tines pointing up. Endoscopic examination revealed the tips of both tines to be embedded deeply into the lateral walls of the esophageal mucosa. Esophagoscopy and protecting the sharp points of the wishbone were used to successfully extract the intact wishbone.

CONCLUSION

Previous techniques have involved cutting the bone; however, in this case, tension was so high that it was felt that cutting the bone would result in perforation. Proper management of such cases requires planning and often multiple strategies.

Intranasal topical local anesthetic and decongestant for flexible nasendoscopy in children: a randomized, double-blind, placebo-controlled trial

IMPORTANCE

To our knowledge, the present study is the first double-blind, randomized, placebo-controlled trial in children to compare nasal preparation sprays administered before flexible nasendoscopy with placebo.

OBJECTIVE

To compare the degree of pain experienced by children undergoing flexible nasendoscopy after 1 of 3 intranasal sprays: placebo, decongestant with topical local anesthetic (TLA), or decongestant without TLA.

DESIGN, SETTING, AND PARTICIPANTS

A randomized placebo-controlled trial with blinding of participants, caregivers, observers, and otolaryngologists was conducted in a tertiary pediatric otolaryngology ambulatory clinic. Participants included a consecutive sample of children aged 3 to 12 years requiring flexible nasendoscopy. Exclusion criteria included concomitant respiratory tract infection, known allergy to a trial agent, or previous flexible nasendoscopy. One hundred fifty-one children were assessed for eligibility; 24 eligible children refused participation and 69 were included and block-randomized. All completed the study, and there were no adverse events.

INTERVENTIONS

Nasal spray administration of placebo (normal saline); xylometazoline hydrochloride, 0.05% (decongestant); or lidocaine hydrochloride, 1%, with xylometazoline hydrochloride, 0.05% (TLA with decongestant) was performed 10 minutes before flexible nasendoscopy.

MAIN OUTCOMES AND MEASURES

Primary outcome measure was the child-reported Wong-Baker Faces Pain (WBFP) scale. Secondary outcomes included the caregiver-proxy WBFP scale; the Face, Legs, Activity, Cry, and Consolability (FLACC) scale; and the physician-reported Difficulty of Procedure Visual Analog Scale (DPVAS).

RESULTS

Twenty-three children were recruited in each of the intervention arms. Baseline characteristics were comparable between groups. The mean child-rated WBFP scale scores were 2.4, 1.8, and 2.2 for the placebo, decongestant, and TLA with decongestant groups, respectively (P = .45). Although the finding was statistically nonsignificant, decongestant had the lowest mean caregiver-proxy WBFP scale score, lowest observer-rated FLACC scale score, and highest physician-rated DPVAS score. Subgroup analysis did not demonstrate any correlation between the outcomes and age or sex.

CONCLUSIONS AND RELEVANCE

This study revealed no statistically significant difference in the discomfort experienced by children undergoing flexible nasendoscopy after placebo, decongestant, or TLA with decongestant. Decongestant was associated with the least discomfort (on child, caregiver, and observer-rated pain scale scores) and the lowest rating for difficulty of procedure. With these findings, the study suggests that there is no significant benefit of topical decongestant with or without TLA compared with placebo in reducing pain associated with pediatric flexible nasendoscopy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01351298.

Modified slide tracheoplasty in a newborn with bronchial and carinal stenosis

Congenital tracheal stenosis (CTS) is a life-threatening condition that is associated with significant morbidity and mortality particularly when symptomatic presentation occurs in the newborn period. The most challenging form of CTS is long segment congenital tracheal stenosis (LSCTS) with compromise of the carina and main stem bronchi. We report the case of a newborn with severe distal tracheal stenosis with carinal and main stem bronchial involvement who was managed successfully with a modified slide and autologous rib graft tracheoplasty. The patient was discharged from hospital without ventilator support or oxygen requirement at 2 months of age. The details of this case and the description of the surgical procedure are presented and the related literature is reviewed.

The rhinological manifestations of women's health

OBJECTIVE

To systematically review the literature and appraise the evidence reporting the effects of women's health, including pregnancy, postpartum, menstruation, oral contraception, menopause, and hormone replacement therapy, on common rhinological pathologies and nasal physiology.

DATA SOURCES

Systematic search strategy using MEDLINE (1966-2012) and EMBASE (1980-2012) databases.

REVIEW METHODS

Title review, abstract screening, and then full paper analysis were undertaken by 2 authors independently. Level of evidence was graded according to the Oxford Centre of Evidence Based Medicine 2011 criteria and risk of bias assessment using the Jadad scale for randomized controlled trials and Newcastle-Ottawa Scale for cohort and case-controlled studies.

RESULTS

Over the 46 years analyzed, the search strategy produced 2904 titles. In total, 314 abstracts were screened, from which 192 full-text articles were evaluated, and 145 research papers met all the criteria for inclusion in the study. Overall, the available evidence was of low quality. Seventy percent of studies (102 of 145) were case reports or case series from which only limited conclusions can be drawn. Only 3% of the included papers (4 of 145) were randomized controlled studies. The remaining data were mainly of a prospective cohort design. Study heterogeneity in design and measured outcomes resulted in data synthesis being limited to a descriptive/exploratory review. Study findings are presented by women's health category and then by rhinological manifestation with important clinical correlations highlighted.

CONCLUSION

Physiological and hormonal changes occurring as a normal part of women's health have an important influence on rhinological function and disease.

Systematic Review: The Rhinological Manifestations in Women

Objective: 1) To understand the current evidence between the effects of pregnancy, postpartum, menopause, contraception, and hormone replacement therapy (HRT) on diseases of the nose. 2) To appraise the level of evidence in the current literature.

Method: Systematic search strategy using PubMed (1966-2011) and EMBASE (1980-2011) was done to study diseases of the nose in women during different stages of life. Study appraisal and data extraction were performed independently by 2 authors. The level of evidence was categorized according to the Oxford Center of Evidence-Based Medicine.

Results: Titles and abstracts of 1005 studies from PubMed and 1756 studies from EMBASE were reviewed, resulting in 429 being retrieved. Included articles were categorized as related to pregnancy, postpartum, menopause, contraception, or hormone replacement therapy with the following findings: Pregnancy: changes reported in olfaction (12 studies), allergy (30 studies), rhinitis (25 studies), epistaxis (8 studies), tumor growth (31 studies), Wegener’s (23 studies), and Churg-Strauss disease (8 studies); Postpartum: effects included allergic rhinitis (20 studies), altered olfaction (7 studies), choanal atresia with drug ingestion (5 studies), and nasal tumors (8 studies); Menstruation: alteration in olfaction (17 studies), rhinitis (7 studies), and allergy (3 studies); Menopause: rhinitis (5 studies); HRT: alteration in olfaction (3 studies), and rhinitis (11 studies); and Estrogen therapy: considered for recurrent epistaxis (15 studies).

Conclusion: The various stages of life in women have been shown to have impact on nasal pathophysiology, altering olfaction and increasing epistaxis, allergic symptoms, tumor growth, and auto-immune disease.

Prevalence of MT-RnR1 in the General Population

Objective: Review the prevalence of MT-RNR1 genetic mutation and assess the need for neonatal screening prior to gentamicin therapy. A comprehensive search of MEDLINE, EMBASE, Cochrane Library, Clinical Evidence, and Cochrane Central Register of Trials was performed. The reference lists were cross-referenced. Review was restricted to human studies in English language.

Method: Studies describing the prevalence/incidence of MT-RNR1 gene mutations (A1555G, C1494T, A7445G) in the population. Relevant studies screening for presence for MT-RNR1 in patients receiving aminoglycoside therapy were included.

Results: Twenty-two articles out of 67 full papers and 206 abstracts from 1948 to November 2011 met the inclusion criteria. These included 9 prospective case-control studies, 12 case series, and a case report. There is weak evidence that MT-RNR1 is globally prevalent with racial bias especially in Chinese and Spanish populations. The prevalence/incidence ranged from 0.09%-2.9% in general population to 17% in the high-risk population. Weak evidence of neonatal sensorineural hearing loss following aminoglycoside exposure was also seen.

Conclusion: There is a need for large national epidemiological studies to assess the prevalence of MT-RNR. Some evidence of a global prevalence of MT-RNR1 with racial bias and link between aminoglycoside exposure and NSHL among at risk group. It is difficult to justify routine screening of patients for MT-RNR1 with the available literature.

Assessment of vocal fold mobility before and after cardiothoracic surgery in children

OBJECTIVES

To assess the incidence of vocal fold immobility (VFI) after cardiothoracic surgery in children and to determine the factors potentially associated with this outcome.

METHODS

Flexible laryngoscopy to assess vocal fold mobility was performed before surgery and within 72 hours after extubation in 100 pediatric patients who underwent cardiothoracic procedures. The 2 operating surgeons recorded the surgical technique and their impression of possible injury to the recurrent laryngeal nerve. The presence of laryngeal symptoms, such as stridor, hoarseness, and strength of cry, after extubation was documented.

RESULTS

Of 100 children included in this study, 8 had VFI after surgery. Univariate analyses showed that these 8 patients were younger and weighed less than the patients with normal vocal fold movement. Monopolar cautery was used in all patients with VFI. On univariate analysis, factors statistically significantly associated with VFI were circulatory arrest and dissection or ligation of the patent ductus arteriosus, left pulmonary artery, right pulmonary artery, or descending aorta. However, multivariate analyses failed to show these associations.

CONCLUSIONS

The incidence of VFI after cardiothoracic surgery in our population of children was 8.0% (8 of 100). Of several factors found to be potentially associated with VFI on univariate analysis, none were significant on multivariate analysis. This may be a result of the few patients with VFI. A larger multicenter prospective study would be needed to definitively identify factors associated with the outcome of VFI.

A systematic review of pediatric sensorineural hearing loss in congenital syphilis

INTRODUCTION

Congenital syphilis is a known cause of progressive sensorineural hearing loss. The prevalence of syphilitic sensorineural hearing loss (SNHL) in childhood is not clearly defined.

OBJECTIVE

To determine the frequency and characteristics of pediatric SNHL following intrauterine infection with or exposure to Treponema pallidum in order to develop evidence-based guidelines for audiologic monitoring.

DATA SOURCES

Medline (1950-March 2008), EMBASE (1980-March 2008), CINAHL (1982-March 2008), BIOSIS Previews (1969-March 2008), and Cochrane databases. Manual search of references of identified articles and book chapters.

STUDY SELECTION

Articles with an inception cohort of children infected with T. pallidum during pregnancy, positive serological identification of syphilis infection in the antenatal period or pathognomonic clinical signs of congenital syphilis infection, and longitudinal serial audiologic evaluations to identify the prevalence and progression of SNHL.

DATA EXTRACTION

Patient information, maternal and infant serologic status, and audiometric data extracted in an independent fashion. Discrepancies resolved through mutual consensus.

DATA SYNTHESIS

Descriptive statistics.

RESULTS

One prospective cohort study met the inclusion criteria. No cases of SNHL in infants with early congenital syphilis treated with antibiotics in the neonatal period were identified.

CONCLUSIONS

There have been no reports of children with confirmed congenital SNHL secondary to in utero syphilis infection. Newborns with positive syphilis serology should have hearing screening performed at birth and receive treatment with an appropriate course of penicillin therapy. Longitudinal hearing screening is recommended for all pediatric patients with congenital syphilis, as further studies documenting longitudinal audiometric data for patients previously treated either fully or partly for congenital syphilis are required.

A systematic review of neonatal toxoplasmosis exposure and sensorineural hearing loss

INTRODUCTION

The Joint Committee on Infant Hearing 2007 Position Statement includes in utero toxoplasmosis infection as a risk indicator for delayed-onset or progressive sensorineural hearing loss. It is recommended that children with congenital toxoplasmosis infection undergo audiologic monitoring to identify congenital and delayed-onset sensorineural hearing loss.

OBJECTIVE

To determine the prevalence of sensorineural hearing loss and to develop evidence-based guidelines for audiologic monitoring of children born with congenital toxoplasmosis infection.

DATA SOURCES

Systematic search of Medline, EMBASE and Cochrane databases and manual search of references.

STUDY SELECTION

Longitudinal studies reporting an inception cohort identified at birth, with serologic confirmation of toxoplasmosis infection, and long-term serial audiometric evaluation.

DATA EXTRACTION

Independent extraction of patient and audiometric data.

DATA SYNTHESIS

Descriptive statistics.

CONCLUSION

The five studies meeting our inclusion criteria report a prevalence of toxoplasmosis-associated hearing loss from 0% to 26%. Improved treatment regimens for toxoplasmosis may account for this range. Three treatment groups were identified and a subgroup analysis of the compiled data was performed. In children receiving limited or no treatment, the prevalence of toxoplasmosis-associated SNHL was found to be 28%. In children prescribed 12 months of antiparasitic treatment but in whom treatment was not confirmed to have started prior to 2.5 months of age and in whom compliance was not ensured, the prevalence of SNHL was 12%. In children treated with 12 months of antiparasitical therapy initiated prior to 2.5 months of age with serologically-confirmed compliance, the prevalence of SNHL was 0%. Only two longitudinal studies were identified and neither reported any cases of delayed-onset or progressive toxoplasmosis-associated SNHL. Children who have received a 12-month course of antiparasitical therapy initiated prior to 2.5 months with serologically-confirmed compliance should have repeat audiometric evaluation at 24-30 months of age. Children with congenital toxoplasmosis that had no treatment, partial treatment, delayed onset of treatment, or compliance issues should undergo annual audiologic monitoring until able to reliably self-report hearing loss.

A systematic review of the incidence of sensorineural hearing loss in neonates exposed to Herpes simplex virus (HSV)

OBJECTIVE

To develop evidence-based guidelines for appropriate audiological monitoring of children born following exposure to or infection with Herpes simplex virus (HSV) for development of immediate or delayed-onset of sensorineural hearing loss (SNHL).

DATA SOURCES

A Medline search of the 1966-July 2007 database was supplemented by search of the additional database Embase (1980-July 2007). Manual search was conducted of references of identified papers and book chapters.

STUDY SELECTION

Articles were sought that were longitudinal in design, to include an inception cohort of children infected with (or exposed to) HSV who were entered at a similar point at birth and followed over time with serial audiometry to identify hearing loss if it developed.

DATA EXTRACTION

Patient information and audiometric data extraction from relevant articles was performed independently by all three researchers. Discrepancies were resolved by mutual consensus.

DATA SYNTHESIS

Data was analyzed using descriptive statistics.

RESULTS

Three papers reported five children with SNHL following apparent disseminated HSV-2 infections in which other obvious clinical sequelae of HSV infection and co-morbid conditions were present. Audiometric information is lacking regarding onset and progression. There are no reports of delayed-onset SNHL following perinatal or asymptomatic HSV infection.

CONCLUSIONS

The development of SNHL in children with exposure to HSV occurs rarely. Routine serological screening for HSV infection in otherwise healthy neonates newly diagnosed with SNHL is unjustified. There is insufficient data to define the incidence and natural history of SNHL in children with HSV infections. Carefully designed and conducted studies are needed to address this issue.

Magnet dislodgement in cochlear implantation: correction utilizing a lasso technique

OBJECTIVES

Magnet displacement is recognized as an uncommon, major complication following cochlear implant surgery. This complication necessitates operative intervention exposing patients to further surgical risk and morbidity. The purpose of this paper is to describe a unique surgical technique for securing internal magnets which have dislodged from their silicone housing within the internal receiver-stimulator.

METHODS

A case involving a 5-year old cochlear implant patient is reviewed. This patient experienced magnet displacement on two separate occasions. A new lasso technique for re-securing the internal implant magnet is described in detail.

RESULTS

The patient's implant remains fully functional with a securely placed internal magnet 36 months post-operatively.

CONCLUSIONS

When compared to other surgical options, the "lasso" technique represents a simple, safe, efficient and cost-effective surgical option with minimal morbidity.

Natural history of hearing loss in children with enlarged vestibular aqueduct syndrome

OBJECTIVE

To determine the natural history of hearing loss in children with enlarged vestibular aqueduct (EVA) syndrome.

DESIGN

(1) Retrospective cohort study and (2) systematic literature review.

SETTING

Tertiary pediatric centre.

METHODS

(1) Charts of children assessed by one physician between 1993 and 2000 were reviewed. (2) Source articles were identified by a search of Medline, Embase, and the Cochrane Library of the English-language literature through January 2006, with manual review of references. The search was limited to English, human, and age less than 18 years.

MAIN OUTCOME MEASURES

Pure-tone average. Hearing was classified as stable, progressive and fluctuating.

RESULTS

(1) Twenty-one children (39 ears) with EVA were identified. Eighty-two percent of ears had stable hearing, and 18% of ears demonstrated progressive hearing loss. (2) Seven source articles were identified and combined with the present data for a total of 310 ears with a mean follow-up of 4 years. Bilateral EVA was found to be six times more common than unilateral EVA, and there was an equal male to female ratio. Stable hearing was found in 67% of ears and progressive hearing loss in 33% of ears. Subgroup analysis demonstrated hearing fluctuations in 50% of progressive hearing loss ears and 34% of stable ears.

CONCLUSIONS

Stable hearing is observed in 67% of ears with EVA of which 34% will demonstrate fluctuations in hearing. Progression of hearing loss is seen in 33% of ears of which half will demonstrate fluctuations.

V37I connexin 26 allele in patients with sensorineural hearing loss: evidence of its pathogenicity

Sensorineural hearing loss (SNHL) is the most common inherited sensory disorder, reported in 1-3 of every 1,000 births. It has been estimated that 50% of all cases of prelingual SNHL are genetically determined. There is tremendous genetic heterogeneity, with multiple dominant and recessive loci. Mutations of the gap junction beta-2 gene (GJB2) emerge as a leading cause of autosomal recessive non-syndromic SNHL. Over 90 sequence alterations have been reported, the pathogenicity of some of them being unknown or unclear. The status of the V37I allele of connexin 26 (GJB2 amino acid product) with regards to its association with SNHL has been controversial. This study examines the pathogenicity of V37I by comparing the frequency of this allele in 40 patients with SNHL of Chinese and Caucasian descent with the frequency of the allele in 100 anonymized, ethnically matched controls. The V37I allele was identified in 43.75 and 11.5% of the patient and control alleles of Chinese ethnicity, respectively, but was not found in either Caucasian cohort. We also compiled the audiograms of 15 individuals with SNHL homozygous for the V37I allele, and showed that these individuals present with a mild to moderate SNHL. These results indicate that (1) the V37I allele is common in individuals of Chinese descent but rarely present in individuals of Caucasian decent; and (2) the V37I allele is pathogenic, but produces milder hearing loss compared to nonsense mutations of connexin 26 such as the 35delG mutation.

Medical management of middle ear disease in children less than 2 years of age with sensorineural hearing loss

OBJECTIVE

With emerging early hearing detection and communication development programs, physicians are increasingly requested to review young children with sensorineural hearing loss (SNHL) and associated conductive hearing loss (CHL). The purpose of this critical review is to develop an evidence-based approach to the management of the child less than 2 years of age with fluctuating CHL and coexisting SNHL.

METHODS

A critical review of the 1966-2002 MEDLINE database was performed to address the diagnosis, natural history, and management of otitis media with effusion (OME) and the management of acute otitis media (AOM) in the child under 2 years of age with underlying SNHL.

RESULTS

Pneumatic otoscopy should be used to diagnose middle ear effusion. Clearance of OME may be prolonged in children with craniofacial abnormalities. Antibiotics provide a small short-term increase in the resolution of OME and may be warranted in children with coexisting SNHL and OME for 4 to 6 weeks. If OME persists for 8 to 12 weeks, bilateral myringotomy and tube placement (BM&T) with short-term tubes will improve hearing and help resolve OME. AOM in children less than 2 years of age should be treated with a 10-day course of antibiotics. Prophylactic antibiotics may be useful in avoiding tube placement in children less than 2 years of age with recurrent AOM. BM&T with short-term tubes are recommended if recurrent AOM persists. Pneumococcal vaccination can decrease episodes of AOM by 6 to 7%.

CONCLUSIONS

An evidence-based algorithm for the management of fluctuating CHL in children less than 2 years of age with an underlying SNHL is presented.

Guidelines for the treatment of tympanostomy tube otorrhea

Treatment of tympanostomy tube otorrhea has evolved with numerous studies demonstrating the superiority of topical therapy in the form of eardrops over systemic antibiotic therapy. Many physicians have been concerned about ototoxicity with antibiotic eardrops because several ototopical agents have a risk of vestibular and cochlear damage, which may be permanent. An expert round table of pediatric and general otolaryngologists, pediatricians, and family physicians met in Quebec City in May 2004 to develop practical Canadian guidelines for the safe treatment of tympanostomy tube otorrhea. The recommendations and guidelines are outlined.

Evidence-Based Algorithm for the Evaluation of a Child with Bilateral Sensorineural Hearing Loss

OBJECTIVE

To develop an evidence-based algorithm for determining the etiology of bilateral sensorineural hearing loss (SNHL) in a child.

METHODS

The frequency of different etiologies was previously determined. A systematic review of the literature for articles published between 1940 and January 2003 was performed for studies providing information on the diagnosis of each etiology relevant to their clinical presentation.

RESULTS

Connexin mutation testing is highly sensitive and specific. CT scanning of the temporal bones is frequently valuable in detecting inner ear malformations. Routine laboratory studies are rarely helpful. ECG is particularly valuable when a history of syncope or arrhythmias or a family history of sudden death in a young child is elicited. There is no literature to support routine urinalysis for the diagnosis of Alport syndrome and thyroid studies lack specificity in the absence of physical findings (goiter).

CONCLUSIONS

An evidence-based algorithm was developed that included: history, physical and audiological evaluation, and ophthalmological evaluation. Further directed investigations may include genetic testing for the Cx26 mutation, CT scan of the temporal bones, ECG and urinalysis.

Pediatric Lateral Sinus Thrombosis: Retrospective Case Series and Literature Review

OBJECTIVE

A comparison between the literature and our management of pediatric patients presenting with otogenic lateral sinus thrombosis.

DESIGN

A retrospective case series of five pediatric patients.

SETTING

Four patients were treated at BC Children's Hospital, whereas the fifth patient was treated in New Westminster, BC. All were treated between 1994 and 2001.

METHODS

A retrospective chart review was conducted with a literature review for otogenic lateral sinus thrombosis.

MAIN OUTCOME MEASURES

Treatment success was based on resolution of acute infection and neurologic symptoms.

RESULTS

Five patients, four males and one female, aged 2 to 14 years were reviewed. Three patients were treated successfully without mastoidectomy. One patient received a mastoidectomy that yielded no pus or granulation tissue within the mastoid cavity. One patient required a mastoidectomy after failure to respond to bilateral myringotomy and tympanostomy tube insertion. Although no pus was seen in the mastoid cavity, perisinus pus was found after unroofing the sigmoid sinus plate; free flow of blood was obtained on needle aspiration of the sinus, and the sinus was not surgically opened.

CONCLUSION

The current literature states that the management of otogenic lateral sinus thrombosis includes high-dose intravenous antibiotics with a mastoidectomy and possible opening of the sinus. In our retrospective case series, three of five patients recovered completely without mastoidectomy, and a fourth had a mastoidectomy deemed to have been unnecessary. We conclude that intravenous antibiotics and insertion of a tympanostomy tube are sufficient treatment for selected cases of otogenic lateral sinus thrombosis. Mastoidectomy with possible opening of the sinus should be reserved for patients refractory to the above conservative treatment.

Foreign body aspiration in infants and toddlers: recent trends in British Columbia

OBJECTIVES

The objectives of this study were to (1) examine recent trends in the demographics and presentation of children with foreign body aspiration at British Columbia's Children's Hospital and (2) develop safety guidelines regarding feeding nuts and other hard, crunchy foods to infants and toddlers.

METHODS

The methods used were a retrospective chart review and a review of swallowing mechanics in early childhood.

RESULTS

Between July 1997 and July 2001, 51 children under 3 years of age underwent rigid bronchoscopy for suspected foreign body aspiration. Of these patients, 27 (53%) were 18 months of age or younger. Of these 27 infants and toddlers, 24 (89%) had a witnessed choking event and 22 (81%) had an airway foreign body. Nuts, raw carrots, and popcorn kernels accounted for 14 (64%) of the foreign bodies aspirated by these infants and toddlers. Before 2 years of age, children are poorly equipped to grind and swallow hard, crunchy food because they lack second molars and are still adjusting to the descent of the larynx.

CONCLUSIONS

Infants and toddlers in British Columbia have been aspirating foreign bodies at an alarmingly high rate. Most cases would have been prevented with better public awareness. Caregivers should be informed that children under 3 years of age should never be fed nuts or other hard, crunchy foods. A public awareness campaign is warranted.