Palatal Motion After Primary and Secondary Furlow Palatoplasty

Importance

Indications for Furlow palatoplasty include primary repair of cleft palate as well as secondary repair, or secondary palatoplasty for treatment of velopharyngeal insufficiency. Speculation exists surrounding the benefit of secondary Furlow palatoplasty in cases of a previously well-reconstructed palate or a short but otherwise anatomically normal soft palate because it has been theorized that reorientation of a previously reconstructed or normal muscular levator sling should in fact worsen palatal motion.

Objective

To compare palatal motion following primary and secondary Furlow palatoplasty using footage from postoperative nasopharyngoscopy videos.

Design, Setting, and Participants

In this retrospective case series, medical records in a database of an urban academic pediatric otolaryngology practice was used to identify patients who had undergone either primary or secondary Furlow palatoplasty. Subjects with adequate postoperative nasopharyngoscopy footage were randomized, and 2 blinded reviewers assessed soft palate motion in each video using an abbreviated version of the Golding-Kushner scale.

Main Outcomes and Measures

Reviewers' blinded ratings of soft palate motion were quantified using a modified Golding-Kushner scale to generate a mean palatal motion score for each subject (range, 0.0-2.0). Scores of primary and secondary Furlow palatoplasty patients were compared.

Results

Over a 4-year period, 20 patients with adequate postoperative nasopharyngoscopy footage were identified (12 primary Furlow palatoplasty patients and 8 secondary Furlow palatoplasty patients). Patients consisted of 8 males and 12 females and ranged in age from 12 months to 22 years at the time of postoperative nasopharyngoscopy. Modified Golding-Kushner scores were similar between groups: mean primary group, 1.61 (range, 0.5-2.0); mean secondary group, 1.53 (range, 0.75-2.0); absolute difference in mean, 0.08 (95% CI, 0.00-0.43); effect size, Hedges g, 0.18. There was fair interrater reliability (interclass coefficient, R = 0.45), consistent with prior reports using this scale. No significant difference in postoperative palatal motion scores was identified between primary and secondary palatoplasty groups in this study.

Conclusions and Relevance

When examined in isolation, postoperative motion of the soft palate appears similar following both primary and secondary Furlow palatoplasty procedures, suggesting that there are no major deleterious effects on palatal motion following secondary Furlow palatoplasty.

Nasal fractures in children and adolescents: Mechanisms of injury and efficacy of closed reduction

OBJECTIVES

To determine the most common mechanisms of traumatic nasal deformity referred to pediatric otolaryngology. To examine the efficacy of closed reduction of nasal fractures in children and adolescents based on the parents' and surgeons' ratings of post-reduction nasal symmetry.

METHODS

Case series and chart review within an urban, tertiary pediatric otolaryngology practice.

RESULTS

100 cases of traumatic nasal deformity met inclusion criteria over a 3-year study period. The mean age at presentation was 13 years (4 weeks-18 years); 55% were male and 70% were over the age of 12 years. The most common mechanism of injury was sports-related trauma (28%), followed by accidental trauma (21%), interpersonal violence (10%), motor vehicle collision (6%) and alcohol-related (2%). Of these 100 cases, 22% underwent closed reduction within a 14-day period following injury. All patients achieved symmetry in the operating room immediately following reduction. 21 of 22 post-reduction patients were assessed for nasal symmetry at the postoperative visit (7-10 days following surgery). The operating surgeon was satisfied with nasal symmetry in 43% of cases and the parent(s) satisfied in 81% of cases. Both parent and surgeon were satisfied with post-reduction symmetry 33% of the time.

CONCLUSION

The most common sources of traumatic nasal deformity in children and adolescents vary by age. In cases meriting operative intervention, parents appear to be satisfied with early postoperative results following closed reduction in approximately 80% of cases, however a result in which both parent and surgeon agree with successful re-establishment of symmetry occurs in only one-third of cases.

Management of hyperosmolar hyperglycaemic state in adults with diabetes

Hyperglycaemic hyperosmolar state (HHS) is a medical emergency, which differs from diabetic ketoacidosis (DKA) and requires a different approach. The present article summarizes the recent guidance on HHS that has been produced by the Joint British Diabetes Societies for Inpatient Care, available in full at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_HHS_Adults.pdf. HHS has a higher mortality rate than DKA and may be complicated by myocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis and there is some evidence that rapid changes in osmolality during treatment may be the precipitant of central pontine myelinolysis. Whilst DKA presents within hours of onset, HHS comes on over many days, and the dehydration and metabolic disturbances are more extreme. The key points in these HHS guidelines include: (1) monitoring of the response to treatment: (i) measure or calculate the serum osmolality regularly to monitor the response to treatment and (ii) aim to reduce osmolality by 3-8 mOsm/kg/h; (2) fluid and insulin administration: (i) use i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, (ii) fluid replacement alone will cause a fall in blood glucose (BG) level, (iii) withhold insulin until the BG level is no longer falling with i.v. fluids alone (unless ketonaemic), (iv) an initial rise in sodium level is expected and is not itself an indication for hypotonic fluids and (v) early use of insulin (before fluids) may be detrimental; and (3) delivery of care: (i) The diabetes specialist team should be involved as soon as possible and (ii) patients should be nursed in areas where staff are experienced in the management of HHS.

Pediatric nasal valve surgery: short-term outcomes and complications

OBJECTIVES

To examine the short-term outcomes and complications of open nasal valve surgery in children under 16 years of age.

STUDY DESIGN

case series and chart review study setting: an urban, tertiary, pediatric otolaryngology practice.

METHODS

Children under 16 years of age who had undergone nasal valve surgery with cartilage grafting for functional indications were identified. Patients with cleft-related nasal deformities were excluded. Charts were reviewed for indications and short-term outcomes (patient satisfaction and postoperative complications within the first 90 days). A literature review assessed prior outcomes in adult nasal valve patients.

RESULTS

Fifteen pediatric patients, 15 years old or younger, were identified as having undergone open nasal valve repair utilizing septal or auricular cartilage grafts. Patient age ranged from 6 to 15 years. Surgical indications were nasal obstruction with nasal valve stenosis related to either previous trauma (n=10), congenital deformity (n=3), iatrogenic injury (n=1) or hemangioma of infancy (n=1). All patients noted improvement of symptoms at the 90 day interval or later. There was one episode of self-limited epistaxis, which occurred on postoperative day 7 following splint removal.

CONCLUSIONS

In children, an obstructive nasal breathing pattern may be caused by nasal valve collapse, which can be addressed with nasal valve surgery. This small series suggests that short-term results in children may be similar to those observed in the adult population. Pediatric nasal valve surgery outcomes have not been described previously; studies focused on long-term outcomes following pediatric nasal valve surgery are needed.

LEVEL OF EVIDENCE

4.

Nasal Fractures in Children and Adolescents: Mechanisms of Injury and Efficacy of Closed Reduction

Objectives:

(1) Determine the most common causes of traumatic nasal deformities referred to pediatric otolaryngology. (2) Examine the efficacy of closed reduction of nasal fractures in children and adolescents based on the parents’ and surgeon’s ratings of post-reduction nasal symmetry.

Methods:

Case series and chart review within an urban pediatric otolaryngology practice.

Results:

One hundred cases of traumatic nasal deformity met inclusion criteria over a 3-year study period. The mean age at presentation was 13 years (4 weeks-18 years); 55% were male and 70% were over the age of 12 years. The most common mechanism of injury was sports-related trauma (28%), followed by accidental trauma (21%), interpersonal violence (10%), motor vehicle collision (6%), and alcohol-related (2%). Of these 100 cases, 21% underwent closed reduction within a 14-day period following injury. All patients achieved symmetry in the operating room immediately following reduction. At the postoperative visit (7-10 days following surgery), the operating surgeon was satisfied with nasal symmetry in 43% of cases and the parent(s) was satisfied in 81% of cases. Both parent and surgeon were satisfied with postreduction symmetry 33% of the time.

Conclusions:

The most common source of traumatic nasal deformity in children and adolescents differs from the most frequent mechanisms of nasal trauma in adults. In cases meriting operative intervention, parents appear to be satisfied with early postoperative results following closed reduction in approximately 80% of cases; however, a result in which both parent and surgeon agree with successful re-establishment of symmetry occurs in only 1/3 of cases.

Neonatal Macroglossia: Demographics, Cost of Care, and Associated Comorbidities

Objectives:

(1) Examine the birth prevalence of macroglossia, assessing for differences across sex, race, socioeconomic status, and geographic location. (2) Identify comorbidities associated with isolated and syndromic forms of macroglossia and determine how such factors may influence length of stay (LOS) and cost of admission.

Methods:

Retrospective cross-sectional study using the 2006 and 2009 Kids’ Inpatient Databases (KID).

Results:

The national birth prevalence of macroglossia was 3.4 out of 10,000 births (n = 556) with a higher rate in females (3.9/10,000, P = .001) and blacks (4.5/10,000, P = .01). Patients were classified as isolated (n = 423, 76%) or syndromic (n = 133, 24%) based on associated diagnoses. Syndromic cases were more prevalent in the West ( P = .01). LOS and cost were increased in the syndromic group (26.2 days vs 4.8 days, P < .01; $30.1k vs $3.9k, P < .01), while LOS and cost for isolated macroglossia were similar to the general population. The rate of concurrent cardiac anomalies, cleft palate, and Down syndrome was increased in patients with macroglossia compared to unaffected newborns ( P < .01). Rates of respiratory distress, feeding problems, GERD, endotracheal intubation, and prolonged ventilator support were higher in the syndromic group ( P < .01). Newborns with isolated macroglossia suffered these conditions at the same rate as the general population.

Conclusions:

The birth prevalence of macroglossia varies by sex, race, and geographic location. Prolonged LOS and increased cost are associated with syndromic forms of macroglossia. Syndromic comorbidities rather than enlargement of the tongue in and of itself appear to be the chief contributors to increased LOS and cost in this population.

National Trends in Tongue Reduction Surgery for Macroglossia in Children

Objectives:

(1) Examine the frequency of partial glossectomy performed for the indication of macroglossia in the United States, assessing for any differences in rates of intervention across various demographics. (2) Identify potential morbidities associated with partial glossectomy in this population and determine how such factors may influence length of stay (LOS) and cost of admission following tongue reduction surgery.

Methods:

Retrospective cross-sectional study using the 2006 and 2009 KidsTM Inpatient Databases (KID). During the 2-year study period, partial glossectomy was performed in 80 children under 5 years with macroglossia.

Results:

A disproportionately higher rate of intervention was seen in whites ( P = .001) and patients in the highest socioeconomic quartile ( P = .007). Conversely, a lower rate of intervention was observed in black children ( P = .011). The average age at the time of partial glossectomy was 23 months (mode, 12 months). Patients were classified as isolated (n = 16, 20%) or syndromic macroglossia (n = 64, 80%) based on associated diagnoses. The average length of stay after partial glossectomy for macroglossia ranged from 5 to 11 days. Differences in LOS (mean, 9.5 days) and cost (mean, $9.8k) between isolated and syndromic macroglossia groups were not significant.

Conclusions:

Partial glossectomy for macroglossia is typically performed prior to age 2 years in the United States. Syndromic comorbidities do not seem to contribute to increased LOS or cost of admission. White children and affluent children appear to be undergoing partial glossectomy at a higher rate than their peers.

Prenatal consultation with the pediatric otolaryngologist

OBJECTIVES

To examine the spectrum of fetal head and neck anomalies that may prompt prenatal referral and to determine the frequency of these consultations.

STUDY DESIGN

Case series with chart review.

METHODS

The billing databases of two urban pediatric otolaryngology practices were queried for ICD-9 codes corresponding to fetal anomalies between January 2010 and December 2012. The pediatric otolaryngology practices in this study evaluate all fetal head and neck anomalies referred to their respective institutions, including craniofacial disorders.

RESULTS

Over a three-year period, 53 women presented for fetal otolaryngology consultation, with each practice seeing approximately one consultation every 6 weeks (every 5 weeks (JDS) and every 7 weeks (ARS)). The average maternal and gestational age at presentation were 28.7 years and 27.2 weeks, respectively. 83% of the cases (n = 44) involved some form of cleft lip with or without cleft palate. Other head and neck anomalies included fetal goiter/other congenital neck mass (9% (n = 5)) and micrognathia (6% (n = 3)). Macroglossia (n = 1) and facial cleft (n = 1) each accounted for 2% of cases. Cleft mothers presented earlier in pregnancy (average 26.8 weeks) than those with a neck mass (average 32.3 weeks) (p < 0.05). Only 3 cases (6%) merited ex utero intrapartum treatment.

CONCLUSIONS

Depending on the referral practices at a given medical center, craniofacial surgeons rather than pediatric otolaryngologists may be evaluating the majority of fetal head and neck anomalies, as orofacial clefts account for most prenatal consultations. The wide spectrum of congenital neck masses may or may not demand monitoring of the airway during the peripartum period.

Facial Cleft Repair on Surgical Mission Trips: Safety, Feasibility, and Impact on Quality of Life

Objectives:

1) Discuss the safety, feasibility, and technical limitations of facial cleft repair performed on medical missions in developing countries. 2) Present several representative cases of oculofacial clefting which were successfully repaired and another that was deferred due to safety concerns and limited resources.

Methods:

Case series and literature review.

Results:

On two separate visits over a two-year period (2011-2013), 4 patients with orofacial clefts were evaluated. Three oculofacial clefts (Tessier 3 (n=1), Tessier 4 (n=1), and Tessier 4-10 (n=1)) were successfully repaired. One of these patients had over 1 year of follow-up. Another patient with frontonasal dysplasia and a wide Tessier 0-14 cleft was screened and operative intervention deferred.

Conclusions:

When feasible, a soft tissue-only repair of oculofacial clefts may offer an acceptable aesthetic result with a reasonable expenditure of resources as part of a larger cleft mission. Facial clefts that require pre-operative imaging, extended procedure time, bone grafting, significant blood loss, and/or neurosurgical involvement demand a greater expenditure of scarce resources and are not advisable in the context of a surgical mission in most areas of the developing world.

Osteomyelitis following Palatoplasty: A Rare Complication

Objectives:

Raise awareness of potential serious complications of oropharyngeal surgery such as osteomyelitis and discuss the role of perioperative antibiotics in such operations. Explore the events leading up to the development of osteomyelitis in a 13-month-old boy following palatoplasty. Discuss the role of perioperative antibiotics in oropharyngeal surgery. Study Design: Single case report with chart and literature review.

Methods:

We present the case of a 13-month-old boy who underwent palatoplasty, received perioperative antibiotics, and subsequently developed group A streptococcal bacteremia along with osteomyelitis of the right calcaneus. A literature review was done to explore the role of antibiotics in oropharyngeal surgery.

Results:

The patient underwent treatment with antibiotics, and the osteomyelitis resolved.

Conclusions:

Surgeons and clinicians should maintain a high level of suspicion for bone and joint infections in any child presenting postoperatively with fevers, bacteremia, and musculoskeletal symptoms. The role of perioperative antibiotics in the prevention of severe postoperative infections such as osteomyelitis is unclear. In the era of evidence-based medicine there is a movement to temper, if not eliminate, the once standard practice of discharging children on a short course of prophylactic antibiotics following palate repair. It should therefore be noted that even when these antibiotics are given, rare infectious complications may still occur.

Predicting Surgical Intervention for Airway Obstruction in Micrognathic Infants

Objective

To determine which factors present in the neonatal period may predict subsequent need for surgical intervention in infants with micrognathia.

Study Design

Case series with chart review.

Setting

Two, urban, tertiary pediatric hospitals.

Subjects and Methods

The otolaryngology databases from 2 institutions were queried for the diagnosis of micrognathia over a 10-year period, and 123 infants were identified (101 with Pierre Robin sequence and 21 with micrognathia without cleft palate). The presence or absence of surgical airway intervention during the first year of life was noted, as were associated diagnoses. Univariate and multivariate analyses were performed to identify risk factors for requiring a definitive airway intervention.

Results

Forty-eight (39%) micrognathic children required definitive airway intervention during infancy in this series. These interventions came in the form of either tracheostomy (12 patients), mandibular distraction osteogenesis (MDO; 33 patients) or prolonged intubation prior to death (3 patients). Factors associated with a need for intervention included a history of intubation or tracheotomy in the first 24 hours of life (odds ratio [OR], 8.22; confidence interval [CI], 3.14-21.53), a history of intrauterine growth restriction (OR, 4.10; CI, 1.00-16.70), prematurity (<37 weeks of gestational age; OR, 2.38; CI, 1.02-5.56), and neurologic impairment (OR, 3.83; CI, 1.33-11.07). Those with isolated micrognathia without cleft palate were less likely to require intervention (OR, 0.20; CI, 0.05-0.71).

Conclusions

While it is understood that the need for MDO or tracheostomy should be determined on a case-by-case basis, this study identifies a number of factors that may predict which neonates with micrognathia are at increased risk for meriting early surgical intervention for respiratory and feeding problems.