Rotational ablation and stent placement for severe calcific coronary artery stenosis after Kawasaki disease

We report on a 5-year-old child who had an episode of Kawasaki disease with giant coronary artery aneurysms at the age of 4 months. Surveillance coronary angiography showed severe calcific stenosis in the proximal left anterior descending artery. Balloon angioplasty failed to resolve the obstruction. Rotational ablation was therefore performed. Surveillance angiogram performed 6 months after rotational ablation showed critical restenosis. Rotational ablation was therefore repeated, followed by stent placement. To the best of our knowledge, this is the youngest child who has undergone coronary stenting after Kawasaki disease.

Endoscopic percutaneous suture lateralization for neonatal bilateral vocal fold immobility

OBJECTIVE

Bilateral vocal-fold immobility (BFVI) is a rare but significant cause of severe respiratory distress in neonates. The primary aim of treatment is to provide an adequate airway while minimizing adverse effects such as aspiration and dysphonia. Our objective here is to describe the outcomes of a series of neonates undergoing percutaneous endoscopic suture lateralization for BVFI using a novel technique.

METHODS

In this retrospective case series, we present 6 neonates (mean age: 18 days) with BVFI from three tertiary academic medical centers. The etiologies included 4 idiopathic, 1 unspecified neurodegenerative disorder, and 1 acquired from cardiac surgery. All had stridor and respiratory distress with hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal-fold lateralization was performed under spontaneous-breathing suspension laryngoscopy using a novel technique of percutaneous needle-directed placement of 4-0 prolene suture without use of specialized equipment.

RESULTS

All patients had clinical improvement in stridor and respiratory support requirements and avoided tracheostomy. One patient had persistent aspiration after lateralization that resolved after suture removal. One patient required bilateral lateralization procedures. One patient expired of epilepsy due to neurodegenerative disease unrelated to airway pathology. At last follow-up (mean 12.6 months), 5/5 remaining patients were on room air without tracheostomy and feeding orally without aspiration; 4/5 had partial or complete return of vocal-fold function.

CONCLUSION

Endoscopic percutaneous suture lateralization may be a safe and effective non-destructive primary treatment modality for neonatal BVFI. All neonates undergoing this procedure avoided tracheotomy.

Flexible bronchoscopy and interdisciplinary collaboration in pediatric large airway disease

OBJECTIVE

Demonstrate the benefits of a multidisciplinary pediatric airway team prepared to evaluate and treat otolaryngology patients with flexible bronchoscopy.

DESIGN

Case series.

SETTING

Tertiary, academic children's hospital.

PATIENTS

10 children (5 male, 5 female age range 2 months-16 years) presenting with complex symptoms potentially referable to large airways.

INTERVENTION

Flexible bronchoscopy for diagnostic (bronchoalveolar lavage, ciliary biopsy, assess ongoing surgical intervention, and rule in or rule out foreign body; N=6) or therapeutic (evacuate bronchial mucus plug, laser subglottis when patient has fused cervical spine, and distal instillation [fibrin glue for bronchopleural fistula and dornase alpha for plastic bronchitis]; N=4).

MAIN OUTCOME MEASURE

Retrospectively ask if flexible bronchoscopy and interdisciplinary management improved patient care in these select otolaryngology cases.

RESULTS

10/10 patients benefited from interdisciplinary management including flexible bronchoscopy.

CONCLUSION

Our experience illustrates many uses for flexible bronchoscopy in otolaryngology patients, and suggests that an airway team prepared to use flexible bronchoscopy will create opportunities for improved patient care.

Otolaryngology resident selection: do rank lists matter?

OBJECTIVES

To examine the relationship between National Residency Matching Program (NRMP) rank list position and future otolaryngology residency performance.

STUDY DESIGN

Cohort study.

METHODS

Eight consecutive residency classes (starting 2001-2008; 4 residents/y) were reviewed. Three hundred and thirty-three applicants (40.6 applicants/y) were interviewed, and 316 (94.9%) were ranked. Residents matching with our program were divided 3 different ways: into quarters, thirds, and halves, based on their rank order. Correlation coefficients were obtained to compare resident rank number and rank group (quarter, third, half) to faculty evaluation, coresident evaluation, and in-service score. Chi-square tests were conducted comparing rank group to chief resident selection and annual teaching award.

RESULTS

Resident NRMP rank number was not significantly correlated with faculty evaluation, coresident evaluation, or in-service exam score (-0.21 < r < 0.05; P > .28). There was also no significant correlation between resident quarter, third, or half rank group and faculty evaluation; coresident evaluation; or in-service exam score (-0.29 < r < 0.10; P > .13). Chi-square analysis found no relationship between resident rank group and chief resident (P > .35) or teaching award (P > .13) selection.

CONCLUSIONS

Applicant rank number and rank group did not correlate with performance of this otolaryngology residency cohort as assessed by faculty evaluation, coresident evaluation, in-service exam score, or selection for chief resident or the annual teaching award. Resident selection committees should consider reallocating manpower hours from creating rank order to recruiting applicants and selecting interview candidates.

Hemostasis in Tonsillectomy

Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.

Standardizing Laryngeal Cleft Evaluations: Reliability of the Interarytenoid Assessment Protocol

Objective

While the Benjamin-Inglis classification system is widely used to categorize laryngeal clefts, it does not clearly differentiate a type 1 cleft from normal anatomy, and there is no widely accepted or validated protocol for systematically evaluating interarytenoid mucosal height. We sought to propose the interarytenoid assessment protocol as a method to standardize the description of the interarytenoid anatomy and to test its reliability.

Study Design

Retrospective review of endoscopic videos.

Setting

Pediatric academic center.

Subjects and Methods

The interarytenoid assessment protocol comprises 4 steps for evaluation of the interarytenoid region relative to known anatomic landmarks in the supraglottis, glottis, and subglottis. Thirty consecutively selected videos of the protocol were reviewed by 4 otolaryngologists. The raters were blinded to identifying information, and the video order was randomized for each review. We assessed protocol completion times and calculated Cohen’s linear-weighted κ coefficient between blinded expert raters and with the operating surgeon to evaluate interrater/intrarater reliability.

Results

Median age was 4.9 years (59 months; range, 1 month to 20 years). Median completion time was 144 seconds. Interrater and intrarater reliability showed substantial agreement (interrater κ = 0.71 [95% confidence interval (CI), 0.55-0.87]; intrarater mean κ = 0.70 [95% CI, 0.59-0.92/rater 1, 0.47-0.85/rater 2]; P < .001). Comparing raters to the operating surgeon demonstrated substantial agreement (mean κ = 0.62; 95% CI, 0.31-0.79/rater 1, 0.48-0.89/rater 2; P < .001).

Conclusion

The interarytenoid assessment protocol appears reliable in describing interarytenoid anatomy. Rapid completion times and substantial interrater/intrarater reliability were demonstrated. Incorporation of this protocol may provide important steps toward improved standardization in the anatomic description of the interarytenoid region in pediatric dysphagia.

Surveillance endoscopy after tracheostomy placement in children: Findings and interventions

OBJECTIVES/HYPOTHESIS

The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions.

STUDY DESIGN

Retrospective case series.

METHODS

This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ² tests and logistic regression were used to identify risk factors for the development of abnormal changes.

RESULTS

There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%).

CONCLUSIONS

The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1327-1332, 2020.

Generation of consensus in the application of a rating scale to nasendoscopic assessment of velopharyngeal function

OBJECTIVE

To generate consensus ratings of velopharyngeal function on nasendoscopy (NE) with the goal of creating a video instruction tool.

METHODS

The American Society of Pediatric Otolaryngology Velopharyngeal Insufficiency Study Group convened to identify NE segments to be included in an instructional video. Of 24 segments reviewed, 11 were selected based on the quality of the examinations and spectrum of closure patterns. Participating otolaryngologists independently rated NE segments using the Golding-Kushner scale. The participants then convened and rated each of the NE segments as a group. Thirty-nine members of the American Society of Pediatric Otolaryngology met and agreed with the group ratings, creating a consensus standard.

RESULTS

Individual scores for palate and lateral wall motion showed high variability, ranging from 0 to 6 points difference from the consensus. Variability was also seen for the following qualitative findings: the Passavant ridge, aberrant pulsations, and dorsal palatal notch. The individual ratings are presented graphically to demonstrate the range of individual responses as well as to compare responses to the consensus ratings. No further changes were made to the proposed consensus ratings when reviewed by the larger group.

CONCLUSIONS

Rating of NE evaluations of velopharyngeal function was variable among a group of pediatric otolaryngologists experienced in treating velopharyngeal insufficiency. These results highlight the need to develop a standardized method of reporting NE findings for velopharyngeal insufficiency. Despite this, consensus ratings were achieved that will facilitate development of a video instruction tool.

Targeted Oncogene Therapy Before Surgery in Pediatric Patients With Advanced Invasive Thyroid Cancer at Initial Presentation: Is It Time for a Paradigm Shift?

Importance

Initial data suggest the effectiveness of oncogene-specific targeted therapies in inducing tumor regression of diverse cancers in children and adults, with minimal adverse effects.

Observations

In this review, preliminary data suggest that systemic therapy may be effective in inducing tumor regression in pediatric patients with unresectable invasive thyroid cancer. Although most pediatric patients with thyroid cancer initially present with operable disease, some children have extensive disease that poses substantial surgical challenges and exposes them to higher than usual risk of operative complications. Extensive disease includes thyroid cancer that invades the trachea or esophagus or encases vascular or neural structures. Previous efforts to manage extensive thyroid cancer focused on surgery with near-curative intent. With the recent development of oncogene-specific targeted therapies that are effective in inducing tumor regression, with minimal drug-associated adverse effects, there is an opportunity to consider incorporating these agents as neoadjuvant therapy. In patients with morbidly invasive regional metastasis or with hypoxia associated with extensive pulmonary metastasis, neoadjuvant therapy can be incorporated to induce tumor regression before surgery and radioactive iodine therapy. For patients with widely invasive medullary thyroid cancer, in whom the risk of surgical complications is high and the likelihood of surgical remission is low, these agents may replace surgery depending on the response to therapy and long-term tolerance.

Conclusions and Relevance

With oncogene-specific targeted therapy that is associated with substantial tumor regression and low risk of adverse reactions, there appears to be an opportunity to include children with advanced invasive thyroid cancer in clinical trials exploring neoadjuvant targeted oncogene therapy before or instead of surgery.

Retrieval of "old" foreign bodies from the cardiovascular system in children

Several techniques have been developed to retrieve catheter and guide wire fragments that have embolized to the heart and pulmonary vasculature. In most instances, retrieval of the embolized fragments is performed soon after the event has occurred. In this report, we summarize our experience with the removal of these fragments in 3 children after a significant amount of time had elapsed since the time of embolization. The embolized catheter and guide wire fragments were removed without any complications. We also describe the techniques used for their removal, and the problems encountered during the removal of these "old" foreign bodies.

Airway Obstruction during Drug-Induced Sleep Endoscopy Correlates with Apnea-Hypopnea Index and Oxygen Nadir in Children

Objective

To determine if standardized intraoperative scoring of anatomic obstruction in children with obstructive sleep apnea correlates with the apnea-hypopnea index (AHI) and lowest oxygen saturation on preprocedural polysomnogram (PSG). A secondary objective was to determine if age, presence of a syndrome, or previous adenotonsillectomy affect this correlation.

Study Design

Case series with chart review.

Setting

Two tertiary care children’s hospitals.

Subjects

Patients with a preprocedural PSG who underwent drug-induced sleep endoscopy (DISE) over a 4-year period.

Methods

All DISEs were graded in a systematic manner with the Chan-Parikh (C-P) scoring system. AHI and nadir oxygen saturations were extracted from preprocedural PSG. Data were analyzed with a multivariate linear regression model that controlled for age at time of sleep endoscopy, syndrome diagnosis, and previous adenotonsillectomy.

Results

A total of 127 children underwent PSG prior to DISE: 56 were syndromic, and 21 had a previous adenotonsillectomy. Mean AHI was 13.6 ± 19.6 (± SD), and mean oxygen nadir was 85.4% ± 9.4%. Mean C-P score was 5.9 ± 2.7. DISE score positively correlated with preoperative AHI ( r = 0.36, P < .0001) and negatively correlated with oxygen nadir ( r = −0.26, P = .004). The multivariate linear regression models estimated that for every 1-point increase in C-P score, there is a 2.6-point increase in AHI (95% confidence interval: 1.4-3.8, P < .001) and a 1.1% decrease in the lowest oxygen saturation (95% confidence interval: –1.7 to −0.6, P < .001).

Conclusion

The C-P scoring system for pediatric DISE correlates with both AHI and lowest oxygen saturation on preprocedural PSG.

Hypernatremia due to amniotic fluid embolism during a saline-induced abortion

A case of fatal amniotic fluid embolism leading to hypernatremia during a hypertonic saline-induced abortion is reported. This sequence of events has not, to our knowledge, been previously reported. Hypernatremia as a diagnostic aid for amniotic fluid embolism is discussed.

Aspirin sensitivity syndrome (Samter's Triad): an unrecognized disorder in children with nasal polyposis

Aspirin sensitivity syndrome is an underdiagnosed entity in pediatric otolaryngology. The diagnosis must be considered in a pediatric non-cystic fibrosis patient with florid nasal polyposis. In this small case series, we will describe 2 patient's presentation, work up, allergic and surgical therapies and their postoperative course. In doing so, we hope to increase awareness and to illustrate the details that are involved in its diagnosis and treatment.

Genetic evaluation of American minority pediatric cochlear implant recipients

OBJECTIVE

To review the results of genetic evaluation of American minority pediatric cochlear implant recipients over a 5-year period.

METHODS

Case series review of pediatric cochlear implant recipients of Caribbean Hispanic and African American admixture descent with severe to profound sensorineural hearing loss at a tertiary care children's hospital.

RESULTS

Out of 28 patients receiving cochlear implants, 14 were of Caribbean Hispanic or African American admixture ancestry. Six (43%) had environmental risk factors for sensorineural hearing loss. Eight (57%) patients had presumed genetic sensorineural hearing loss; two of whom were syndromic and six non-syndromic. Patients with no clear etiology for hearing loss were tested for Gap Junction Beta 2 (GJB2) mutations. Within this admixture group, we found no biallelic mutations in GJB2, while two patients, both with environmental risk factors for sensorineural hearing loss, had monoallelic GJB2 variants. One patient of mixed ethnicity (Caribbean Hispanic, Turkish, Macedonian), not included as part of the 14, had the common Caucasian founder mutation, 35delG, along with a heterozygous polymorphism in the GJB2 gene. This extends previous data showing a paucity of GJB2 mutations in these admixture populations.

CONCLUSIONS

We found no biallelic GJB2 mutations in our admixture cochlear implant population, and two sequence variants of the gene, only one of which was disease causing. This suggests that the incidence of GJB2 mutations in these admixture populations is low. Hence, there may be low cost-benefit of GJB2 mutation analysis in these admixture populations with severe to profound non-syndromic sensorineural hearing loss.

An unusual case of rhabdomyosarcoma presenting as orbital apex syndrome

PRECIS

A 12-year-old female presented with symptoms and signs of orbital apex syndrome (OAS), secondary to stage IV alveolar rhabdomyosarcoma (RMS) originating in the sphenoid and ethmoid sinuses.

OBJECTIVE

To present a case of alveolar rhabdomyosarcoma, unusual in its presentation as orbital apex syndrome and also its origin from the sphenoid and ethmoid sinuses.

DESIGN

: Observational case report.

METHODS

Ophthalmologic findings, neuroimaging, medical and surgical intervention, histopathologic analysis, and clinical course are described.

RESULTS

A 12-year-old female presented with progressive visual loss in her left eye, difficulty with eye movements, and mild headache. Her examination was consistent with orbital apex syndrome. Imaging with contrast revealed a mass originating in the left sphenoid and ethmoid sinuses invading the left optic canal. Emergent biopsy was interpreted as alveolar rhabdomyosarcoma; subsequent metastatic work-up revealed bone marrow metastases. The patient was diagnosed with stage IV alveolar rhabdomyosarcoma and immediately started on combination orbital radiation therapy (RT) and systemic chemotherapy. She experienced gradual improvement of ocular motility, though her optic neuropathy persisted.

CONCLUSION

Alveolar rhabdomyosarcoma of paranasal origin, specifically from the sphenoid and ethmoid sinuses, should be included in the differential diagnosis for orbital apex syndrome in children.