Children's Visual Perception of Facial Scarring and Cleft Lip Deformity Using Eye Tracking Data

OBJECTIVE

The purpose of this study is to determine children's perception of secondary cleft lip deformity (SCLD) using objective eye tracking technology and subjective responses on a survey to understand pediatric perceptions of facial scarring.

DESIGN

Cross-sectional study of participants aged 5-17 years old.

METHODS

Participants viewed images of children's faces with an eye tracking device. Sixteen images were displayed, 12 with unilateral SCLD and four with no facial scarring. Eye tracking data were obtained. Gaze samples were analyzed for areas of interest (AOIs). Immediately after viewing each image, participants answered two survey questions relating to facial asymmetry attitude toward the child pictured. For analysis, participants were divided into age groups.

RESULTS

A total of 259 participants were enrolled (42.5% female). Mean age was 10.5 years and 78% identified as White. In all age groups, total fixation time was greater for SCLD compared to control images. Early elementary age children spent significantly less time assessing the nose AOI compared to other groups, and also spent the least total fixation time and had the lowest visit count on all AOIs. Subjective survey questions showed similar trends with elementary age not noticing facial asymmetry compared to older age groups.

CONCLUSION

This study demonstrates the successful use of eye tracking technology in children as young as 5 years old. This study suggests that SCLD is perceived as less noticeable in elementary age children and becomes more noticeable to older groups. Understanding peer perception on SCLD from this study may impact decision on revision surgery for SCLD.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:2726-2733, 2024.

Choice of suture technique may mitigate figure-of-8 deformity in slide tracheoplasty

OBJECTIVES

To demonstrate varying degrees of immediate postoperative figure of 8 deformity following three different methods of tracheal suturing.

STUDY DESIGN

Comparative ex-vivo study.

METHODS

A fresh, unfixed rabbit trachea was harvested and bisected at its midpoint. The posterior membranous trachea was excised from both segments to mimic the anatomy of complete tracheal rings following longitudinal release. A slide tracheoplasty was performed on the same tracheal segments as an internal control, using three different methods of closure: simple running, running horizontal mattress, and a modified baseball stitch. Endoscopic and external photographs were taken immediately following repair to document the effect of closure technique on external and endoluminal anatomy.

RESULTS

A simple running closure, in which traveling occurs between needle passes, showed the greatest degree of postoperative figure of 8 deformity. A running horizontal mattress suture closure showed less deformity and a modified running closure, in which traveling occurs within needle passes, showed the least deformity.

CONCLUSIONS

Our study suggests that a minor modification of standard running closure techniques may help limit the common figure-of-8 deformity often noted following slide tracheoplasty.

LAY SUMMARY

Figure of-8 deformity is a problem that can occur when repairing a narrow trachea referred to as tracheal stenosis. This deformity may be prevented using particular suture techniques which may decrease the likelihood that the trachea becomes blocked again following repair.

Presentation, Management, and Outcomes of Pathologic Scars Within a Pediatric Otolaryngology Practice

OBJECTIVES

This study aims to review the spectrum of scarring that may present to an urban, pediatric otolaryngology practice and determine if associations exist between race, scar location, treatment modality, and outcomes following interventions for scarring.

METHODS

Retrospective cohort study among 115 pediatric patients with 138 unique keloids or hypertrophic scars (HTS), and 141 children presenting for tonsillectomy at Tufts Medical Center. Age at presentation and sex assigned at birth were collected for both populations. For those presenting for pathologic scars, income quintile, self-identified race/ethnicity, anatomical location, treatment number and type, and clinical outcome were also analyzed. Multivariate analyses calculated adjusted odds ratios (aORs) and 95% confidence intervals to assess associations between scar subsite, intervention type, and persistence after treatment.

RESULTS

Compared to individuals presenting for tonsillectomy, a disproportionate percentage of patients presenting for scarring identified as Black (26.6% vs. 13.5%) or Asian (17.4% vs. 7.1%, p = 0.016) or were male (61.7% vs. 49.7%, p = 0.053). Individuals identifying as Black or Asian were more likely to present with ear lobe and neck scars, respectively (50.0% vs. 45.5%, p = <0.001). Ear scars were significantly more likely to receive excision at initial treatment (aOR = 5.86 [1.43-23.96]) compared to other subsites, and were more likely to require >1 treatment (aOR = 5.91 [1.53-22.75]).

CONCLUSION

Among pediatric patients presenting with keloids or HTS, children who identified as Black or Asian were more likely to present with ear and neck scars, respectively. Ear scars were frequently treated with excision and appear more likely to require adjuvant treatments and multiple interventions.

LEVEL OF EVIDENCE

Level III Laryngoscope, 2024.

Syndromic Craniofacial Disorders

This article reviews the most common craniofacial syndromes encountered in clinical practice. Key physical features of each condition are highlighted to aid in accurate recognition and diagnosis. Optimal individualized treatment approaches are discussed.

Tender Cervical Lymphadenopathy in a Pediatric Patient

An 11-year-old boy presented with enlarged and tender cervical lymph nodes that showed areas of central hypodensity and necrosis with histiocytes and an absence of neutrophils. What is your diagnosis?

Medical School Factors Associated With Students Entering Otolaryngology

OBJECTIVE

To determine medical school characteristics that are associated with medical students entering otolaryngology residency programs.

STUDY DESIGN

Cross-sectional study.

SETTING

Publically available data on otolaryngology residents and academic otolaryngology programs.

METHODS

Publicly available websites were used to collect demographic and bibliometric characteristics for 1527 residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited otolaryngology programs accounting for the 2017 to 2021 match periods. For each medical school, information on class size, number of otolaryngology faculty, presence of a home academic otolaryngology program, NIH research funding, presence of a student interest group, and top 10 ranking by Doximity or U.S. News and World Report (USNWR) were collected. Univariate and multivariate analyses were performed between the medical school factors and the percentage of each medical school class that matriculated into an otolaryngology residency program.

RESULTS

On multivariate analysis, the following factors were found to be associated with a higher percentage of graduates entering an otolaryngology residency program: presence of a home academic otolaryngology program (standardized beta value (β) = 0.397, p < 0.0001), a 2021 top 10 ENT ranking according to USNWR (β = 0.206, p = 0.0028), and the average h-index of students from a medical school (β = 0.327, p < 0.0001).

CONCLUSIONS

After controlling for multiple factors including research productivity, we found that the presence of a home academic program and a top 10 ranking on USNWR were associated with an increasing percentage of medical school graduates entering otolaryngology. NIH funding and the number of otolaryngology faculty were not associated with more students matriculating into an otolaryngology residency program. These findings can help guide medical schools and otolaryngology programs to recruit students into the field.

Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes

Background: The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges. Objectives: Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair. Methods: This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models. Results: Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2-12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and -0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2-4, 5-7, 8-12, 13-24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015-0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair. Conclusions: In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study

Objective

To qualitatively assess surgeons decision making for lip surgery in patients with cleft lip/palate (CL/P).

Design

Prospective, non-randomized, clinical trial.

Setting

Clinical data institutional laboratory setting.

Patients Participants

The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the Standardized Assessment for Facial Surgery (SAFS) for systematic viewing by the surgeons.

Interventions

The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either in person or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method.

Results

Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. For diagnoses/treatments, surgeons agreed, and level of surgical experience was not a factor.

Conclusions

The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

Unplanned Intensive Care Unit Admission Following Cleft Palate Repair by Head and Neck Surgeons

OBJECTIVE

To examine the incidence of pediatric intensive care unit (PICU) admission following primary repair of cleft palate by otolaryngologist-head and neck surgeons at 2 tertiary centers. To identify potential diagnoses associated with admission or unanticipated PICU transfer.

STUDY DESIGN

Multi-institutional case series with chart review.

SETTING

Two tertiary pediatric medical centers.

METHODS

Children who underwent primary repair of cleft palate at 2 cleft centers over a 10-year period were identified. Charts were reviewed for demographics, comorbidities, and whether PICU admission was required.

RESULTS

From 2009 to 2019, 464 patients underwent primary repair of a cleft palate by 1 of 6 otolaryngologist-head and neck surgeons with subspecialty training in cleft surgery; 459 patients had sufficient postoperative documentation and 443 children met inclusion criteria. The incidence of PICU admission was 9.3% (41/443), with 33 (7.4%) planned admissions and 8 (1.8%) unexpected PICU transfers. Syndromic conditions were associated with both planned and unanticipated PICU admissions.

CONCLUSION

The incidence of unanticipated postoperative PICU admission following cleft palate repair by otolaryngologist-head and neck surgeons was low. Risk stratification by surgeons with expertise in airway management may inform decisions regarding postoperative disposition of patients with medical or airway complexity who are undergoing cleft palate repair.

LEVEL OF EVIDENCE: 4

Acquired nasopharyngeal stenosis after radiation treatment for nasopharyngeal carcinoma

INTRODUCTION

Nasopharyngeal stenosis (NPS) is a rare and morbid complication following radiation therapy for nasopharyngeal carcinoma. This review provides an update on management and prognosis.

METHODS

A comprehensive PubMed review using the terms "nasopharyngeal stenosis," "choanal stenosis," and "acquired choanal stenosis" was performed.

RESULTS

Fourteen studies identified 59 patients who developed NPS after radiotherapy for NPC. 51 patients underwent endoscopic nasopharyngeal stenosis excision by cold technique (80-100% success). The remaining 8 underwent carbon dioxide (CO₂) laser excision with balloon dilation (40-60% success). Adjuvant therapies included postoperative topical nasal steroids in 35 patients. The need for revision was 62% in the balloon dilation group, vs 17% in the excision group (p-value <0.01).

CONCLUSION

When NPS occurs after radiation, primary excision of scarring is the most effective method of management with less need for revision surgery relative to balloon dilation.

Identification of micrognathia by prenatal ultrasound may improve timely diagnosis and management of infants with Robin sequence

OBJECTIVE

Robin sequence (RS) is a craniofacial anomaly characterized by small jaw (micrognathia) with associated tongue base airway obstruction. With advances in fetal imaging, micrognathia may be detected prenatally. This study aims to determine if prenatal recognition of micrognathia offers any advantage over being unaware of the condition until after delivery and to assess if prenatal consultation for micrognathia adds benefits beyond merely noting the presence of the condition.

METHOD

Retrospective chart review examining cases from 01/01/2010 to 12/31/2020 at an urban tertiary medical center.

RESULTS

Forty seven infants with RS were included. 40.4% (n = 19) had micrognathia/retrognathia noted on prenatal ultrasound. 47.4% (n = 9) of those 19 pregnancies saw a maternal fetal medicine (MFM) program with craniofacial consultation. Compared to 28 infants not diagnosed with micrognathia until after birth, the 19 infants identified prenatally required fewer transfers from birth hospital (p = 0.02). Additionally, those referred to MFM with craniofacial consultation had shorter lengths of stay when airway intervention was required (p = 0.05).

CONCLUSION

Prenatal recognition of micrognathia may lead to early detection and management of RS. When RS is suspected, prenatal consultation with MFM and craniofacial team may further optimize care of the infant following delivery.

Type IA Oromandibular-Limb Hypogenesis Syndrome: A Case Report and A Case Update

Hypoglossia is a rare congenital anomaly resulting in a small rudimentary tongue. It is classified under the oromandibular-limb hypogenesis syndrome and can be found in isolation (Type IA) but is more often associated with other congenital disorders, such as limb defects. Isolated hypoglossia cases are rare, and while feeding disorders are common, in some cases, neonatal airway obstruction is the most problematic. In the present report, we discuss two cases of newborns presenting with hypoglossia without limb deformities or visceral anomalies: one new case and a 10-year update of a previously reported case. These two cases highlight the variability in presenting symptoms and the challenges in diagnosis and management of a rare clinical entity. We focus on the discussion of early diagnosis, multidisciplinary management, and shared decision-making, with emphasis on the current therapeutic strategies available to the clinician and their limitations during the neonatal period. Early surgical multivector mandibular distraction osteogenesis can be proposed with minimal short- and long-term morbidity, pending a consistent follow-up. This clinical entity will require multidisciplinary team care into adult years.

Specialized Pro-Resolving Mediators Reduce Scarring After Cleft Lip Repair

Objective

Residual scarring after cleft lip repair surgery remains a challenge for both surgeons and patients and novel therapeutics are critically needed. The objective of this preclinical experimental study was to evaluate the impact of the methyl-ester of pro-resolving lipid mediator lipoxin A4 (LXA4-ME) on scarring in a novel rabbit model of cleft lip repair.

Methods

A defect of the lip was surgically created and repaired in eight six-week old New Zealand white rabbits to simulate human cleft lip scars. Rabbits were randomly assigned to topical application of PBS (control) or 1 ug of LXA4-ME (treatment). 42 days post surgery all animals were euthanized. Photographs of the cleft lip area defect and histologic specimens were evaluated. Multiple scar assessment scales were used to compare scarring.

Results

Animals treated with LXA4-ME exhibited lower Visual Scar Assessment scores compared to animals treated with PBS. Treatment with LXA4-ME resulted in a significant reduction of inflammatory cell infiltrate and density of collagen fibers. Control animals showed reduced 2D directional variance (orientation) of collagen fibers compared to animals treated with LXA4-ME demonstrating thicker and more parallel collagen fibers, consistent with scar tissue.

Conclusions

These data suggest that LXA4-ME limits scarring after cleft lip repair and improves wound healing outcomes in rabbits favoring the resolution of inflammation. Further studies are needed to explore the mechanisms that underlie the positive therapeutic impact of LXA4-ME on scarring to set the stage for future human clinical trials of LXA4-ME for scar prevention or treatment after cleft lip repair.

Pharyngeal wall and soft palate motion after two common speech surgeries

PURPOSE

To assess how pharyngeal wall and soft palate motion are affected after two common interventions for velopharyngeal insufficiency.

MATERIALS AND METHODS

A retrospective observational study was performed. A database of patients who had undergone Furlow palatoplasty or pharyngeal flap surgery between 2011 and 2019 and had video-archived preoperative and postoperative nasopharyngoscopy recordings was created. Recordings were deidentified and randomized, with 5 randomly-selected videos duplicated to determine intra-rater reliability. The videos were scored by 3 experienced raters using a modified Golding-Kushner scale. Pre- and postoperative scores were compared using paired t-test. Inter- and intra-rater reliability were estimated using intra-class correlation (ICC).

RESULTS

There were 17 patients who met inclusion criteria. The mean age was 6.9 years (range 3-22 years, 59% male). In the Furlow palatoplasty group (n = 9), an increase in left soft palate motion was noted postoperatively (t(8) = 2.71, p = 0.02). In the pharyngeal flap group (n = 8), increases in lateral pharyngeal wall motion (left: t(7) = 3.58, p = 0.008, right: t(7) = 3.84, p = 0.006) and right soft palate motion (t(6) = 2.49, p = 0.04) were identified. Intra-rater reliability and inter-rater agreement were lower than prior studies utilizing the Golding Kushner scale.

CONCLUSIONS

Our results provide objective evidence that Furlow palatoplasty and pharyngeal flap surgeries achieve velopharyngeal closure by increasing movement at different anatomical sites. Palatal and pharyngeal wall motion observed during preoperative nasopharyngoscopy may influence a surgeon's choice of intervention.

Symptomatic Lingual Thyroglossal Duct Cyst in Children: A Laryngomalacia Phenotype

OBJECTIVES

Patients with lingual thyroglossal duct cyst (TGDC) can present as symptomatic with obstructive airway and feeding difficulties.

METHODS

We present 3 cases of symptomatic lingual TGDC.

RESULTS

All 3 patients were diagnosed with laryngomalacia and underwent further concurrent or delayed airway intervention, in addition to cyst removal.

CONCLUSIONS

We reason that there is a phenotype of laryngomalacia in the symptomatic lingual thyroglossal duct cyst patients who present with symptoms due to disruption in laryngeal anatomy rather than the cyst itself causing obstructive symptoms. Distinguishing this phenotype, especially in comparison to other pathologies such as vallecular cysts, may better allow for planning of concurrent or delayed airway procedures and overall counseling of parents.

Ambient noise limits efficacy of smartphone-based screening for hearing loss in children at risk

OBJECTIVE

To determine if hearScreen®, a smartphone-based pure tone audiometric screen, serves as an effective hearing screen for identifying hearing loss in children at risk, such as those with chronic otitis media and/or craniofacial anomalies.

METHODS

A cross-sectional, single-center, prospective study at an urban tertiary care hospital was completed. From June to October 2019, a total of 208 pediatric ears at risk for hearing loss were evaluated by both hearScreen® and conventional pure tone audiometry. The efficacy of hearScreen® for detecting hearing loss in a pediatric population at risk was determined.

RESULTS

A total of 208 pediatric ears at risk for hearing loss were screened. HearScreen® demonstrated a sensitivity of 85%, a specificity of 41%, a positive predictive value of 36%, and a negative predictive value of 87%. Subgroup analysis stratified by hearing loss type showed that hearScreen® screens for conductive hearing loss with increased sensitivity.

CONCLUSIONS

This investigation suggests that hearScreen® may serve as a an accessible, low-cost, and sensitive pure tone audiometric screen for hearing loss in children at risk, particularly those with conductive hearing loss, with the caveat that it may generate a high proportion of false positives due to the influence of ambient noise, especially when screening at 500 Hz. Future investigations should weigh the utility of including 500 Hz in the screening protocol as well as assess methods that may mitigate the influence of ambient noise during a pure-tone audiometric screen.

The Safety and Efficacy of Mandibular Distraction Osteogenesis Among Infants Less Than 3 kg

OBJECTIVES/HYPOTHESIS

Mandibular distraction osteogenesis (MDO) is a safe and effective surgery to address respiratory and feeding issues due to micrognathia in patients with Robin Sequence (RS). Previous studies examining postoperative complications in neonates receiving MDO have considered 4 kg as the cut-off for low weight; however, an increasing number of MDO interventions are performed in infants <4 kg. To determine if a weight <3 kg at time of MDO is a risk factor for postoperative complications or need for subsequent tracheostomy or gastrostomy tube (G-tube).

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective review of all infants <6 months of age undergoing MDO at two tertiary pediatric hospitals from 2008 to 2018. Demographic data, syndromic status, weight, and age at time of surgery, length of postoperative hospital stay, and postoperative outcomes were recorded including tracheostomy placement, G-tube placement, hardware infection, reintubation, facial/marginal mandibular nerve damage, and need for revision MDO.

RESULTS

Sixty-nine patients with RS were included. The mean age at MDO was 25 ± 20 days and mean weight was 3.32 ± 0.44 kg. There was no statistically significant correlation between weight (P = .699) or age (P = .422) and unfavorable postoperative outcomes. No patients (0%) underwent tracheostomy pre-MDO. Two patients (2.9%) required tracheostomy postsurgery; neither was <3 kg. Eight patients (11.6%) required a G-tube postoperatively.

CONCLUSION

Newborns <3 kg who undergo MDO experience the same rates of success and complication as larger infants, suggesting that MDO is a safe and efficacious procedure in infants less than 3 kg. Laryngoscope, 2021.

Does Prematurity Play a Role in Newborn Microtia-Anotia?

OBJECTIVE

Microtia-anotia (MA) describes a range of external ear anomalies which is commonly associated with various syndromes and malformations of the head and neck. Previous studies have suggested a strong association between MA and male sex, maternal diabetes, and Hispanic race/ethnicity. This study seeks to evaluate the associations between MA and preterm newborns in the United States.

METHODS

Population-based inpatient registry analysis was conducted. Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnosis of prematurity or MA. Demographic information was obtained, and odds ratios (ORs) were used to determine associations between prematurity and MA.

RESULTS

Among patients included in our dataset, 8.655% (326 285) were preterm and 0.016% (523) had MA. 0.003% (109) of patients were preterm and had MA. Preterm infants had 2.19 times the odds (95% C.I. = 1.78-2.69) of having MA when compared to the full-term population. The binary logistic regression model accounting for possible confounding variables produced an aOR of 1.48 (95% C.I. = 1.17-1.87) for the association between prematurity and MA.

CONCLUSION

Infants who are born preterm are more likely to have MA than full term infants. The current results will allow for improved risk stratification, maternal counseling, and interventions in the case of prematurity.

Detection of Chronic Hypoventilation Among Infants With Robin Sequence Using Capillary Blood Gas Sampling

OBJECTIVES/HYPOTHESIS

To describe the use of capillary blood gas (CBG) sampling to detect and quantify hypoventilation in infants with Robin sequence (RS).

METHODS

Case series with chart review at two institutions. Infants with RS presenting over a 10-year period were identified using departmental databases. CBG values obtained during infancy or until airway intervention (AI) were reviewed.

RESULTS

From 2008 to 2018, 111 infants with RS were identified as having had been assessed and managed from birth or transfer until discharge home and having CBG data available. In most cases, CBG sampling was obtained every other day until intervention or discharge. A total of 81 (73%) infants required AI: 72 (89%) underwent mandibular distraction osteogenesis, five (6%) underwent tracheotomy, and four (5%) were discharged home with a nasopharyngeal airway. The mean PCO₂ at day of life (DOL) 7-30 for the AI group was 52.7 mmHg (95% confidence interval: 51.7-53.7) and for the no AI group was 45.9 mmHg (44.8-47.0; P < .0001). The mean HCO₃ at DOL 7-30 for the AI group was 29.8 mEq/L (29.4-30.1) and for the no AI group was 27.0 mEq/L (26.5-27.4; P < .0001). Receiver operating characteristic curves were created for maximum PCO₂ and HCO₃ values and cutoffs were established by optimizing a balance of sensitivity and specificity. Infants requiring AI surpassed the PCO₂ and HCO₃ cutoff at a median of DOL 9.

CONCLUSIONS

Among infants with RS and hypoventilation, objective measures of respiratory acidosis may be apparent by DOL 9.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

The spiral flap: A novel approach to scalp closure in children

BACKGROUND

The spiral rotational advancement flap is a single-stage technique that has been described for the closure of nasal ala defects and in nipple reconstruction. Herein we present our experience using the spiral flap for closure of moderately sized defects of the scalp vertex in children. Compared to other scalp reconstructive approaches, such as a simple rotational flap or primary linear closure, the spiral flap design offers improved cosmesis through recreation of the natural whorl pattern within the hair-bearing scalp. Scar camouflage is especially important in the pediatric population, as increased skin elasticity and continued cranial growth impart a high risk of scar widening in children.

METHODS

The electronic patient database at a single, urban, academic, tertiary pediatric otolaryngology and facial plastic surgery practice was queried to identify children who had undergone scalp reconstruction. The medical records of three children who had undergone spiral rotational advancement flap closure by a single surgeon were reviewed. Indications for scalp reconstruction in these patients were limited to the excision of benign, congenital lesions, such as infantile hemangioma unresponsive to propranolol and hypertrophic scarring and alopecia from aplasia cutis congenita A case example of a 15-month-old boy with scarring of the scalp, secondary to aplasia cutis congenita, is chosen for demonstration of the spiral flap design in step-by-step instructional video.

RESULTS

A spiral rotational advancement flap was conceived for multi-layer repair in three pediatric patients. By reproducing the main elements of the logarithmic spiral flap design, the apex of the flap is rotated in on itself to complete a spiral closure pattern. There were no operative or post-operative complications. At various post-operative timepoints, the wounds appeared well-healed without evidence of flap necrosis, skin discoloration, or residual alopecia.

CONCLUSION

We report satisfactory results using the spiral rotational advancement flap to address moderately sized defects of the scalp vertex in three pediatric patients. Although this flap has primarily been used in the reconstruction of the nasal ala in adults, we feel that this technique is ideally suited for scalp reconstruction, particularly in young children with highly elastic tissues in areas with decreased pliability. This approach has the added advantage of simulating the natural hair whorl in a cosmetically sensitive region and may serve as an effective alternative to linear reconstruction methods. The technique described can be added to the armamentarium of the pediatric plastic surgeon.

Race, Income, and the Timeliness of Cleft Palate Repair in the United States

Objective To determine if differences exist in the timing of cleft palate repair with respect to sex, race, income, and geographical location within the United States. Design Retrospective cross-sectional study using the Kids' Inpatient Database (KID) from 1997 to 2009. Setting Inpatient. Patients Children with cleft palate with or without cleft lip undergoing inpatient cleft palate repair. Main outcome measures Age at the time of palatoplasty (in months) by sex, race, income quartile, and geographic location. Results A total of 7,218 children with cleft palate underwent repair at a mean age of 12.1 months (95% CI 12.0-12.3). Females underwent palatoplasty at an older age (13.6 months) than males (13.2 months), a difference of 0.47 months (SE: 0.19, p=0.015). White children underwent surgery at an earlier age (12.1 months) than Black (12.9 months) (difference: 0.73 months, SE: 0.37, p=0.045), Hispanic (12.7 months) (difference: 0.57 months, SE 0.25, p=0.025), and Asian children (15.7 months) (difference: 3.60 months, SE 0.49, p<0.0001). Asian children were also found to undergo repair later than Hispanic (difference 3.03 months, SE 0.51, p<0.0001) and Black (difference: 2.87 months, SE 0.59, p<0.0001) children. Patients born into the highest income brackets were repaired 0.75 months earlier than those in the lowest bracket (SE: 0.26, p=0.005). Patients in the Midwest underwent palatoplasty later (14.3 months) than in the Northeast (12.9 months) (difference: 1.36 months, SE: 0.31, p<0.0001), South (13.2 months) (difference: 1.05 months, SE: 0.36, p=0.004), and West (13.2 months) (difference: 1.09 months, SE: 0.32, p=0.0007). Conclusions After controlling for confounding factors, our results suggest that in recent history, Black, Hispanic, and Asian children with cleft palate were repaired later than their White counterparts. In addition, children of affluent families were repaired earliest, and economically disadvantaged children were repaired later than their peers.

Cleft Palate Repair by Otolaryngologist-Head and Neck Surgeons: Risk Factors for Postoperative Fistula

OBJECTIVES/HYPOTHESIS

To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist-Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development.

STUDY DESIGN

Retrospective case series with chart review.

METHODS

Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation.

RESULTS

From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist-Head and Neck Surgeons. Twenty-four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon).

CONCLUSIONS

Among six Otolaryngologist-Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1281-1285, 2021.

Autologous costochondral graft harvest in children

INTRODUCTION

Autologous costochondral grafting is a commonly employed technique in pediatric otolaryngology for reconstructing a cartilaginous or bony structure, such as the trachea, larynx, nose or mandible by harvesting rib cartilage or bone from the same patient. Complications include infection, pneumothorax, hematoma, scarring, and pleural leak, and the literature regarding these complication rates in pediatric patients undergoing this procedure is sparse. The objective of this study was to determine the donor site complication rate associated with rib graft harvest procedures performed by pediatric otolaryngologists in infants and children and to compare this to established complication rates reported in adults.

METHODS

A retrospective cohort study was performed, examing the charts of 33 patients who underwent airway, mandible, nose, or external ear reconstruction by means of autologous rib grafting between 2010 and 2018 at an urban tertiary medical center in Boston, Massachusetts. All patients were under the age of 18 years old and had undergone rib harvest and subsequent airway, mandible, nose, or external ear reconstruction by two pediatric otolaryngologists.

RESULTS

Of these, 20 were female and 13 were male, with a mean age of 2.5 years at date of surgery. No patients were excluded. A total of 41 costochondral graft harvests from a total of 36 incision sites were included. Pooled donor site complication incidences were 1 intraoperative pleural leak (2.8%) and 1 incision site infection (2.8%). Drains were not utilized postoperatively; there were no incidences of postoperative hematoma or seroma. No outside specialty consults were necessary to manage these. There were 2 instances of hypertrophic scarring, both developing in patients who underwent skin excisions for skin graft harvest or scar excision from the same incision used for graft harvest (5.6%).

CONCLUSIONS AND RELEVANCE

Autologous rib grafting amounts to a simple, extrapleural chest wall procedure, which may be safely performed in children by pediatric otolaryngologists with acceptably low complication rates.

Pediatric Septal Perforation Repair With the Endoscopic Anterior Ethmoid Artery Flap

Pediatric nasal septal perforations can lead to crusting, obstruction, whistling, and recurrent epistaxis. Current approaches for pediatric nasal septal repair center on combination endonasal and external approaches. Herein we describe the successful utilization of a purely endoscopic anterior ethmoid artery flap, an established technique in adults, for nasal septal perforation repair in 3 children aged 12 to 13 years who presented with septal perforations ranging in size from 6 to 12 mm. Successful closure was achieved with an endoscopic anterior ethmoid artery flap, with all patients achieving complete closure and symptom resolution. Children with nasal septal defects are typically treated with temporizing measures until early adulthood, when definitive open repair may be performed. Our initial experience with the anterior ethmoid artery flap technique suggests that this surgery may be easily performed in children as young as 12 years, without the use of previously described adjunctive procedures such as turbinate translocation.

Prophylactic Flexible Bronchoscopy Immediately following Open Airway Reconstruction in Children

OBJECTIVES

Prophylactic flexible bronchoscopy immediately following open airway reconstruction allows for directed clearance of the distal airways, potentially reducing the rate of certain postoperative respiratory complications. In this investigation, we sought to determine if prophylactic flexible bronchoscopy at the conclusion of pediatric open airway reconstruction has any benefit over blind flexible suctioning of the trachea.

METHODS

A retrospective, single-center study at an urban tertiary care hospital was completed. From January 2010 to April 2013, patients underwent open airway reconstruction, immediately followed by blind flexible suctioning of the trachea for distal airway clearance. From May 2013 through December 2016, sequential patients underwent prophylactic flexible bronchoscopy immediately following airway reconstruction.

RESULTS

A total of 29 patients (age: 3.6 months-6.2 years) met inclusion criteria. Sixteen sequential patients underwent simple blind flexible suctioning and 13 sequential patients underwent directed, prophylactic flexible bronchoscopy. Demographics and comorbidities between the groups were equivalent other than slightly older age in the prophylactic bronchoscopy group. All clinical outcomes analyzed were equivalent other than faster time to room air (P < .002) and a decrease in the number of chest physical therapy sessions (P < .02) in a subset of patients who did not undergo prophylactic bronchoscopy.

CONCLUSION

This investigation suggests that the use of prophylactic flexible bronchoscopy immediately following open airway reconstruction may not be superior to blind flexible suctioning of the trachea in limiting postoperative pulmonary complications. Further studies of greater power are needed to better elucidate any small differences that may exist between these two interventions.

Weight Gain in Infants With Pierre Robin Sequence in the First Year of Life

OBJECTIVE

To compare growth trends among infants with Pierre Robin sequence (PRS) to normal World Health Organization (WHO) growth standards.

STUDY DESIGN

Case series with chart review.

SUBJECTS AND METHODS

Twenty-four infants with syndromic and nonsyndromic PRS (54% male) treated at an urban academic medical center between 2009 and 2017 were included. Infants with symptomatic hypoventilation underwent mandibular distraction osteogenesis (71%). Weights were recorded at roughly 1- to 3-month intervals from birth to 12 months, with ages adjusted for prematurity. The 50th percentile (P50) for this cohort was calculated and compared to WHO standards.

RESULTS

In total, 135 weight entries for 24 subjects were included. The birth weight P50 was similar to the WHO standard (females: 0.09 kg above WHO [95% CI, -0.25 to +0.43; z score = 0.19]; males: 0.38 kg below WHO [95% CI, -0.77 to 0.00; z score = -0.79]). A slower growth rate was noted among female and male infants with PRS: in month 5, the PRS P50 among females was 1.42 kg below the WHO standard (95% CI, -1.77 to -1.07; z score = -1.64). Among males in month 3, the PRS P50 was 1.68 kg below the WHO standard (95% CI, -2.12 to -1.24; z score = -2.19). By month 12, weight deficiencies had resolved in both groups.

CONCLUSION

Newborns with and without PRS may have similar birth weights, but the growth rate among male and female infants with PRS may lag behind that of unaffected infants, even when upper airway obstruction has been addressed in early infancy.

Use of the facelift incision for excision of non-tuberculous mycobacterial lymphadenitis in children

OBJECTIVES

To present cases of pediatric periparotid nontuberculous mycobacterial lymphadenitis excised through a facelift incision in order to review the advantages of this approach to parotidectomy. We also aim to discuss scenarios in which to forgo the facelift incision in favor of a traditional modified Blair incision.

METHODS

Retrospective series of seven consecutive patients who underwent parotidectomy for nontuberculous mycobacterial lymphadenitis between 2013 and 2018.

RESULTS

The series included three uses of the facelift incision and four uses of the modified Blair incision, which was specifically selected for cases of bulky lymphadenopathy anterior to the masseter muscle. All cases of Modified Blair incision involved circumferential dissection of the marginal mandibular branch of the facial nerve. The facelift incision permitted complete removal of disease in cases located posterior to the masseter as well as neck dissection as inferiorly as level III. Post-operatively, temporary marginal mandibular nerve weakness was seen in all cases of Modified Blair incision. Scar widening was most notable in patients who required skin excision or dermal curettage.

CONCLUSION

The facelift incision offers a more hidden scar. This may serve as an alternative approach to parotid surgery in young children with nontuberculous mycobacterial lymphadenitis, except in cases of bulky disease anterior to the masseter muscle for which optimal exposure of the marginal mandibular nerve via a modified Blair incision is warranted.

A Standardized Care Pathway following Mandibular Distraction in Infants Less Than 3 Months of Age

OBJECTIVES

To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol.

STUDY DESIGN

Retrospective chart review.

SETTING

Urban tertiary pediatric hospital.

SUBJECTS AND METHODS

The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications.

RESULTS

Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; P = .51). The mean postoperative LOS was 13.3 days less among infants managed with the protocol (P = .06), and the mean number of midazolam boluses was fewer among protocol patients (P < .01). A more consistent postoperative LOS, duration of mechanical ventilation, and exposure to sedating medications was observed among protocol subjects (P < .01). The LOS for 2 patients in the preprotocol group was extended due to iatrogenic withdrawal syndrome. There were no instances of accidental extubation or anoxia in either group.

CONCLUSIONS

Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.

Peripartum Management of Neonatal Pierre Robin Sequence

Pierre Robin sequence (PRS) is a congenital condition characterized by the presence of micrognathia, glossoptosis, and cleft palate. PRS has varying effects on airway patency and feeding ability and thus has a broad range of management options. The purpose of this article is to describe the nature of the background of the condition and address the previous and current trends in diagnosis and management of PRS.

A novel approach to columellar reconstruction in a child

We present a novel method for columellar reconstruction using a hidden donor site and review the challenges and limitations of columellar reconstruction in children with Fitzpatrick VI skin type. A staged reconstruction was conceived in which a full-thickness skin graft was transferred to the superior gingivolabial sulcus in the area of the maxillary frenulum. Six months later, the prelaminated soft tissue flap was delivered through a horizontal incision at the subnasale, and the donor site closed primarily. We report satisfactory results following a novel approach to composite soft tissue reconstruction of the columellar subunit in a 9-year-old child. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2718-2720, 2018.

TIA: algorithms for development of identity-linked SNP islands for analysis by massively parallel DNA sequencing

Background

Single nucleotide polymorphisms (SNPs) located within the human genome have been shown to have utility as markers of identity in the differentiation of DNA from individual contributors. Massively parallel DNA sequencing (MPS) technologies and human genome SNP databases allow for the design of suites of identity-linked target regions, amenable to sequencing in a multiplexed and massively parallel manner. Therefore, tools are needed for leveraging the genotypic information found within SNP databases for the discovery of genomic targets that can be evaluated on MPS platforms.

Results

The SNP island target identification algorithm (TIA) was developed as a user-tunable system to leverage SNP information within databases. Using data within the 1000 Genomes Project SNP database, human genome regions were identified that contain globally ubiquitous identity-linked SNPs and that were responsive to targeted resequencing on MPS platforms. Algorithmic filters were used to exclude target regions that did not conform to user-tunable SNP island target characteristics. To validate the accuracy of TIA for discovering these identity-linked SNP islands within the human genome, SNP island target regions were amplified from 70 contributor genomic DNA samples using the polymerase chain reaction. Multiplexed amplicons were sequenced using the Illumina MiSeq platform, and the resulting sequences were analyzed for SNP variations. 166 putative identity-linked SNPs were targeted in the identified genomic regions. Of the 309 SNPs that provided discerning power across individual SNP profiles, 74 previously undefined SNPs were identified during evaluation of targets from individual genomes. Overall, DNA samples of 70 individuals were uniquely identified using a subset of the suite of identity-linked SNP islands.

Conclusions

TIA offers a tunable genome search tool for the discovery of targeted genomic regions that are scalable in the population frequency and numbers of SNPs contained within the SNP island regions. It also allows the definition of sequence length and sequence variability of the target region as well as the less variable flanking regions for tailoring to MPS platforms. As shown in this study, TIA can be used to discover identity-linked SNP islands within the human genome, useful for differentiating individuals by targeted resequencing on MPS technologies.

Electronic supplementary material

The online version of this article (10.1186/s12859-018-2133-2) contains supplementary material, which is available to authorized users.

National trends in tongue reduction surgery for macroglossia in children

OBJECTIVES

To examine the frequency of partial glossectomy performed for the indication of macroglossia in children within the United States, assessing for differences in rates of intervention across various demographics. To identify potential morbidities associated with partial glossectomy in this population and determine how such factors may influence length of stay and cost of admission following tongue reduction surgery.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

The Kids' Inpatient Database 2003, 2006, 2009, and 2012.

SUBJECTS

Patients under age 5 diagnosed with macroglossia who underwent partial glossectomy.

METHODS

Demographics were analyzed and cross tabulations, linear regression modeling, and multivariate analysis were performed.

RESULTS

During the four-years studied, partial glossectomy was performed in 196 children under age 5 with macroglossia. A disproportionately higher rate of intervention was seen in white children (p = 0.001), patients undergoing surgery in the mid-west (p < 0.001) and patients in the highest socioeconomic quartile (p = 0.015). Most patients underwent glossectomy in their second year of life. The average length of stay in patients who underwent partial glossectomy for macroglossia was 9.59 days (Range 1-211 days, median 3.45 days) and the average cost was $56,602 (median $16,330).

CONCLUSION

Partial glossectomy for macroglossia is typically performed prior to age 2 in the United States. A higher rate of intervention is seen in white children, those who have surgery in the mid-west and affluent children even when controlling for confounding variables.

LEVEL OF EVIDENCE

III.

Benefits and Limitations of Entry-Level 3-Dimensional Printing of Maxillofacial Skeletal Models

Importance

A protocol for creating exceptionally low-cost 3-dimensional (3-D) maxillofacial skeletal models does not require proficiency with computer software or intensive labor. Small and less affluent centers can produce models with little loss in accuracy and clinical utility.

Objectives

To highlight the feasibility and methods of introducing in-house, entry-level additive manufacturing (3-D printing) technology to otolaryngologic craniofacial reconstruction and to describe its clinical applications and limitations, including a comparison with available vendor models.

Design, Setting, and Participants

This case series of 6 models (3 pairs) compared cost, side-by-side anatomical model fidelity, and clinical versatility using entry-level, in-house 3-D pediatric mandible model production vs high-end, third-party vendor modeling, including a review of the literature. Comparisons were made at an urban pediatric otolaryngology practice among patients who had previously undergone pediatric craniofacial reconstruction with use of a commercially produced medical model for surgical planning. Each vendor model had been produced using computed tomographic imaging data. With the use of this same data source, in-house models were printed in polylactic acid using a commercially available printer. Data were collected from November 1 to December 30, 2015.

Main Outcomes and Measures

Models created from these 2 methods of production were assessed for fidelity of surface anatomy, resilience to manipulation and plate bending, cost of production, speed of production, sterilizability, virtual surgical planning options, and alveolar nerve canal and tooth root visibility in mandibles.

Results

For the quantitative comparisons between in-house models (1 neonatal, 1 pediatric, and 1 adult model) and their commercial counterparts, the mean value of 7 independent measurements was analyzed from each of 3 model pairs. Caliper measurements from models produced through entry-level, in-house manufacturing were comparable to those taken from commercially produced counterparts, suggesting an acceptable degree of accuracy (0.54 mm; 95% CI, 0.36-0.72 mm). Fixed costs for in-house production included acquiring an entry-level printer (retail $2899) and an annual software subscription ($699 per year). After purchase of these initial assets, the printing cost for an in-house mandible was approximately $90, with 98% of that cost related to labor. Physical qualities of entry-level, in-house models such as nerve canal visibility, tooth root visibility, and sterilizability were inferior compared with commercially-produced stereolithic renderings.

Conclusions and Relevance

This low-cost method of in-house, entry-level 3-D printing of straightforward, skeletal models may suit a general otolaryngology practice that performs maxillofacial reconstruction. Although commercial modeling offers several unique features, such as sterilizable materials and advanced virtual planning, in-house modeling also produces renderings with high fidelity, which may be used as tools for education and surgical planning, including preoperative plate bending.

Level of Evidence

4.

Current and Emerging Treatments for Postsurgical Cleft Lip Scarring: Effectiveness and Mechanisms

Cleft lip with or without cleft palate is the most common congenital malformation of the head and the third-most common birth defect. Surgical repair of the lip is the only treatment and is usually performed during the first year of life. Hypertrophic scar (HTS) formation is a frequent postoperative complication that impairs soft tissue form, function, or movement. Multiple lip revision operations are often required throughout childhood, attempting to optimize aesthetics and function. The mechanisms guiding HTS formation are multifactorial and complex. HTS is the result of dysregulated wound healing, where excessive collagen and extracellular matrix proteins are deposited within the wound area, resulting in persistent inflammation and resultant fibrosis. Many studies support the contribution of dysregulated, exaggerated inflammation in scar formation. Fibrosis and scarring result from chronic inflammation that interrupts tissue remodeling in normal wound healing. Failure of active resolution of inflammation pathways has been implicated. The management of HTS has been challenging for clinicians, since current therapies are minimally effective. Emerging evidence that specialized proresolving mediators of inflammation accelerate wound healing by preventing chronic inflammation and allowing natural uninterrupted tissue remodeling suggests new therapeutic opportunities in the prevention and management of HTS.