Decannulation in Revision Pediatric Laryngotracheal Reconstruction

OBJECTIVES

To evaluate how patient characteristics and surgical techniques influence the rate of and time to decannulation after pediatric revision laryngotracheal reconstruction.

METHODS

The study was a retrospective cohort investigation of children with a history of laryngotracheal stenosis treated between 2008 and 2021 with revision open airway surgery. The primary outcome evaluated was decannulation. The secondary outcome analyzed was time to decannulation.

RESULTS

Thirty-nine children were included in the study with median age 49 months; 61.5% were male. Children undergoing single stage revision surgery were far more likely to be decannulated (OR 6.25, 95% CI 1.33-45.97, p = 0.0343). Rolling logistic regression of the probability of decannulation stratified by time between open surgeries demonstrated significantly decreased chance of decannulation with reoperation within 6 months. Children managed with anterior/posterior grafting compared with a single graft were observed to have an increased time to decannulation, (HR 0.365, 95% CI 0.148-0.899, p = 0.005, Log-Rank).

CONCLUSION

We observe that in the case of revision pediatric open airway surgery, chance of decannulation is improved when surgery is performed in a single stage as well as 6 months after the most recent procedure. Patients and families should be counseled that complex stenosis requiring double stage procedures or anterior/posterior grafting is associated with a decreased probability of decannulation and increased postoperative time with a tracheostomy, respectively.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1926-1932, 2024.

Pediatric cochlear implantation: Early surgical intervention and parental quality of life

OBJECTIVES

Pediatric cochlear implantation (CI) provides sound perception to children with significant sensorineural hearing loss and, despite its challenging process, early implantation can enhance children's speech/language outcomes and potentially improve parental quality of life (PQoL). This study aims to examine parental perspectives on quality of life and parenting children with CI.

METHODS

This study combined retrospective chart review and parent reported outcomes. Data were abstracted from medical charts of 85 children who underwent CI between 2016 and 2022 at a tertiary pediatric hospital. Parents were administered the Acceptance and Action Questionnaire (AAQ-MCHL), an 8-item self-report assessment of quality of life for parents of children with CI. Multivariate linear regression analyses examined clinical factors associated with PQoL scores.

RESULTS

Parents whose children were implanted at less than two years of age reported significantly higher PQoL, indicated by lower AAQ scores, with a mean AAQ-MCHL of 7.6 + 5.7. In contrast, implantation at age >2 years yielded a mean AAQ-MCHL of 16.2 + 9.6. Parents interviewed within one year post-surgery reported lower PQoL, with a mean AAQ-MCHL of 12.3 + 8.8 compared to those interviewed after one year, with 20.5 + 10.4.

CONCLUSION

Early identification of profound hearing loss in children, coupled with early surgical CI, may be associated with higher parental quality of life. The beneficial outcomes appear to be potentiated over time. Further research is essential to fully comprehend the impact of CI on the quality of life of children and their parents.

PANEL 3: Otitis media animal models, cell culture, tissue regeneration & pathophysiology

OBJECTIVE

To review and summarize recently published key articles on the topics of animal models, cell culture studies, tissue biomedical engineering and regeneration, and new models in relation to otitis media (OM).

DATA SOURCE

Electronic databases: PubMed, National Library of Medicine, Ovid Medline.

REVIEW METHODS

Key topics were assigned to the panel participants for identification and detailed evaluation. The PubMed reviews were focused on the period from June 2019 to June 2023, in any of the objective subject(s) or keywords listed above, noting the relevant references relating to these advances with a global overview and noting areas of recommendation(s). The final manuscript was prepared with input from all panel members.

CONCLUSIONS

In conclusion, ex vivo and in vivo OM research models have seen great advancements in the past 4 years. From the usage of novel genetic and molecular tools to the refinement of in vivo inducible and spontaneous mouse models, to the introduction of a wide array of reliable middle ear epithelium (MEE) cell culture systems, the next five years are likely to experience exponential growth in OM pathophysiology discoveries. Moreover, advances in these systems will predictably facilitate rapid means for novel molecular therapeutic studies.

Laryngotracheal Reconstruction Outcomes in Children Born Extremely Premature

INTRODUCTION

There has been a notable increase in the number of neonates born 28 weeks gestational age or younger in the United States. Many of these patients require tracheostomy early in life and subsequent laryngotracheal reconstruction (LTR). Although extremely premature infants often undergo LTR, there is no known study to date examining their post-surgical outcomes.

OBJECTIVES

To compare decannulation rates, time to decannulation and complication rates between LTR patients born extremely premature to those born preterm and term.

METHODS

We identified 179 patients treated at a stand-alone tertiary children's hospital who underwent open airway reconstruction from 2008 to 2021. A Chi Squared test was used to detect differences in categorical clinical data between the groups of patients. A Mann-Whitney test was used to analyze continuous data within these same groups. Time to decannulation analysis was performed using Kaplan Meier analysis and evaluated with log-rank and Cox proportional hazards regression.

RESULTS

Children born extremely premature were more likely to incur complications following LTR (OR = 2.363, p = 0.005, CI 1.295-4.247). There was no difference in time to decannulation (p = 0.0543, Log-rank) or rate of decannulation (OR = 0.4985, p = 0.05, CI 0.2511-1.008). Extremely premature infants were more likely to be treated with an anterior and posterior grafts (OR = 2.471, p = 0.004, CI 1.297-4.535) and/or an airway stent (OR = 3.112, p < 0.001, CI 1.539-5.987).

CONCLUSION

Compared with all other patients, extremely premature infants have equivalent decannulation success, but are at an increased risk for complications following LTR.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3608-3614, 2023.

Otolaryngologic manifestations among MPOX patients: A systematic review and meta-analysis

PURPOSE

MPOX has numerous otolaryngologic presentations that have been recognized as clinically important, especially with the onset of the 2022 outbreak. However, how these features vary across region and outbreak have yet to be elucidated or supported by meta-analysis. The objective of this study is to identify the otolaryngologic manifestations of MPOX across previous and current outbreaks and among endemic and non-endemic regions.

BASIC PROCEDURES

Data sources of MEDLINE (PubMed), the Cochrane Library, Scopus, Embase, Web of Science, Google Scholar, and OpenGrey were searched through August 2022. All observational studies reporting data on laboratory-confirmed MPOX patients with otolaryngologic symptoms were included. Two authors independently performed the screening process while a third resolved disagreements. Data were extracted into a structured form by two authors independently. We performed a meta-analysis of the prevalence of otorhinolaryngologic symptoms using MetaXL software (version 5.3) under a random-effects model.

MAIN FINDINGS

38 studies with 5952 patients were included. The four most prevalent manifestations were headache at 31 % (95 % CI [0.16-0.49], I 2  = 99 %), sore throat at 22 % (95 % CI [0.09-0.37], I 2  = 99 %), cough at 16 % (95 % CI [0.05-0.30], I 2  = 99 %), and cervical lymphadenopathy at 10 % (95 % CI [0.01-0.26], I 2  = 100 %). Otolaryngologic features were more prevalent in previous outbreaks as compared to the 2022 outbreak including 37 % prevalence of headache (95 % CI [0.11-0.66], I 2  = 100 %), 33 % prevalence of cough (95 % CI [0.21-0.47], I 2  = 98 %), 27 % prevalence of sore throat (95 % CI [0.07-0.53], I 2  = 99 %), 15 % prevalence of cervical lymphadenopathy (95 % CI [0.00-0.428], I 2  = 100 %), 13 % prevalence of oral ulcers (95 % CI [0.02-0.30], I 2  = 99 %), 6 % prevalence of oral exanthem (95 % CI [0.00-0.17], I 2  = 99 %), 5 % prevalence of dysphagia (95 % CI [0.00-0.18], I 2  = 99 %), and 5 % prevalence of tonsillar signs (95 % CI [0.00-0.13], I 2  = 99 %). Features that were more prevalent in endemic areas versus non-endemic areas include 27 % prevalence of cough (95 % CI [0.14-0.41], I 2  = 99 %), 15 % prevalence of oral ulcers (95 % CI [0.02-0.36], I 2  = 99 %), 6 % prevalence of tonsillar signs (95 % CI [0.00-0.18], I 2  = 99 %), and 19 % prevalence of cervical lymphadenopathy (95 % CI [0.00-0.48], I 2  = 100 %), while the only feature more prevalent in non-endemic areas was headache with a prevalence of 36 % (95 % CI [0.24-0.47], I 2  = 96 %).

PRINCIPAL CONCLUSIONS

In this systematic review and meta-analysis, four symptoms - headache, sore throat, cough, and cervical lymphadenopathy - were found to be the most prevalent otolaryngologic features of MPOX. Otolaryngologic manifestations of MPOX were more pronounced in prior outbreaks and in endemic areas as compared to the 2022 outbreak and non-endemic areas. These findings may aid MPOX recognition in an otolaryngology setting.

Ensuring the future of otitis media research: Interest in and feasibility of a mentoring network program within the otitis media research community

OBJECTIVES

The goal of this study was to assess the feasibility of the implementation of a mentoring network program based on expressed interest and the diverse composition of the otitis media research community in order to address attrition of the scientific workforce.

METHODS

An online survey was sent to basic, translational, and clinical researchers with a known interest in otitis media.

RESULTS

Of 509 eligible participants, 119 (23.4%) responded to the survey. Survey respondents had a diverse background by completed education, current job description, and membership in an underrepresented group in science. Most faculty respondents (76.4%) were willing to participate in the proposed program as mentors and faculty lecturers, or had early-career researchers or trainees in their research group who were willing to participate as mentees in the mentoring network. Scientific and non-scientific topics for inclusion in the training program were ranked, with immunology and inflammation, microbiology, science leadership and collaboration, mentoring, and grantsmanship as main foci of interest among respondents.

CONCLUSION

Our survey results showed enthusiastic participation among responding otitis media researchers, indicating the feasibility of implementing a mentoring network program that will address workforce attrition, particularly among underrepresented groups in science.

Pediatric Otolaryngology fellowship virtual interview sentiments

BACKGROUND

Interviews for Pediatric Otolaryngology fellowship rapidly transitioned to virtual interviews mid-cycle in March 2020 due to the COVID-19 pandemic.

OBJECTIVE

This study aims to describe perspectives on virtual versus in-person interviews for both applicants and program directors.

METHODS

Cross-sectional study. Surveys were conducted of all Pediatric Otolaryngology fellowship applicants participating in the San Francisco Match and program directors in 2020 and 2021.

RESULTS

Out of 32 U.S. trained fellowship applicants, 24 completed the survey in 2020 and 18 in 2021. While 70% of applicants felt they did not get the same experience with virtual interviews, 75% did not feel it changed how they ranked programs. Applicant perception of virtual interviews improved in 2021, with the majority (56%) preferring virtual interviews if provided an option. Twenty out of 36 fellowship directors completed the survey in 2020, and eighteen in 2021. While fellowship directors continued to prefer in-person in 2021, an increased number (10% in 2020, 30% in 2021) felt continuing with virtual interviews may increase the number of applicants in the future.

CONCLUSION

Based on the survey, both applicants and fellowship directors had a less favorable perception of virtual interviews compared to in-person interviews initially; however, applicant perception favored virtual interviews in 2021, while Program Directors continued to prefer in-person.

ALDH1A2-related disorder: A new genetic syndrome due to alteration of the retinoic acid pathway

Aldehyde Dehydrogenase 1, Family Member A2 (ALDH1A2) is essential for the synthesis of retinoic acid from vitamin A. Studies in model organisms demonstrate a critical role for ALDH1A2 in embryonic development, yet few pathogenic variants are linked to congenital anomalies in humans. We present three siblings with multiple congenital anomaly syndrome linked to biallelic sequence variants in ALDH1A2. The major congenital malformations affecting these children include tetralogy of Fallot, absent thymus, diaphragmatic eventration, and talipes equinovarus. Upper airway anomalies, hypocalcemia, and dysmorphic features are newly reported in this manuscript. In vitro functional validation of variants indicated that substitutions reduced the expression of the enzyme. Our clinical and functional data adds to a recent report of biallelic ALDH1A2 pathogenic variants in two families with a similar constellation of congenital malformations. These findings provide further evidence for an autosomal recessive ALDH1A2-deficient recognizable malformation syndrome involving the diaphragm, cardiac and musculoskeletal systems.

Decannulation in Trisomy 21 patients undergoing laryngotracheal reconstruction

BACKGROUND

Down Syndrome (DS) patients are more susceptible to either congenital or acquired subglottic stenosis (SGS). This often creates a multilevel airway obstruction and can lead to tracheostomy dependence early in life. As a result, they may require Laryngotracheal Reconstruction (LTR) to achieve decannulation. The primary objective of this study was to assess decannulation rates, time to decannulation and potential barriers to decannulation in DS patients undergoing LTR.

METHODS

We performed a retrospective chart review from 2008 to 2021 of 193 children who underwent LTR for treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. The relationship between clinical data and decannulation status was evaluated using multivariable logistic regression and Fisher exact tests. Time to decannulation analysis was performed using Kaplan Meier analysis and evaluated with log-rank and Cox proportional hazards regression.

RESULTS

We determined that DS patients carry an inherit risk for decannulation failure compared to the general population (OR: 6.112, P = . 044, CI 1.046-35.730). Of the 8 patients with DS only three were decannulated. Overall, patients with Trisomy 21 had a significantly increased time to decannulation when compared to all LTR patients (P = .008, Log-rank). We found that these patients are more likely to have both suprastomal collapse (P = .0004, Fischer's Exact) and Tracheomalacia (P = .034, Fischer's Exact) compared to all other LTR patients. While post-operative tracheomalacia did not significantly affect decannulation failure (P = .056, Fischer's Exact) it did significantly prolong decannulation in all LTR patients (P = .018, Log-rank).

CONCLUSION

Trisomy 21 patients are at an increased risk for decannulation failure. Our study illustrates that these poor outcomes are likely a result of conditions more commonly found in this cohort including: narrow tracheal caliber, tracheomalacia and hypotonia.

Adaptive immune responses to SARS-CoV-2 persist in the pharyngeal lymphoid tissue of children

Most studies of adaptive immunity to SARS-CoV-2 infection focus on peripheral blood, which may not fully reflect immune responses at the site of infection. Using samples from 110 children undergoing tonsillectomy and adenoidectomy during the COVID-19 pandemic, we identified 24 samples with evidence of previous SARS-CoV-2 infection, including neutralizing antibodies in serum and SARS-CoV-2-specific germinal center and memory B cells in the tonsils and adenoids. Single-cell B cell receptor (BCR) sequencing indicated virus-specific BCRs were class-switched and somatically hypermutated, with overlapping clones in the two tissues. Expanded T cell clonotypes were found in tonsils, adenoids and blood post-COVID-19, some with CDR3 sequences identical to previously reported SARS-CoV-2-reactive T cell receptors (TCRs). Pharyngeal tissues from COVID-19-convalescent children showed persistent expansion of germinal center and antiviral lymphocyte populations associated with interferon (IFN)-γ-type responses, particularly in the adenoids, and viral RNA in both tissues. Our results provide evidence for persistent tissue-specific immunity to SARS-CoV-2 in the upper respiratory tract of children after infection.

Topical Delivery of Elastic Liposomal Vesicles for Treatment of Middle and Inner Ear Diseases

We present a topical drug delivery mechanism through the ear canal to the middle and inner ear using liposomal nanoparticles without disrupting the integrity of the tympanic membrane. The current delivery method provides a noninvasive and safer alternative to transtympanic membrane injections, ear tubes followed by ear drops administration, and systemic drug formulations. We investigate the capability of liposomal NPs, particularly transfersomes (TLipo), used as drug delivery vesicles to penetrate the tympanic membrane (TM) and round window membrane (RWM) with high affinity, specificity, and retention time. The TLipo is applied to the ear canal and found to pass through the tympanic membrane quickly in 3 h post drug administration. They are identified in the middle ear cavity 6 h and in the inner ear 24 h after drug administration. We performed cytotoxicity in vitro and ototoxicity in vivo studies. Cell viability shows no significant difference between the applied TLipo concentration and control. Furthermore, auditory brainstem response (ABR) reveals no hearing loss in 1 week and 1 month post-administration. Immunohistochemistry results demonstrate no evidence of hair cell loss in the cochlea at 1 month following TLipo administration. Together, the data suggested that TLipo can be used as a vehicle for topical drug delivery to the middle ear and inner ear.

Ceftriaxone use for acute otitis media: Associated factors in a large U.S. primary care population

BACKGROUND

Clinicians in the authors' primary care academic practice have anecdotally perceived an increased use of intramuscular (IM) ceftriaxone, particularly for otitis-conjunctivitis in recent years (pre-pandemic). Increasing rates of ceftriaxone administration for acute otitis media (AOM) may be an important marker of antimicrobial resistance.

OBJECTIVE

We aimed to characterize the population of patients who received ceftriaxone for treatment of AOM, testing our hypothesis that patients with concomitant conjunctivitis would have increased rates of ceftriaxone receipt.

DESIGN/METHODS

We reviewed cases of AOM at a large U.S. primary care practice from August 2017 to July 2019. We determined the association between each of the following variables and ceftriaxone injection using multivariate analysis: age at AOM diagnosis, provider type, insurance (public vs private), season of year, and presence of conjunctivitis.

RESULTS

There were 6028 AOM episodes in 5195 patients resulting in a total of 7688 patient encounters. Of these episodes, 642 (10.7%) had a concurrent diagnosis of conjunctivitis; 362 (6.0%) ultimately received ceftriaxone. Conjunctivitis was the strongest predictor of treatment with ceftriaxone. The proportion of episodes with conjunctivitis treated with ceftriaxone was 14.5% (93/642) versus 5.0% (269/5386) without conjunctivitis (p < 0.0001). Patients who received ceftriaxone were younger; mean age (SD) for patients receiving ceftriaxone was 14.0 (8.8) months versus 25.0 (23.4) months (p < 0.0001).

CONCLUSION(S)

There is a strong correlation between the presence of conjunctivitis and receipt of IM ceftriaxone in this large U.S. academic primary care clinic. Younger age was also associated with ceftriaxone treatment. Further study on emerging resistance patterns and implications for management of AOM in young children is warranted.

Characteristics of acute otitis media in primary care are associated with tympanostomy tube outcomes

Objective

To identify characteristics of acute otitis media (AOM) at primary care presentation associated with TT placement and outcomes.

Methods

A retrospective cohort study of pediatric patients (birth—12 years old) with AOM at an academic primary care pediatric practice and affiliated tertiary referral free‐standing Children's hospital from August 1, 2017 to December 31, 2019 was performed. The outcomes measured were TT placement, postoperative otorrhea, need for additional tube placement, and other complications (i.e., perforation and/or granulation).

Results

The 3189 patients were included, 484 of whom were referred to otolaryngology. Multivariate logistic regression analysis revealed that a greater number of AOM episodes diagnosed at primary care was associated with tube placement (OR = 1.21; 95% CI, 1.04–1.41, p = .02). Of the 336 patients who received tubes, older age at first AOM diagnosis was associated with postoperative otorrhea (OR = 1.02; 95% CI, 1.01–1.03; p = .001) and additional tube placement (OR = 1.03; 95% CI, 1.02–1.04; p < .001). Older age was also associated with other complications (OR = 1.02; 95% CI, 1.01–1.03; p = .001) by univariate analysis. Additionally, postoperative otorrhea was more common among patients who first received an AOM diagnosis at primary care in the spring (OR = 2.69; 95% CI, 1.37–5.29; p = .004), summer (OR = 2.88; 95% CI, 1.46–5.69; p = .002), and fall (OR = 2.18; 95% CI, 1.20–3.96; p = .01) seasons.

Conclusions

Clinical data from pediatric primary care visits found older age at first AOM diagnosis and having a first AOM diagnosis outside of winter to be associated with a more complicated eventual disease course.

Level of evidence

3—cohort study.

Underinsurance in children is associated with worsened quality of life after cochlear implantation

IMPORTANCE

Research has suggested that early cochlear implantation is associated with improved language outcomes. Select studies demonstrate that this translates into a higher quality of life following implantation. Previous work from our group has shown that underinsurance represents a risk factor for worsened auditory and language outcomes for implantees. However, to our knowledge, the effect of insurance status on quality of life outcomes following cochlear implantation has not been evaluated.

OBJECTIVE

To assess quality of life outcomes for children receiving cochlear implants, accounting for age at implantation, insurance status, gender, surgeon, number of implants and duration of follow-up since implantation.

DESIGN

A retrospective study using the Glasgow Children's Benefit Inventory (GCBI), a validated questionnaire measuring quality of life across four domains: learning, emotion, vitality and physical heath. Multivariate linear regression was used to examine the effects of age at implantation, insurance status, number of implants, sex, surgeon, and duration of follow-up on GCBI scores. Age at implantation was assessed as both a continuous and dichotomous variable, comparing children implanted by 12 months of age with those implanted after 12 months.

SETTING

Children's National Health System in Washington, DC, a tertiary academic referral center.

PARTICIPANTS

The GCBI was administered telephonically to parents/guardians of prelingually deaf children aged 2-16 years who received cochlear implants at the center between January 1, 2008 and December 31, 2018.

RESULTS

Of 169 prelingually deafened implantee children who met inclusion criteria, parents/guardians of 64 (37.9%) responded to the questionnaire. After excluding children with late implantation (≥7 years age at CI) and missing GCBI responses, the final analytic sample consisted of 57 children. The mean age (SD) of the children at the time of the study was 3.3 (1.9) years, 63.2% were publicly insured, and 73.7% were implanted after 12 months of age. Average duration of follow-up was 3.9 (2.8) years. On a scale of -100 to +100, GCBI scores ranged from 41.7 to 95.8 (mean (SD), 64.0 (10.3)). Public health insurance (β, -5.8 [95% CI, -10.6 to -0.01]), and older age at the time of implantation (β, -0.1 [95% CI, -0.3 to 0.0]), particularly implantation following 12 months of age (p < 0.05), were significantly associated with lower GCBI scores after implantation.

CONCLUSION

Publicly insured recipients of cochlear implants and children implanted at an older age, particularly after 12 months of age, experienced significantly lower quality of life measures.

Robust, persistent adaptive immune responses to SARS-CoV-2 in the oropharyngeal lymphoid tissue of children

SARS-CoV-2 infection triggers adaptive immune responses from both T and B cells. However, most studies focus on peripheral blood, which may not fully reflect immune responses in lymphoid tissues at the site of infection. To evaluate both local and systemic adaptive immune responses to SARS-CoV-2, we collected peripheral blood, tonsils, and adenoids from 110 children undergoing tonsillectomy/adenoidectomy during the COVID-19 pandemic and found 24 with evidence of prior SARS-CoV-2 infection, including detectable neutralizing antibodies against multiple viral variants. We identified SARS-CoV-2-specific germinal center (GC) and memory B cells; single cell BCR sequencing showed that these virus-specific B cells were class-switched and somatically hypermutated, with overlapping clones in the adenoids and tonsils. Oropharyngeal tissues from COVID-19-convalescent children showed persistent expansion of GC and anti-viral lymphocyte populations associated with an IFN-γ-type response, with particularly prominent changes in the adenoids, as well as evidence of persistent viral RNA in both tonsil and adenoid tissues of many participants. Our results show robust, tissue-specific adaptive immune responses to SARS-CoV-2 in the upper respiratory tract of children weeks to months after acute infection, providing evidence of persistent localized immunity to this respiratory virus.

Round window anatomy predicts ease of cochlear implantation in children

OBJECTIVES

We aim to evaluate the utility of the Round Window Angle (RWA) as a predictor of difficulty and operative time in cochlear implantation.

METHODS

A retrospective study of pediatric patients that underwent cochlear implantation and CT temporal bone imaging from January 2008 to November 2019. Correlation, univariate, and multivariate analysis were conducted.

RESULTS

347 implantations met inclusion criteria. We found a difference in RWA for difficult (median: 101°, n = 5) and non-difficult (median: 74, n = 317) implantations (p < 0.0001). There was also a difference in RWA in patients with round windows visualized intra-operatively (p < 0.0197). When controlling for age and intraoperative round window visualization, logistic regression showed RWA was significantly associated with difficult insertion (OR: 1.687; p = 0.0246). Further, there was positive correlation between RWA and operative time (r = 0.1779, p = 0.0013) with patients with acute RWAs having shorter operative times (mean 115.7 ± 32.1 min) than those with obtuse RWA (mean 183.5 ± 97.0 min) (p = 0.0035). When accounting for surgeon and patient age, multivariate linear regression showed round window visualization (β = 3.456, p = 0.0006) and obtuse RWA (β = 6.172, p < 0.0001) was associated with an increase in operative time.

CONCLUSION

Further research is needed to identify difficult cochlear implantations to increase the success and reduce risks associated with the surgery. Our study reports the possibility that an obtuse RWA both significantly increases difficulty and time of operation due to decreased round window visualization.

Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media

BACKGROUND

Official recommendations differ regarding tympanostomy-tube placement for children with recurrent acute otitis media.

METHODS

We randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment. The primary outcome was the mean number of episodes of acute otitis media per child-year (rate) during a 2-year period.

RESULTS

In our main, intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P = 0.66). Because 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, we conducted a per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively. Among secondary outcomes in the main analysis, results were mixed. Favoring tympanostomy-tube placement were the time to a first episode of acute otitis media, various episode-related clinical findings, and the percentage of children meeting specified criteria for treatment failure. Favoring medical management was children's cumulative number of days with otorrhea. Outcomes that did not show substantial differences included the frequency distribution of episodes of acute otitis media, the percentage of episodes considered to be severe, and antimicrobial resistance among respiratory isolates. Trial-related adverse events were limited to those included among the secondary outcomes of the trial.

CONCLUSIONS

Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. (Funded by the National Institute on Deafness and Other Communication Disorders and others; ClinicalTrials.gov number, NCT02567825.).

Effects of Premedication With Midazolam on Recovery and Discharge Times After Tonsillectomy and Adenoidectomy

Background

Midazolam is commonly used preoperatively for anxiety. Adverse effects data in pediatric patients with obstructive sleep apnea (OSA) undergoing tonsillectomy and adenoidectomy (T&A) is limited.

Aims

We hypothesized that preoperative midazolam increases the time to emergence from anesthesia and postoperative discharge. Secondary objectives assessed if patients receiving midazolam experienced increased side effects or complications from treatment.

Methods

This study was a retrospective chart review of patients undergoing T&A from July 2014 to December 2015. Midazolam receiving patients (midazolam group: MG) were compared to patients who did not (non-midazolam group: NMG). Multivariable analyses were performed and adjusted for predefined potential cofounder variables.

Results

Emergence and discharge times were 5.2 minutes (95% CI [-7.1, 17.4]; p=0.41) and 10.1 minutes (95% CI [-6.7, 26.8]; p=0.24) longer in MG. These results were not statistically significant. Comparing by OSA status, there was no statistical difference in emergence and discharge times between mild, moderate and severe OSA groups or between MG and NMG within each OSA group. Emergence and discharge times in moderate OSA was 6.1 minutes (95% CI [-17.6, 29.8]; p=0.61) and 18.8 minutes (95% CI [-16.4, 53.9]; p=0.29) longer than mild OSA, and in the severe OSA group, 2.6 minutes (95% CI [-19.9, 25.1]; p=0.82) shorter and 2.8 minutes (95% CI [-30.3, 35.9]; p=0.87) longer. The incidence of postoperative complications was comparable between MG and NMG groups.

Conclusions

Premedication with midazolam was not associated with prolonged emergence or discharge time or higher incidence of complications after anesthesia for T&A in patients with OSA.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Delphi method-based survey series.

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E1941-E1949, 2021.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Blinded modified Delphi consensus process.

SETTING

Tertiary care center.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Review of otitis media microbiome studies: What do they tell us?

OBJECTIVES

To provide a state of the art review on accruing studies focused on defining the middle ear microbiome, highlighting the relationship of the microbiome to disease pathophysiology.

DATA SOURCES

Pubmed indexed peer-reviewed articles and published textbooks.

REVIEW METHODS

Comprehensive review of the literature using the following search terms: "microbiome" "bacterial pathogens" with the term "otitis media," and "middle ear."

RESULTS

A multitude of microbiome studies have been published in the recent past. In general findings from these studies underscore distinct profiles based on disease category. The adenoidal reservoir theory may not explain all etiologies of middle ear effusion production. The host immune system appears to be associated to the bacterial population identified in the middle ear space. Atopic respiratory diseases correlate to the middle ear microbiome. Some novel middle ear bacterial genera may be protective in terms of disease.

CONCLUSION

The understanding of otitis media disease progression pathophysiology is evolving, informed by accruing middle ear microbiomic data. The functional implications of middle ear microbiome findings need to be studied further. This may help counterbalance probiotic vs antibiotic approaches to disease mitigation.

Retained Tympanostomy Tubes: Who, What, When, Why, and How to Treat?

BACKGROUND

Tympanostomy tube placement is one of the most common surgical procedures performed across the globe. Controversies exist regarding what to do when a tube is considered to be retained in the tympanic membrane for too long.

MATERIALS AND METHODS

Review of the PubMed medical literature starting in 1990, focusing on English language studies reporting on the definition, complications, and management of retained tympanostomy tubes.

RESULTS

The medical literature reporting on outcomes regarding retained tympanostomy tubes is relatively sparse. Most studies recommend prophylactic removal of tubes after a defined period of time, usually around 2 to 3 years after placement. A preferred method of myringoplasty after tympanostomy tube retrieval has not been established, but most studies recommend grafting the perforation at the time of tube removal.

CONCLUSIONS

Although a consensus as to the optimal management of retained tympanostomy tubes is not yet established in the medical literature, a preponderance of studies recommend prophylactic removal at defined period of time (>2-3 years) before the onset of complications such as otorrhea and granulation tissue formation. Due to a lack of best evidence, the surgeon's preference remains the guiding principle as to the best technique for myringoplasty at the time of removal.

MUC5B induces in vitro neutrophil extracellular trap formation: Implication in otitis media

BACKGROUND

Chronic otitis media (COM) is characterized by middle ear fluid predominantly containing cytokines, Nontypeable haemophilus influenzae (NTHi), the mucin MUC5B, and neutrophil extracellular traps (NETs). NETs consist of extracellular DNA coated with antibacterial proteins such as myeloperoxidase (MPO) and citrullinated histone 3 (CitH3). NETs can damage tissues and sustain inflammation. Our study aimed to develop an in vitro model of NETosis, testing COM inductors.

METHODS

NETosis was evaluated in fresh blood human neutrophils attached to collagen-coated plates and in suspension exposed to phorbol myristate acetate (PMA) as a control, and COM relevant mediators. Confocal microscopy, DNA fluorescence assay and flow cytometry were used to quantify NETosis.

RESULTS

PMA exposure induced DNA, MPO, and CitH3 by immunofluorescence (IF) most significantly at 3 hours (3.8-fold for DAPI, 7.6-fold for MPO, and 6.9-fold for CitH3, all P < .05). IL-8 and TNF-α cytokines showed milder increases of DAPI, MPO, and CitH3 positive cells. NTHi had no effect on these NETs markers. Purified salivary MUC5B (10 to 40 μg/mL) produced potent increases, comparable to PMA. A composite NET score summing the fold-increases for DAPI, MPO, and CitH3 demonstrated PMA at 13.6 to 19 relative to control set at 1; and MUC5B at 8.6 to 16.3 (all P < .05). IL-8 and TNF-α showed scores of 5.4 and 3, respectively, but these were not statistically significant.

CONCLUSION

We developed a reliable in vitro assay for NETosis which demonstrated that salivary MUC5B is a potent inductor of NETs whereas IL-8, TNF-α, live and lyzed NTHi demonstrated minimal to no NETosis.

LEVEL OF EVIDENCE

NA.

Panel 7 - Pathogenesis of otitis media - a review of the literature between 2015 and 2019

OBJECTIVE

To perform a comprehensive review of the literature from July 2015 to June 2019 on the pathogenesis of otitis media. Bacteria, viruses and the role of the microbiome as well as the host response are discussed. Directions for future research are also suggested.

DATA SOURCES

PubMed database of the National Library of Medicine.

REVIEW METHODS

PubMed was searched for any papers pertaining to OM pathogenesis between July 2015 and June 2019. If in English, abstracts were assessed individually for their relevance and included in the report. Members of the panel drafted the report based on these searches and on new data presented at the 20th International Symposium on Recent Advances in Otitis Media.

CONCLUSIONS

The main themes that arose in OM pathogenesis were around the need for symptomatic viral infections to develop disease. Different populations potentially having different mechanisms of pathogenesis. Novel bacterial otopathogens are emerging and need to be monitored. Animal models need to continue to be developed and used to understand disease pathogenesis.

IMPLICATIONS FOR PRACTICE

The findings in the pathogenesis panel have several implications for both research and clinical practice. The most urgent areas appear to be to continue monitoring the emergence of novel otopathogens, and the need to develop prevention and preventative therapies that do not rely on antibiotics and protect against the development of the initial OM episode.

Panel 2- recent advance in otitis media bioinformatics

OBJECTIVES

To update the medical literature on recent large-scale studies employing bioinformatics data analysis tools in otitis media (OM) disease models with a principal focus on developments in the past 5 years.

DATA SOURCES

Pubmed indexed peer-reviewed articles.

REVIEW METHODS

Comprehensive review of the literature using the following search terms: 'genomics, inflammasome, microRNA, proteomics, transcriptome, bioinformatics' with the term 'otitis media', and 'middle ear'. Included articles published in the English language from January 1, 2015-April 1, 2019.

IMPLICATIONS FOR PRACTICE

Large scale bioinformatics tools over the past five years lend credence to the paradigm of innate immune response playing a critical role in host defense against bacteria contributing to Otitis Media (OM) progression from acute to chronic. In total, genomic, miRNAomic, and proteomic analyses all point to the need for a tightly regulated innate immune and inflammatory response in the middle ear. Currently, there is an urgent need for developing novel therapeutic strategies to control immunopathology and tissue damage, improve hearing and enhance host defense for both acute and chronic OM based on full understanding of the basic molecular pathogenesis of OM.

Sedation withdrawal following single stage laryngotracheal reconstruction: Does dexmedetomidine help?

OBJECTIVES

Single-stage laryngotracheal reconstruction (SS-LTR) requires a period of post-operative intubation, during which time adequate sedation is needed to ensure graft healing. Commonly used agents include benzodiazepines, opioids, and more recently, dexmedetomidine, a centrally-acting α₂ adrenoreceptor. This study aims to compare withdrawal outcomes between various sedation regimens following SS-LTR.

METHODS

Retrospective chart review of 56 patients who underwent SS-LTR between 2008 and 2018 at a tertiary free-standing children's hospital was performed. Of 47 patients with complete records, 18 patients received dexmedetomidine for >75% of their intubation period with midazolam (DexWM), 9 received dexmedetomidine for >75% without midazolam (DexWOM), and 20 received dexmedetomidine for <75% with midazolam (noDex).

RESULTS

There was no significant difference in length of PICU or hospital stay between the groups. The noDex group trended toward a higher re-intubation rate of 25%, as compared with 11% of DexWOM and 5.6% of DexWM (p = 0.21). There was no significant difference in days of oral sedation taper required or Withdrawal Assessment Tool (WAT-1) score for post-extubation days 1 and 3. By post-extubation day 5, 100% of the DexWM group had WAT-1 scores <3 as compared with 71.4% of the noDex group (p = 0.037). Notably, lower average daily doses of dexmedetomidine and midazolam were used in the DexWM group, as compared with the DexWOM and noDex groups, respectively.

CONCLUSION

Dexmedetomidine as a primary sedation agent with midazolam allows for adequate sedation following SS-LTR. The combination of the two drugs in the DexWM group not only reduced the dosage of each drug needed, but also significantly improved WAT-1 scores by post-extubation day 5, as compared with the alternative sedation regimens.

Otitis Media Middle Ear Effusion Identification and Characterization Using an Optical Coherence Tomography Otoscope

OBJECTIVE

To determine the feasibility of detecting and differentiating middle ear effusions (MEEs) using an optical coherence tomography (OCT) otoscope.

STUDY DESIGN

Cross-sectional study.

SETTING

US tertiary care children's hospital.

SUBJECTS AND METHODS

Seventy pediatric patients undergoing tympanostomy tube placement were preoperatively imaged using an OCT otoscope. A blinded reader quiz was conducted using 24 readers from 4 groups of tiered medical expertise. The primary outcome assessed was reader ability to detect presence/absence of MEE. A secondary outcome assessed was reader ability to differentiate serous vs nonserous MEE.

RESULTS

OCT image data sets were analyzed from 45 of 70 total subjects. Blinded reader analysis of an OCT data subset for detection of MEE resulted in 90.6% accuracy, 90.9% sensitivity, 90.2% specificity, and intra/interreader agreement of 92.9% and 87.1%, respectively. Differentiating MEE type, reader identification of nonserous MEE had 70.8% accuracy, 53.6% sensitivity, 80.1% specificity, and intra/interreader agreement of 82.9% and 75.1%, respectively. Multivariate analysis revealed that age was the strongest predictor of OCT quality. The mean age of subjects with quality OCT was 5.01 years (n = 45), compared to 2.54 years (n = 25) in the remaining subjects imaged (P = .0028). The ability to capture quality images improved over time, from 50% to 69.4% over the study period.

CONCLUSION

OCT otoscopy shows promise for facilitating accurate MEE detection. The imageability with the prototype device was affected by age, with older children being easier to image, similar to current ear diagnostic technologies.

Quality of life outcomes following velopharyngeal insufficiency surgery

OBJECTIVES

Velopharyngeal insufficiency (VPI) may be due to functional or anatomic causes, and can lead to speech deficits, communication difficulty, and emotional strain on patients and their caregivers. The VPI Effects on Life Outcomes (VELO) instrument quantifies quality of life outcomes in VPI patients both before and after VPI surgery. This study aims to identify pre-operative patient characteristics associated with better post-operative quality of life.

METHODS

This study is a retrospective chart review of 51 patients who underwent VPI surgery between 2009 and 2018 at a tertiary free-standing children's hospital. A 26-item parent-proxy VELO questionnaire was administered by telephone to parents to assess their child's quality of life post-VPI surgery.

RESULTS

Twenty-seven parents responded to the VELO questionnaire. Average post-operative VELO score was significantly higher in non-syndromic patients as compared with syndromic patients. Average post-operative VELO score was not significantly different between patients with and without submucous cleft (SMC) or those with mild to moderate versus severe pre-operative hypernasality. On multivariate analysis, absence of genetic syndrome, lack of submucous cleft, and presence of severe-pre-operative hypernasality were significantly and positively associated with increased post-operative VELO scores.

CONCLUSION

Children who undergo VPI surgery are more likely to have better post-operative quality of life outcomes if their VPI was not associated with a genetic syndrome or submucous cleft. Non-syndromic and non-SMC patients with severe pre-operative hypernasality may benefit significantly from VPI surgery and have improved post-operative quality of life.

Index of pediatric voice handicap: Translation, transculturalization and validation to Argentinian Spanish

OBJECTIVE

Voice disorders are very common in the pediatric population, with 6% and 23% of all children presenting with some form of dysphonia [1,2]. For many years, these patients have been underdiagnosed. There has been increasing awareness and interest in the study of voice alterations in children, and, most importantly, their impact in their quality of life. To do this, an instrument capable of measuring the quality of life in pediatric patients with vocal pathology is required, which can be used extensively in the scientific community. The objective of our study is to carry out the translation, transculturalization and validation of pVHI (Pediatric Voice Handicap Index) to Argentinian Spanish-speakers.

MATERIAL AND METHODS

A study was carried out in the Hospital de Pediatria Dr. JP Garrahan in the city of Buenos Aires, Argentina. It included patients between 3 and 18 years old. The pVHI was translated and transculturalized for said population and for its validation, a survey was carried out in two groups of patients: one group being children with a background of both reconstructive larynx surgery, and dysphonia (n = 35) and the other group being control patients, without any voice pathology (n = 35). The survey was conducted among either parents or caregivers of the children in question.

RESULTS

A significant difference was found between both groups, for both overall pVHI score and survey subgroups score (p < 0.001) with an optimal internal confidence and a good Alpha Cronbach for each of the subgroups (functional 0,92; organic 0,87 and emotional 0,88). Test-retest for reliability revealed "p-values" without any significant difference (p > 0.05) for each of all subgroups (functional 0,68; organic 0,32 and emotional 0,72).

CONCLUSION

The validation and transculturalization of the rate of pediatric vocal impairment to Argentinian Spanish population presented an adequate validity and reliability. The rate of pediatric vocal impairment was identified through this simple and practical survey, offering additional information on the child's own vocal perception by part of the caregiver. We recommend this survey being included as a valuable tool in the evaluation of pediatric dysphonia in Spanish-speaking families.

Human primary middle ear epithelial cell culture: A novel in vitro model to study otitis media

Objectives

Otitis media (OM) is a ubiquitous pediatric disease leading to a significant health care burden. There is no medication beneficial to resolving COM fluid, highlighting the need for research in the field. Crucially, current human middle ear epithelial cell models are transformed cells not recapitulating physiological functions. Herein, we describe a new method to proliferate and differentiate pediatric primary middle ear epithelial cells (pMEEC) from patients as a physiological model for the study of OM.

Methods

We adapted a cell reprogramming protocol using irradiated fibroblast feeder medium in addition to Rho kinase inhibitor to proliferate pMEEC collected during cochlear implant surgery. Cells were plated on transwell membranes, proliferated with conditionally reprogrammed culture medium, and transferred to air–liquid interface (ALI). Cultures were maintained for 4 weeks at ALI, photos were taken and cell lysates and secretions were collected over time for characterization analysis using quantitative polymerase chain reaction, Western bolt, and proteomics. Keratins, MUC5B and MUC5AC mucins, and beta tubulin (TUBB) were analyzed at the mRNA and protein level.

Results

Cultures took a mean of 2 weeks to proliferate before transwell plating and forming a tight epithelium at ALI from 2 to 4 weeks. Although mRNA expression of MUC5B, MUC5AC, TUBB, and keratin 5 (KRT5) were variable depending on the differentiation stage and the patient, both TUBB and KRT5 proteins were detected until week 2.

Conclusion

We demonstrate a novel method to proliferate and differentiate pMEECs that express epithelial markers and that are able to secrete mucins for the study of OM.

Level of Evidence

NA

Altered Middle Ear Microbiome in Children With Chronic Otitis Media With Effusion and Respiratory Illnesses

Chronic otitis media with effusion (COME) is a common childhood disease characterized by an accumulation of fluid behind the eardrum. COME often requires surgical intervention and can also lead to significant hearing loss and subsequent learning disabilities. Recent characterization of the middle ear fluid (MEF) microbiome in pediatric patients has led to an improved understanding of the microbiota present in the middle ear during COME. However, it is not currently known how the MEF microbiome might vary due to other conditions, particularly respiratory disorders. Here, we apply an amplicon sequence variant (ASV) pipeline to MEF 16S rRNA high-throughput sequencing data from 50 children with COME (ages 3–176 months) undergoing tube placement. We achieve a more detailed taxonomic resolution than previously reported, including species and genus level resolution. Additionally, we provide the first report of the functional roles of the MEF microbiome and demonstrate that despite high taxonomic diversity, the functional capacity of the MEF microbiome remains uniform between patients. Furthermore, we analyze microbiome differences between children with COME with and without a history of lower airway disease (i.e., asthma or bronchiolitis). The MEF microbiome was less diverse in participants with lower airway disease than in patients without, and phylogenetic β-diversity (weighted UniFrac) was significantly different based on lower airway disease status. Differential abundance between patients with lower airway disease and those without was observed for the genera Haemophilus, Moraxella, Staphylococcus, Alloiococcus, and Turicella. These findings support previous suggestions of a link between COME and respiratory illnesses and emphasize the need for future study of the middle ear and respiratory tract microbiomes in diseases such as asthma and bronchiolitis.

Airway Papillomatosis: New Treatments for an Old Challenge

Recurrent respiratory papillomatosis (RRP) is the recurrent growth of small, benign tumors, or papillomas, in the respiratory tract, caused by human papillomavirus (HPV). Currently, there is no cure. Palliative treatments seek to prevent airway obstruction, keep underlying tissues healthy, and maintain voice quality. The most common intervention, the local surgical removal of papillomas, may be inadequate as a standalone treatment for pediatric populations that experience rapid papilloma regrowth, as repeated surgeries cause increased damage to the surrounding tissues and impose significant emotional and economic burden on families. Interferon α and Cidofovir have been shown to lengthen the time between surgical interventions and/or decrease the total number of procedures needed, although the evidence of their efficacy and safety is controversial. Novel therapies, including photodynamic therapy, indole-3-carbinol, anti-reflux medication, heat shock protein, and Mumps and HPV vaccination, may provide potential avenues for treatment, but require further research. Among all the novel therapies investigated, systemic bevacizumab seems to offer the most promising alternative to surgery. Randomized control trials to investigate its impact, especially in a pediatric population, should be conducted before implementing it as a standard form of care. This review will summarize the latest literature on medical care for aggressive RRP disease.

Characterization of mucoid and serous middle ear effusions from patients with chronic otitis media: implication of different biological mechanisms?

BACKGROUND

Chronic otitis media with effusion (COME) is characterized by persistent middle ear effusions that are in most cases highly viscous, but some patients present with serous fluid. This study aimed at comprehensively characterizing the macromolecular composition of mucoid vs. serous middle ear effusions (MEEs).

METHODS

MEEs from patients with COME were analyzed for proteins by mass spectrometry (MS) and western blot techniques, total DNA quantity, bacterial DNA (16S sequencing), and cytokine content. Proteomics datasets were studied in Ingenuity Pathway Analysis (IPA).

RESULTS

Mucoid samples showed a global tendency of increased pro-inflammatory mediators. Interleukin-1β (IL-1β) and IL-10 were significantly more abundant in serous samples (p < 0.01). Mucoid samples had higher DNA quantity (p = 0.04), more likely to be positive in MUC5B protein (p = 0.008) and higher peptide counts (12,786 vs. 2225), as well as an overall larger number of identified proteins (331 vs. 177), compared to serous. IPA found the mucoid sample dataset to be related to immune cell function and epithelial remodeling, whereas the serous sample dataset showed acute responses and blood-related proteins. Interestingly, serous samples showed more bacterial DNA than mucoid ones, with less bacterial genera variability.

CONCLUSION

This study demonstrates divergent immune responses in children with COME by effusion quality.

Changes in biofilm in chronic cholesteatomatous otitis media in children following the application of sodium 2-mercaptoethanesulfonate (MESNA)

BACKGROUND

Pediatric cholesteatoma is a clinically challenging disease entity. Its biological behavior in the pediatric population differs from its behavior in adult population in terms of aggressiveness and recurrence. Several studies have shown the presence of biofilms associated with cholesteatoma that hinder the management and eradication of the infection. This led is to study the use of non-antimicrobial treatments impacting on the structure or composition of biofilms.

OBJECTIVE

To evaluate the changes that occur in the biofilm of cholesteatoma in pediatric patients after the application of sodium 2-mercaptoethanesulfonate (MESNA).

METHODS

A pilot study of 10 pediatric patients, with a median age of 10 years and a diagnosis of cholesteatomatous chronic otitis media, who underwent surgery for primary or revision mastoidectomy in the Otorhinolaryngology Service of the Hospital Infantil de México Federico Gómez between January 2016 and May 2017. During the surgery, basal samples of cholesteatoma and tissue were taken after topical application of 4% MESNA for 10 min. The samples were then processed for confocal laser microscopy.

RESULTS

In all samples structures compatible with bacterial biofilms were identified. The most relevant finding was the changes in the structure of the biofilm after the application of MESNA, such as disintegration and separation of the underlying tissue.

CONCLUSIONS

This is the first study that showing changes associated with cholesteatoma in the structure of the bacterial biofilm after the application of MESNA. The observed disintegration of cholesteatoma biofilm ultrastructure could aid in the management of the chronic infection associated with cholesteatoma.

Nontypeable Haemophilus influenzae lysates increase heterogeneous nuclear ribonucleoprotein secretion and exosome release in human middle-ear epithelial cells

Nontypeable Haemophilus influenzae (NTHi), one of the most common acute otitis media (OM) pathogens, is postulated to promote middle-ear epithelial remodeling in the progression of OM from acute to chronic. The goal of this study was to examine early quantitative proteomic secretome effects of NTHi lysate exposure in a human middle-ear epithelial cell (HMEEC) line. NTHi lysates were used to stimulate HMEEC, and conditional quantitative stable isotope labeling with amino acids in cell culture of cell secretions was performed. Mass spectrometry analysis identified 766 proteins across samples. Of interest, several heterogeneous nuclear ribonucleoproteins (hnRNPs) were regulated by NTHi lysate treatment, especially hnRNP A2B1 and hnRNP Q, known to be implicated in microRNA (miRNA) packaging in exosomes. After purification, the presence of exosomes in HMEEC secretions was characterized by dynamic light scattering (<100 nm), transmission electron microscopy, and CD63/heat shock protein 70 positivity. hnRNP A2B1 and hnRNP Q were confirmed to be found in exosomes by Western blot and proteomic analysis. Finally, exosomal miRNA content comprised 110 unique miRNAs, with 5 found to be statistically induced by NTHi lysate (miR-378a-3p + miR-378i, miR-200a-3p, miR-378g, miR30d-5p, and miR-222-3p), all known to target innate immunity genes. This study demonstrates that NTHi lysates promote release of miRNA-laden exosomes from middle-ear epithelium in vitro. -Val, S., Krueger, A., Poley, M., Cohen, A., Brown, K., Panigrahi, A., Preciado, D. Nontypeable Haemophilus influenzae lysates increase heterogeneous nuclear ribonucleoprotein secretion and exosome release in human middle-ear epithelial cells.

Conditional reprogramming of pediatric airway epithelial cells: A new human model to investigate early-life respiratory disorders

BACKGROUND

Airway epithelial cells (AEC) are quite difficult to access in newborns and infants. It is critically important to develop robust life-extended models to conduct translational studies in this age group. We propose the use of a recently described cell culture technology (conditionally reprogrammed cells-CRC) to generate continuous primary cell cultures from nasal and bronchial AEC of young children.

METHODS

We collected nasal and/or bronchial AEC from a total of 23 subjects of different ages including newborns/infants/toddlers (0-2 years; N = 9), school-age children (4-11 years; N = 6), and a group of adolescent/adult donors (N = 8). For CRC generation, we used conditioned medium from mitotically inactivated 3T3 fibroblasts and Rho-associated kinase (ROCK) inhibitor (Y-27632). Antiviral immune responses were studied using 25 key antiviral genes and protein production of type III epithelial interferon (IFN λ1) after double-stranded (ds) RNA exposure.

RESULTS

CRC derived from primary AEC of neonates/infants and young children exhibited: (i) augmented proliferative capacity and life extension, (ii) preserved airway epithelial phenotype after multiple passages, (iii) robust immune responses characterized by the expression of innate antiviral genes and parallel nasal/bronchial production of IFN λ1 after exposure to dsRNA, and (iv) induction of airway epithelial inflammatory and remodeling responses to dsRNA (eg, CXCL8 and MMP9).

CONCLUSION

Conditional reprogramming of AEC from young children is a feasible and powerful translational approach to investigate early-life airway epithelial immune responses in humans.

Association of Recurrence of Infected Congenital Preauricular Cysts Following Incision and Drainage vs Fine-Needle Aspiration or Antibiotic Treatment: A Retrospective Review of Treatment Options

Importance

Treatment modalities for preauricular sinus tract infections vary.  Effort should be taken to decrease methods that lead to increased recurrence after surgical excision.

Objective

To determine whether incision and drainage (I & D) of infected congenital preauricular cysts is associated with increased rate of recurrence when compared with fine-needle aspiration or antibiotic treatment.

Design, Setting, and Participants

This was a 9-year (2006-2014) retrospective cohort study undertaken at a tertiary care pediatric hospital. Children treated for preauricular sinus tract infections were identified using the procedure code for excision of preauricular pit, cyst, or sinus tract.

Main Outcomes and Measures

Postexcision recurrence.

Results

Sixty-nine children ranging in age from 4 months to 17 years (mean age, 5.9 years) underwent excision of a preauricular cyst. Thirty-seven of 69 patients (54%) were female. Fifty-seven of 69 (83%) had a preoperative history of infection; the remainder had chronic drainage. Of children with preoperative infection, 27 were initially treated with incision and drainage (I & D), 12 were treated with fine-needle aspiration only, and 18 received antibiotic therapy alone. Overall, the recurrence rate was 8 in 69 (11.6%). Among the 27 patients with a preoperative history of infection treated with I & D, 5 lesions (18.5%) recurred, and among those who only received preoperative antibiotic therapy or fine-needle aspiration 1 in 30 lesions (3.3%) recurred (absolute difference of 15.2%; 95% CI, -1.7% to 33.6%).

Conclusions and Relevance

Among infants and children undergoing excision of preauricular cysts, a history of infection was not associated with a higher recurrence rate. There was, however, evidence to suggest that a higher rate of recurrence exists among children who had a preoperative history of infection treated with I & D. Our results suggest a more conservative treatment of infected preauricular pit and/or sinus.

Delays in Sound Recognition and Imitation in Underinsured Children Receiving Cochlear Implantation

Importance

Barriers to early pediatric cochlear implantation in underinsured populations have been previously reported. However, to our knowledge, the effect of this delay on the development of auditory and speech-language objectives has not been evaluated.

Objective

To determine if health care insurance status affects the achievement of proficiency in basic sound access and imitation tasks in children with cochlear implants.

Design, Setting, and Participants

A retrospective review of 123 children aged 1 to 12 years receiving cochlear implants at the single tertiary referral academic free-standing Children's National Health System in Washington, DC, between January 1, 2008, and December 31, 2015.

Main Outcomes and Measures

Auditory function after cochlear implantation, time to proficiency in Ling-6 scores, and number of speech therapy and audiological appointments, as well as current educational setting, were compared with patient age at diagnosis of hearing loss, age at cochlear implantation, cochlear implantation insertion technique, and health care insurance status for recipients of cochlear implants.

Results

A total of 123 children aged 1 to 12 years (mean [SD] age, 64.0 [57.4] years) with cochlear implants were included in the study. Of 37 patients with complete and accurate Ling-6 test scores, 23 (62.1%) were able to have proficiency a mean of 5.1 months at follow-up. Despite equal auditory performance on pure-tone audiometry after cochlear implantation, publicly insured recipients had Ling-6 proficiency a mean of 6.0 months (95% CI, 5.5-6.5 months) later than privately insured recipients (11.0 vs 5.0 months). When controlling for patient age, time to cochlear implantation, number of therapy sessions, and cochlear implantation insertion technique, multivariable logistic regression analysis revealed health care insurance status to be the independent variable associated with inadequate Ling-6 discrimination scores (odds ratio, 46.2; 95% CI, 2.9-729.4).

Conclusions and Relevance

Despite equal speech detection scores, publicly insured recipients of cochlear implantation had a significant and critical delay in attaining proficiency in a fundamental measure of sound recognition and imitation.

A New Surgical Drill Instrument With Force Sensing and Force Feedback for Robotically Assisted Otologic Surgery

Drilling through bone is a common task during otologic procedures. Currently, the drilling tool is manually held by the surgeon. A robotically assisted surgical drill with force sensing for otologic surgery was developed, and the feasibility of using the da Vinci research kit to hold the drill and provide force feedback for temporal bone drilling was demonstrated in this paper. To accomplish intuitive motion and force feedback, the kinematics and coupling matrices of the slave manipulator were analyzed and a suitable mapping was implemented. Several experiments were completed including trajectory tracking, drill instrument calibration, and temporal bone drilling with force feedback. The results showed that good trajectory tracking performance and minor calibration errors were achieved. In addition, temporal bone drilling could be successfully performed and force feedback from the drill instrument could be felt at the master manipulator. In the future, it may be feasible to use master–slave surgical robotic systems for temporal bone drilling.

Novel case examples of the submental island flap in pediatric head and neck reconstruction

The submental island flap was first described as a tool for facial reconstruction after tumor resection. It is now widely used for reconstructing numerous structures in the head and neck region of adults. Pediatric surgical reconstruction is a challenging task that continues to evolve over time. We describe two novel uses of this flap in the pediatric population. The submental island flap is an excellent option for reconstruction in pediatrics given its ease of elevation, excellent cosmetic outcomes, and low donor site morbidity.

Purification and characterization of microRNAs within middle ear fluid exosomes: implication in otitis media pathophysiology

BACKGROUND

Otitis media (OM) is characterized by acute infection progressing to chronic middle ear effusion (MEE). Extracellular secretion of microRNAs (miRNAs) in exosomes is a newly discovered mechanism for cells exerting distant cell genetic regulation. Whether MEE contains exosomes with specific miRNAs is unknown. This study aimed to purify and characterize the exosomal and miRNA content of MEE.

METHOD

MEEs were subjected to Exoquick exosomal purification and EXOCET exosomal quantification. Extracted vesicles were analyzed by dynamic light scattering (DLS), transmission electron microscopy (TEM), and immunoblotting of HSP-70. NanoString hybridization was performed to profile miRNAs. Exosomal protein content was profiled by Liquid chromatography tandem mass spectrometry (LC-MS/MS).

RESULTS

EXOCET assays showed presence of exosomes (0-0.5 × 10⁷/ml) in MEEs. DLS confirmed exosomal size between 10 and 200 nm. Western blot analysis showed presence of HSP-70. Twenty-nine miRNAs were found to be unique to MEEs. The most abundant miRNA was miR-223, a miRNA typically secreted by neutrophils. Proteomics demonstrated typical neutrophil markers as well as common innate immune molecules.

CONCLUSION

To our knowledge, this the first report demonstrating the presence of exosomes transporting miRNAs in MEEs. These findings open a broad and novel area of research in OM pathophysiology as driven by miRNA cell communication.

Panel 8: Report on Recent Advances in Molecular and Cellular Biochemistry

Objectives To update the medical literature on recent cellular and molecular advances in otitis media disease models with a principal focus on developments in the past 5 years. We also aim to explain recent translational advances in cellular and molecular biology that have influenced our understanding and management of otitis media. Data Sources PubMed-indexed peer-reviewed articles. Review Methods A comprehensive review of the literature was conducted with the term otitis media and the following search terms: molecular biology, cell biology, innate immunity, oxidative stress, mucins, molecular diagnostics. Included articles were published in the English language from January 1, 2010, to July 31, 2015. Implications for Practice The molecular understanding of otitis media disease progression has rapidly advanced over the last 5 years. The roles of inflammation, mucins, and cell signaling mechanisms have been elucidated and defined. Advances in the field provide a plethora of opportunities for innovative molecular targeting in the development of novel therapeutic strategies for otitis media.