International pediatric otolaryngology group (IPOG) consensus on approach to aspiration

OBJECTIVE

To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration.

METHODS

Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step.

RESULTS

Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children.

CONCLUSION

Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

Establishment of novel immortalized middle ear cell lines as models for otitis media

Objective

Otitis media (OM) is among the most frequently diagnosed pediatric diseases in the US. Despite the significant public health burden of OM and the contribution research in culture models has made to understanding its pathobiology, a singular immortalized human middle ear epithelial (MEE) cell line exists (HMEEC-1, adult-derived). We previously developed MEE cultures from pediatric patients with non-inflamed MEE (PCI), recurrent OM (ROM), or OM with effusion (OME) and demonstrated differences in their baseline inflammatory cytokine expression and response to stimulation with an OM-relevant pathogen lysate and cytokines. Herein, we sought to immortalize these cultures and assess retention of their phenotypes.

Methods

MEE cultures were immortalized via lentivirus encoding temperature-sensitive SV40 T antigen. Immortalized MEE lines and HMEEC-1 grown in monolayer were stimulated with non-typeable Haemophilus influenzae (NTHi) lysate. Gene expression (TNFA, IL1B, IL6, IL8, MUC5AC, and MUC5B) was assessed by qPCR.

Results

Similar to parental cultures, baseline cytokine expressions were higher in pediatric OM lines than in HMEEC-1 and PCI, and HMEEC-1 cells were less responsive to stimulation than pediatric lines.

Conclusion

Immortalized MEE lines retained the inflammatory expression and responsiveness of their tissues of origin and differences between non-OM versus OM and pediatric versus adult cultures, supporting their value as novel in vitro culture models for OM.

American society of pediatric otolaryngology vascular anomalies task force review of tongue venous malformations: Techniques, pearls, and pitfalls

Management of tongue venous malformations can be challenging in the pediatric population due to their heterogeneity in presentation, extent of involvement and functional compromise. It is important to recognize the value of various treatment options in order to guide management of each patient in an individualized fashion. Here we describe a series of patients with tongue venous malformations that are managed using diverse modalities to illustrate the relative benefits and risks of each technique. The challenges of venous malformation treatment can be mitigated by tailoring the approach to each individual patient and malformation. This case series also emphasizes the need and importance of working in the setting of a multidisciplinary vascular anomalies team.

International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of non-tuberculous mycobacterial cervicofacial lymphadenitis

INTRODUCTION

Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cervicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial.

OBJECTIVES

This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges.

METHODS

A modified three-iterative Delphi method was used to establish expert recommendations on the diagnostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature.

SETTING

Multinational, multi-institutional, tertiary pediatric hospitals.

RESULTS

Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation.

CONCLUSION

The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation.

Association of Pepsin With Inflammatory Signaling and Effusion Viscosity in Pediatric Otitis Media

OBJECTIVE

Otitis media (OM) is a common inflammatory disease spectrum. Cytokine signaling, neutrophil activity, and mucin hypersecretion during recurrent and chronic OM contribute to persistent, viscous middle ear (ME) effusions, hearing loss, and potential for developmental delay. Extraesophageal reflux (EER), specifically pepsin, triggers inflammatory signaling in respiratory mucosa and is associated with OM. The objective of this study was to investigate the association of pepsin with ME inflammatory signaling and the outcomes and examine causality in vitro.

STUDY DESIGN

Cross-sectional study.

METHODS

ME fluid (MEF) and preoperative audiometric data were collected from 30 pediatric subjects undergoing tympanostomy tube placement for recurrent OM or OM with effusion. MEF viscosity was characterized by the surgeon. Pepsin, inflammatory molecules, and mucin were assayed by enzyme-linked immunosorbent assay (ELISA). ME epithelial primary culture was exposed to 0.1 to 1 mg/ml pepsin at pH 5, 6, and 7 for 30 minutes, and cytokine expression was assayed via qPCR.

RESULTS

Pepsin was observed in the MEF of 77% of patients (range 71-2,734 ng/ml). Pepsin correlated with effusion viscosity, interleukins -6 and -8, neutrophil elastase, and mucin 5B (P < .05). Pepsin-negative MEF was more frequently absent of interleukin 8 or mucin 5B (P < .05). Weak acid was generally insufficient to elicit cytokine expression in ME cells in vitro, however, pepsin induced IL6, IL8, and TNF at pH 7 (P < .05) and weak acid (pH 6) facilitated a response at lower pepsin concentration.

CONCLUSIONS

Pepsin may contribute to inflammatory signaling, persistent viscous effusion, and poorer OM outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

RNA Sequencing and Pathways Analyses of Middle Ear Epithelia From Patients With Otitis Media

OBJECTIVES

Otitis media (OM) is the most common pediatric diagnosis in the United States. However, our understanding of the molecular pathogenesis of OM remains relatively poor. Investigation of molecular pathways involved in OM may improve the understanding of this disease process and elucidate novel therapeutic targets. In this study, RNA sequencing (RNA-Seq) was used to discern cellular changes associated with OME compared to healthy middle ear epithelium (MEE).

STUDY DESIGN

Ex vivo case-control translational.

METHODS

Middle ear epithelia was collected from five pediatric patients diagnosed with OME undergoing tympanostomy tube placement and five otherwise healthy pediatric patients undergoing cochlear implantation. Specimens underwent RNA-Seq and pathways analyses.

RESULTS

A total of 1,292 genes exhibited differential expression in MEE from OME patients compared to controls including genes involved in inflammation, immune response to bacterial OM pathogens, mucociliary clearance, regulation of proliferation and transformation, and auditory cell differentiation. Top networks identified in OME were organismal injury and abnormalities, cell morphology, and auditory disease. Top Ingenuity canonical pathways identified were axonal guidance signaling, which contains genes associated with auditory development and disease and nicotine degradation II and III pathways. Associated upstream regulators included β-estradiol, dexamethasone, and G-protein-coupled estrogen receptor-1 (GPER1), which are associated with otoprotection or inflammation during insult.

CONCLUSIONS

RNA-Seq demonstrates differential gene expression in MEE from patients with OME compared to healthy controls with important implications for infection susceptibility, hearing loss, and a role for tobacco exposure in the development and/or severity of OME in pediatric patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations

INTRODUCTION

There is limited data regarding the role of direct laryngoscopy and rigid bronchoscopy (DLRB) in infants with failed extubations. Pediatric otolaryngologists are frequently consulted to perform DLRB in infants with failed extubations.

OBJECTIVE

To determine the DLRB findings in infants with failed extubations and the interventions performed based on these findings.

METHODS

A retrospective chart review was performed on infants less than 12 months old undergoing DLRB for failed extubations from January 2013-June 2017 at a tertiary care children's hospital. Data was collected on age, birth weight, perinatal complications, comorbid conditions, number of failed extubations, length of most recent intubation, operative findings, and subsequent interventions, including tracheostomy. Descriptive and comparative analyses were performed.

RESULTS

Of the 62 subjects who met study criteria, median age at DLRB was 3.0 months, corrected age was 1.0 months, gestational age was 27.1 weeks, birth weight was 0.97 kg, and number of failed extubations was 2.0. About 80% had respiratory distress at birth requiring intubation, and 76% carried a diagnosis of bronchopulmonary dysplasia (BPD). The median number of days intubated prior to DLRB was 27. Twenty-seven percent of subjects had no significant abnormal findings on DLRB, and 26% had subglottic stenosis. The majority (74%) underwent tracheostomy. Eighteen percent of subjects had an initial intervention for abnormal DLRB finding(s) other than tracheostomy and were able to avoid tracheostomy as a future intervention. Tracheostomy placement was associated with a diagnosis of BPD (RR 1.78, 95% CI 1.02, 3.10), having a birth weight less than 0.71 kg (RR 1.45, CI 1.01, 2.10), and being intubated for 48 or more days prior to DLRB (RR 1.57, 95% CI 1.05, 2.36); it was not associated with the number of failed extubations prior to DLRB.

CONCLUSIONS

Infants with failed extubations commonly had abnormal findings on airway evaluation by DLRB. Most children in this population still required tracheostomy placement, but about 20% were able to have an alternate intervention and avoid tracheostomy.

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.

Significance of positive tracheal cultures in the 30 days following tracheostomy

INTRODUCTION

Positive tracheal cultures obtained after tracheostomy are often considered organ/space surgical site infections by the National Surgical Quality Improvement Project. However, the definition of bacterial tracheitis after tracheostomy is not well described.

OBJECTIVE

To determine the relationship of positive tracheal cultures in the 30 days following pediatric tracheostomy, antibiotic treatment of these cultures, and signs/symptoms of respiratory infection.

METHODS

A retrospective chart review was performed on subjects who underwent tracheostomy from November 2012-September 2017 at a tertiary care pediatric center. The following data was studied: positive tracheal cultures, antibiotic treatment for positive cultures, and other signs/symptoms of infection including fever and elevated white blood cell count. Descriptive data analysis was performed, and relative risk and 95% confidence intervals were calculated. Multivariate logistic regression model was used to assess independent association when applicable.

RESULTS

There were 173 subjects who met study criteria. Median age at tracheostomy was 4.6 months. Fifty-one percent (89/173) of subjects had at least one positive tracheal culture in the 30 days following tracheostomy. Of those subjects, 38% (34/89) had fever, 71% (32/45) had an elevated white blood cell count, 31% (22/72) had consolidation on chest imaging, 61% (54/89) had increased tracheal secretions, 70% (62/89) had increased ventilation requirements, and 60% (53/89) were treated with antibiotics for a diagnosis of tracheitis. There was no meaningful difference when comparing fever, increased white blood cell count, lung consolidation, increased tracheal secretions, or increased ventilation requirements in those with and without a positive tracheal culture or in those with and without antibiotic treatment for a positive culture. Multivariate logistic regression analysis showed that increased age at time of tracheostomy, more days on the ventilator after tracheostomy, and an increased number of positive cultures in the year after tracheostomy were related to having a positive tracheal culture within 30 days of tracheostomy.

CONCLUSION

For post-operative pediatric tracheostomy subjects, there were no meaningful differences when comparing signs/symptoms of infection between those with and without a positive tracheal culture and between those with and without antibiotic treatment for a positive culture.

Primary tracheocutaneous fistula closure with immediate transition to nocturnal noninvasive positive pressure ventilation in two children with Congenital Central Hypoventilation Syndrome

Transitioning children with Congenital Central Hypoventilation Syndrome (CCHS) from nocturnal invasive ventilation via tracheostomy to noninvasive positive pressure ventilation (NIPPV) is challenging due to the leak caused by the tracheocutaneous fistula (TCF), resulting in insufficient ventilation. Decannulation and primary closure of the TCF with immediate transition to nocturnal NIPPV was performed in two children with CCHS at a tertiary care children's hospital. Neither child developed significant adverse effects such as pneumomediastinum or pneumothorax. This technique is a novel approach that may improve decannulation outcomes and aid transition to NIPPV in this patient population.

Use of a Cervicofacial Flap in Closing Large Defects Following Wide Local Excision of Complicated Preauricular Lesions

PURPOSE

To describe innovative surgical technique for closure of large defect following complicated preauricular cyst excision secondary to prior failed excision attempts, infections, and drainage procedures. Preauricular cysts must be widely excised including any fistulous tracts in order to reduce recurrence rates; however, the resultant large local excision poses cosmetic challenges.

METHODS

Retrospective chart review of 3 patient cases who underwent excision of recurrent preauricular lesions involving cervical parotid flap closure. All three cases demonstrate complicated preauricular congenital cysts which were infected and had prior drainage, excision attempts, or sclerotherapy. A cervicoparotid flap was used to close all defects cosmetically with no facial nerve weakness and without distortion to the oral commissure or lateral canthus.

RESULTS/CONCLUSIONS

There is a high recurrence rate seen with wide local congenital cyst excisions that have been previously excised, infected, and drained; as well as, cosmetically unfavorable outcomes utilizing traditional repair. Utilizing our closure technique which involves reconstructive local regional flap with cervicoparotid approach our 3 patients have had no reoccurance of cyst or infection. Our approach also maximizes cosmetic outcomes, with reduced scar visibility. Pre and postoperative photos will be shown.

Analysis of Inflammatory Signaling in Human Middle Ear Cell Culture Models of Pediatric Otitis Media

OBJECTIVES/HYPOTHESIS

Cell culture models are valuable tools for investigation of the molecular pathogenesis of diseases including otitis media (OM). Previous study indicates that age-, sex-, and race-associated differences in molecular signaling may impact disease pathophysiology. Currently, a singular immortalized middle ear epithelial (MEE) cell line exists, HMEEC-1, derived from an adult without known middle ear disease. In this study, HMEEC-1 and primary MEE cultures from pediatric patients with and without OM were stimulated with inflammatory cytokines or OM-pathogenic bacterial lysates to examine differences in the response of molecules associated with OM pathogenesis.

STUDY DESIGN

Case-control series.

METHODS

MEE cultures were established from patients aged <6 years: two with recurrent OM (ROM), two with OM with effusion (OME), and one patient without OM who was undergoing cochlear implant surgery control undergoing cochlear implantation (Peds CI). Primary MEE cultures and HMEEC-1 cells were stimulated with tumor necrosis factor-α, interleukin (IL)-1β, or nontypeable Haemophilus influenzae lysate. TNFA, IL1B, IL6, IL8, IL10, and MUC5B were assayed via quantitative polymerase chain reaction. IL-8 was assayed by enzyme-linked immunosorbent assay.

RESULTS

Gene/protein target expressions were frequently higher in pediatric OM lines than in HMEEC-1 and Peds CI. HMEEC-1 cells were frequently less responsive to stimuli than all pediatric lines. OME lines were often more responsive than ROM lines.

CONCLUSIONS

OM may be associated with specific molecular phenotypes that are retained in primary cell culture. Adult-derived HMEEC-1 cells differ significantly in baseline expression and response of OM-associated molecules relative to pediatric MEE cells. Work is underway to immortalize pediatric OM MEE cultures as improved tools for the OM research community.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:410-416, 2021.

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

OBJECTIVES/HYPOTHESIS

Create a competency-based assessment tool for pediatric tracheotomy.

STUDY DESIGN

Blinded, modified, Delphi consensus process.

METHODS

Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.

RESULTS

The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.

CONCLUSIONS

It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:2700-2707, 2020.

Attenuation of Helper T Cell Capacity for TH1 and TH17 Differentiation in Children With Nontuberculous Mycobacterial Infection

Nontuberculous mycobacteria (NTM) infect children with increasing frequency worldwide. Using blood and lymph node tissue from children with NTM lymphadenitis, and uninfected lymph node tissue from community controls, we evaluated helper T (TH) cells in functional assays of TH1/TH17 differentiation and measured the concentration of their associated cytokines at the site of infection. Circulating TH cells from infected children were attenuated in their TH1/TH17 differentiation capacity and expressed less interferon γ and interleukin 17 after polyclonal stimulation. Similar differences were observed at the site of infection, where most cytokine concentrations were unchanged relative to controls. Our data are consistent with a model wherein TH1/TH17 differentiation is attenuated in NTM-infected children.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

Objectives:

Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting.

Methods:

Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR.

Results:

Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; P < .001). Four patients with laryngomalacia developed symptoms requiring supraglottoplasty. Presence and level of salivary pepsin was not significantly associated with need for surgical management, nor were the levels or presence of IL-1β or IL-8 significantly associated with presence or level of pepsin, diagnosis of laryngomalacia, or need for operative management.

Conclusion:

Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.

Combined Nd:YAG laser and bleomycin sclerotherapy under the same anesthesia for cervicofacial venous malformations: A safe and effective treatment option

INTRODUCTION

Extensive cervicofacial venous malformations (VM) pose significant challenges to a patient's quality of life (altered breathing, dysphagia, dysarthria). Treatment options include: 1) Surgical debulking; 2) Sclerotherapy; 3) laser therapy; or 4) Combined modalities. Recent studies have demonstrated the importance of multimodality and multidisciplinary management of these patients. However, no studies have described combined single anesthetic laser and sclerotherapy treatment. We sought to demonstrate the safety and efficacy of combined Nd:YAG laser and sclerotherapy under the same anesthetic administration.

METHODS

Retrospective review of 8 patients (Age 6 mo -74 yrs, x͂ 31) with extensive cervicofacial VM with significant airway involvement. Patients were treated with combined suspension laryngoscopy with Nd:YAG laser of airway VM followed by image guided direct puncture sclerotherapy using bleomycin in the airway VM and sodium tetradecyl sulfate (STS) foam in the cervicofacial VM during the same anesthetic encounter.

RESULTS

All 8 patients had extensive cervicofacial VMs that were symptomatic with snoring or orthopnea. Four of the patients had previously been treated at outside institutions with residual disease or significant complications. All patients remained intubated post procedure (Avg. 1.07 days) and tolerated extubation without re-intubation or any major complications. The average length of hospital stay was 3.2 days, of which 1.9 days were spent in the ICU. Patients reported symptomatic improvement or had decreased VM disease on MRI follow up.

CONCLUSION

Combined Nd:YAG laser therapy and sclerotherapy allows treatment of both superficial and deep components of VMs in a safe and efficient manner. In addition, suspension laryngoscopy provides improved visualization and access for the interventional radiologist in difficult to reach areas for sclerotherapy.

Management trends of infantile hemangioma: A national perspective

INTRODUCTION

The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown.

MATERIALS AND METHODS

The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4.

RESULTS

The number of qualified admissions significantly increased over the years (9271 in 2003-12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001).

CONCLUSIONS

Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

Association of Gel-Forming Mucins and Aquaporin Gene Expression With Hearing Loss, Effusion Viscosity, and Inflammation in Otitis Media With Effusion

Importance

Persistent, viscous middle ear effusion in pediatric otitis media (OM) contributes to increased likelihood of anesthesia and surgery, conductive hearing loss, and subsequent developmental delays. Biomarkers of effusion viscosity and hearing loss have not yet been identified despite the potential that such markers hold for targeted therapy and screening.

Objective

To investigate the association of gel-forming mucins and aquaporin 5 (AQP5) gene expression with inflammation, effusion viscosity, and hearing loss in pediatric OM with effusion (OME).

Design, Setting, and Participants

Case-control study of 31 pediatric patients (aged 6 months to 12 years) with OME undergoing tympanostomy tube placement and control individuals (aged 1 to 10 years) undergoing surgery for cochlear implantation from February 1, 2013, through November 30, 2014. Those with 1 or more episodes of OM in the previous 12 months, immunologic abnormality, anatomical or physiologic ear defect, OM-associated syndrome (ie, Down syndrome, cleft palate), chronic mastoiditis, or history of cholesteatoma were excluded from the study. All patients with OME and 1 control were recruited from Children's Hospital of Wisconsin, Milwaukee. The remainder of the controls were recruited from Sick Kids Hospital in Toronto, Ontario, Canada.

Main Outcomes and Measures

Two to 3 middle ear biopsy specimens, effusions, and preoperative audiometric data (obtained <3 weeks before surgery) were collected from patients; only biopsy specimens were collected from controls. Expression of the mucin 2 (MUC2), mucin 5AC (MUC5AC), mucin 5B (MUC5B), and AQP5 genes were assayed in middle ear biopsy specimens by quantitative polymerase chain reaction. One middle ear biopsy specimen was sectioned for histopathologic analysis. Reduced specific viscosity of effusions was assayed using rheometry.

Results

Of the 31 study participants, 24 patients had OME (mean [SD] age, 50.4 [31.9] months; 15 [62.5%] male; 16 [66.7%] white) and 7 acted as controls (mean [SD] age, 32.6 [24.4] months; 2 [26.6%] male; 6 [85.7%] white). Mucins and AQP5 gene expression were significantly higher in patients with OME relative to controls (MUC2: ratio, 127.6 [95% CI, 33.7-482.7]; MUC5AC: ratio, 3748.8 [95% CI, 558.1-25 178.4]; MUC5B: ratio, 471.1 [95% CI, 130.7-1697.4]; AQP5: ratio, 2.4 [95% CI, 1.1-5.6]). A 2-fold increase in MUC5B correlated with increased hearing loss (air-bone gap: 7.45 dB [95% CI, 2.65-12.24 dB]; sound field: 6.66 dB [95% CI, 6.63-6.69 dB]), effusion viscosity (2.75 mL/mg; 95% CI, 0.89-4.62 mL/mg), middle ear epithelial thickness (3.5 μm; 95% CI, 1.96-5.13 μm), and neutrophil infiltration (odds ratio, 1.7; 95% CI, 1.07-2.72). A 2-fold increase in AQP5 correlated with increased effusion viscosity (1.94 mL/mg; 95% CI, 0.08-3.80 mL/mg).

Conclusions and Relevance

Further exploration of the role of MUC5B in the pathophysiology of OME holds promise for development of novel, targeted therapies to reduce effusion viscosity, facilitation of effusion clearance, and prevention of disease chronicity and hearing loss in patients with OME.

Endoscopic esophageal and tracheal cauterization for closure of recurrent tracheoesophageal fistula: A case report and review of the literature

OBJECTIVE

Recurrent tracheoesophageal fistula (TEF) can be a diagnostic and therapeutic challenge. Traditional treatment is thoracotomy, which carries significant morbidity and technical difficulty especially in a previously operated field. Recently, endoscopic techniques have been advocated as a primary approach for treatment of recurrent TEF prior to open repair. This case report describes the endoscopic technique used to address a recurrent TEF. The existing literature of all reported endoscopic cauterization methods is reviewed.

METHODS

An 8 month old with proximal esophageal atresia and distal TEF underwent endoscopic closure of a recurrent TEF. The fistula was approached endotracheally utilizing Bugbee electrocautery (EC) and endoluminally through the esophagus using argon plasma coagulator and placement of porcine submucosa graft into the tract. Current literature review is presented with a synthesis of data on cases utilizing endoscopically applied EC and the combined results of this closure technique.

RESULTS

Our patient has maintained successful closure after a single treatment confirmed on follow up endoscopy 6 months post repair. Including this patient, there have been 30 patients with recurrent TEF treated utilizing endoscopic EC reported in the literature. The overall success rate is 78.8% with a mean of 1.88 procedures per successful closure. Comparing EC alone to EC combined with tissue glues or laser, success rates are 67% and 86% respectively.

CONCLUSION

Endoscopic repair of recurrent TEF has proven to be safe and effective in the literature as an alternative to a second thoracotomy/open surgical repair. EC combined with tissue glues or laser is more effective than EC alone based on available data.

Pepsin as a biomarker for laryngopharyngeal reflux in children with laryngomalacia

OBJECTIVES/HYPOTHESIS

Laryngomalacia is a common cause of newborn stridor. Laryngopharyngeal reflux (LPR) has been associated with laryngomalacia. Although pepsin, a component of LPR, has been associated with inflammatory diseases of the aerodigestive tract, its presence in the airways of laryngomalacia patients is unknown.

STUDY DESIGN

Prospective case-control study comparing patients under age 3 years with laryngomalacia to children without laryngomalacia.

METHODS

Children less than 3 years old undergoing supraglottoplasty for laryngomalacia or surgery unrelated to the airway, without a history of laryngomalacia, reflux, or respiratory disease, were offered enrollment. Supraglottic lavage samples (3 mL) were obtained from all subjects. Two-millimeter arytenoid biopsies were collected from laryngomalacia patients. Pepsin Western blot and enzyme-linked immunosorbent assay were performed.

RESULTS

Ten laryngomalacia and five control subjects were enrolled. Pepsin was detected in lavages of laryngomalacia patients (8/10) but absent in controls (0/5; P = .007). Pepsin was observed more frequently in lavages (8/10) than biopsies (4/10; P = .046) of laryngomalacia subjects. Higher median pepsin concentration was observed in laryngomalacia than control lavages (P = .025).

CONCLUSIONS

Pepsin in supraglottic specimens demonstrated an association with laryngomalacia, supporting a role for refluxed pepsin in laryngomalacia. These data corroborate previous work implicating pepsin in inflammatory diseases of the upper airways. Further studies are warranted to investigate the contribution of pepsin to the pathophysiology of laryngomalacia.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:2413-2417, 2017.

Safety of Ultrasound-Guided Botulinum Toxin Injections for Sialorrhea as Performed by Pediatric Otolaryngologists

OBJECTIVE

To evaluate incidence of complications and hospital readmission as a result of ultrasound-guided botulinum toxin injections to manage sialorrhea.

STUDY DESIGN

Case series with chart review.

SETTING

Children's Hospital of Wisconsin.

SUBJECTS AND METHODS

A case series with chart review was performed of all cases of ultrasound-guided injection of botulinum toxin by pediatric otolaryngologists from March 5, 2010, to September 26, 2014,. Primary outcomes included complications such as dysphagia, aspiration pneumonia, and motor paralysis. Secondary outcomes included hospitalization, intubation, and nasogastric tube placement.

RESULTS

There were 48 patients, 111 interventions, and 306 intraglandular injections identified. Botulinum toxin type A and type B were utilized in 4 and 107 operative interventions, respectively. Type A was injected into 4 parotid and 4 submandibular glands, utilizing doses of 20 U per parotid and 30 U per submandibular gland. Type B was injected into 98 parotid and 200 submandibular glands, with average dosing of 923 U per parotid and 1170 U per submandibular gland, respectively. There were 2 instances of subjectively worsening of baseline dysphagia that self-resolved. No cases were complicated by aspiration pneumonia or motor paralysis. No patients required hospital readmission, intubation, or nasogastric tube placement.

CONCLUSION

Prior published data indicated 16% complication incidence with ultrasound-guided injection of botulinum toxin. Our study found a low complication rate (0.6%) with ultrasound-guided injections of botulinum toxin to manage sialorrhea, without cases of aspiration pneumonia or motor paralysis. Of 306 intraglandular injections, there were 2 cases of worsening baseline subjective dysphagia that self-resolved.

Recurrence patterns of cervical infections in children

OBJECTIVES

(1) Elucidate the recurrence rate of pediatric cervical cellulitis and abscess (2) Evaluate the impact of pre-procedural imaging, length of stay, culture results, age and gender on readmission rate.

METHODS

A retrospective review of all admissions to a tertiary pediatric hospital for cellulitis and abscess of the neck (ICD-9 682.1) from 2007 to 2013 including all readmissions within 91 days.

RESULTS

There were a total of 178 admissions (171 patients) with the diagnosis of cellulitis and abscess of the neck between 2007 and 2013. The rate of surgical intervention was 74% (n=128). The overall readmission rate within 91 days was 3.5% (n=6). All patients requiring readmission had undergone a procedure during the initial admission and a second procedure during readmission. The readmission rate for patient who initially required a procedural intervention was 4.6%. There was no statistically significant effect of pre-procedural imaging, length of stay, culture results, age or gender on readmission rate. Patients with abscess >20mm in diameter had a significantly longer LOS than patient with smaller abscesses (4.265 days vs 3.667 days, p<0.001). Furthermore, in patients 3 years old or greater, the patients with a larger diameter (>20mm) and larger total size were more likely to need surgical drainage.

CONCLUSIONS

This retrospective review of patients admitted with neck cellulitis and abscess at a tertiary care pediatric hospital shows an overall readmission rate of 3.5%. All readmissions required a surgical procedure. Older children with larger abscess are more likely to require surgical drainage.

Lingual hamartoma associated with a cleft palate in a newborn

A hamartoma is a benign malformation of native tissue that may occur in any area of the body. Hamartoma of the tongue is a rare developmental lesion. We describe the case of a pendulant lingual hamartoma in a 2-day-old girl that had not been identified on prenatal ultrasonography. We also review the utility of prenatal imaging options, the role of preoperative imaging, the mechanical relationship between lingual hamartoma and cleft palate, the histopathology of this tumor, surgical treatment, and emergency airway management.

Office-Based Subglottic Evaluation in Children With Risk of Subglottic Hemangioma

PURPOSE

Children with V3 cutaneous infantile hemangiomas (IH) and PHACE syndrome have a high incidence for airway hemangioma, 29% and 52%, respectively. Therefore, a clinical evaluation for these high-risk children is essential. We report our experience with in-office lower airway evaluation (OLAE) in these high-risk children.

RESULTS

Since 2003, 5 children with IH of the V3 cutaneous distribution and 3 children with PHACE syndrome underwent OLAE. Average age of presentation was 2.75 months. Two children had stridor at initial evaluation, and 1 child had subglottic hemangioma. This child was evaluated serially with OLAE to monitor disease progression and treatment response. A total of 10 upper tracheoscopies were performed on the 8 patients without respiratory complications.

CONCLUSION

An airway evaluation is essential to evaluate and manage this high-risk population. Typically, operative endoscopy requires general anesthesia. However, in these high-risk children, we have performed OLAE without sedation to evaluate the trachea. High-speed recording and playback is essential in this method. Our series demonstrates that awake OLAE is possible and may be a safe technique to evaluate and monitor disease progression in these high-risk patients. These patients avoided general anesthesia and delay in diagnosis and did not incur any complications during or after OLAE.

A Case of Necrotizing Epiglottitis Due to Nontoxigenic Corynebacterium diphtheriae

Diphtheria is a rare cause of infection in highly vaccinated populations and may not be recognized by modern clinicians. Infections by nontoxigenic Corynebacterium diphtheriae are emerging. We report the first case of necrotizing epiglottitis secondary to nontoxigenic C diphtheriae. A fully vaccinated child developed fever, poor oral intake, and sore throat and was found to have necrotizing epiglottitis. Necrotizing epiglottitis predominantly occurs in the immunocompromised host. Laboratory evaluation revealed pancytopenia, and bone marrow biopsy was diagnostic for acute lymphoblastic leukemia. Clinicians should be aware of aggressive infections that identify immunocompromised patients. This case highlights the features of a reemerging pathogen, C diphtheriae.

Imaging submandibular pathology in the paediatric patient

A wide range of pathologies may arise from the submandibular space (SMS) or submandibular gland (SMG) in children. We review herein the normal anatomy of the SMS and describe the role of imaging in the evaluation of SMS lesions. A schematic approach for the categorisation of SMS pathology based on imaging characteristics is provided.

Standardized Outcome and Reporting Measures in Pediatric Head and Neck Lymphatic Malformations

Objective

To develop general and site-specific treatment effect and outcome measures to standardize the reporting of head and neck lymphatic malformation (HNLM) treatments.

Study Design

Consensus statement/expert opinion.

Setting

Multiple tertiary academic institutions.

Subjects and Methods

The modified Delphi method is an iterative process of collecting expert opinions, refining opinions through discussion and feedback, statistically aggregating opinions, and using these aggregates to generate consensus opinion in the absence of other data. The modified Delphi method was used by a multi-institutional group of otolaryngology and interventional radiology experts in the field of vascular anomalies to formulate a list of recommended reporting outcomes for the study and treatment of head and neck lymphatic malformations.

Results

Through 3 rounds of iteration, 10 expert panelists refined 98 proposed outcome measures and 9 outcome categories to a final consensus set of 50 recommended outcome measures in 3 global categories (general, demographics, and treatment complications) and 5 site-specific categories (orbit, oral cavity, pharynx, larynx, and neck).

Conclusions

We propose the first consensus set of standardized reporting measures for clinical and treatment outcomes in studies of HNLMs. Consistent outcome measures across future studies will facilitate comparison of treatment options and allow systematic review. We hope that these guidelines facilitate the design and reporting of subsequent HNLM studies.

Factors influencing successful peer-reviewed publication of original research presentations from the American Society of Pediatric Otolaryngology (ASPO)

OBJECTIVE

To analyze factors associated with progression of an original scientific presentation at the American Society of Pediatric Otolaryngology (ASPO) Annual Meeting to publication in a peer-reviewed journal. A dataset of presenters was created to enable prospective follow-up to assess early impressions regarding publication success with longer-term publication outcomes.

METHODS

Prior to the Annual ASPO meeting in 2013, a survey consisting of 10 questions was e-mailed to all 59 presenters. Questions were designed to assess presenter expectations on publication, barriers to publishing, and experience in presenting, publishing and clinical practice. A second survey was sent 12 months later to those respondents of the first survey who were amenable to follow-up.

RESULTS

Overall, 46 of 59 (78%) presenters responded to the initial survey prior to their ASPO 2013 presentation. Of these, 34 agreed to participate in a longer-term follow-up of their presentation to publication experience. Of these 34, there were 17 who participated in the follow-up survey 1 year later. Just under half of the original respondents were residents (46%). All presenters (100%) planned to re-submit a revised manuscript if initially rejected. However, 35% of follow-up respondents did not make initial submission to a peer-reviewed journal. Results of a descriptive analysis suggest that more experienced researchers expect their submitted manuscript to be accepted for publication within a shorter time frame than those that have published fewer papers. Time was ranked as the greatest barrier to publication (60%) of those surveyed both in the initial prospective survey and for those who did not publish a paper in the follow-up survey (83%).

CONCLUSION

This study suggests a strong desire and expectation of publishing ASPO presentations. Despite this expectation, past research and this data set suggest this expectation often does not materialize. "Time constraints" were the most commonly identified barrier to publication. To enhance dissemination of new findings from ASPO meetings, institutions and individuals should examine methods that facilitate and incentivize publication of findings in peer-reviewed publications.

Resource utilization and national demographics of laryngotracheal trauma in children

IMPORTANCE

Pediatric laryngotracheal trauma is rare but can carry considerable morbidity and health care resource expenditure. However, the true cost of these injuries has not been thoroughly investigated.

OBJECTIVE

To use a national administrative pediatric database to identify normative data on pediatric laryngotracheal trauma, specifically with regard to cost and resource utilization.

DESIGN AND PARTICIPANTS

Retrospective medical record review using the Kids' Inpatient Database (KID) 2009. Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for fractures or open wounds of the larynx and trachea.

MAIN OUTCOMES AND MEASURES

Among many data analyzed were demographic information and admission characteristics, including length of stay, diagnoses, procedures performed, and total charges.

RESULTS

There were 106 admissions that met inclusion criteria. Patient mean (SE) age was 15.9 (0.45) years, and 79% were males. The mean (SE) length of stay (LOS) was 8.4 (1.1) days; more than 50% of patients had a LOS longer than 4 days. The mean number of diagnoses per patient was 6.9 (0.6); other traumatic injuries included pneumothorax (n = 18). More than 75% of patients underwent more than 2 procedures during their admission; 60.2% underwent a major operative procedure. The most common procedures performed were laryngoscopy (n = 54) and operative repair of the larynx and/or trachea (n = 32). Tracheostomy was performed in only 30 patients. The mean (SE) total charge was $90,879 ($11,419), and one-third of patients had total charges more than $100,000.

CONCLUSIONS AND RELEVANCE

Pediatric laryngotracheal trauma remains a relatively rare clinical entity. These injuries primarily affect older children and are associated with long hospitalizations, multiple procedures, and high resource utilization.

Otolaryngologic surgeries are frequent in children with eosinophilic esophagitis

OBJECTIVE

The aim was to study the prevalence of otolaryngologic surgeries in pediatric patients with eosinophilic esophagitis (EoE).

METHODS

Retrospective cohort study at a tertiary care center. The type of otolaryngologic surgeries performed in patients with diagnosis of EoE was recorded during a 5-year period.

RESULTS

Seventy-five percent of patients were male, with average age of EoE diagnosis at 7.5 years with an 83% incidence of atopy. Cohort analysis revealed that 33% (119/362) had a total of 275 otolaryngologic surgeries. Surgeries performed on 119 patients are as follows: 20% bilateral myringotomy with tubes, 14% tonsillectomy, 18.5% adenoidectomy, 1.4% sinus irrigation, 3.3% bronchoscopy, and 1.4% laryngotracheoplasty (LTP); 63% of patients underwent multiple procedures. Thirty percent of patients undergoing bilateral myringotomy with tube placement (BMT) needed additional tubes. Four of 5 LTP patients had successful operations. Twelve percent of patients had EoE diagnosis prior to an otolaryngologic surgery.

CONCLUSION

Thirty-three percent of children with EoE required otolaryngologic surgical intervention and nearly one-third who underwent BMT required additional ear tubes. A large fraction of children with EoE will undergo an otolaryngologic surgery, only a minority with a preoperative EoE diagnosis. Until the nature of this relationship is clarified, the high coincidence with otolaryngologic surgeries dictates that otolaryngologists should be familiar with diagnosis of EoE in patients.

Transient swallowing dysfunction in typically developing children following supraglottoplasty for laryngomalacia

OBJECTIVE

To evaluate early postoperative swallowing function in otherwise typically-developing children following supraglottoplasty.

METHODS

Retrospective chart review case series.

RESULTS

Of 37 children identified as having undergone supraglottoplasty for severe laryngomalacia at our institution between January 2007 and October 2011, 24 were identified as otherwise typically developing with no indications/signs of swallowing problems pre-operatively and eligible for inclusion in this study. Twenty-two children underwent bilateral supraglottoplasty and 2 children underwent unilateral supraglottoplasty using the CO2 laser or the laryngeal skimmer microdebrider in combination with cold steel technique, based on the discretion of four Pediatric Otolaryngologists. Seventeen children were seen post-operatively for a clinical swallow evaluation. Six children were found to have swallowing dysfunction. Four of the six children showed variable symptoms, signs, or findings concerning for aspiration with oral feeding. Three of six underwent video fluoroscopic swallow study (VFSS). All 6 children responded to dietary modifications, positioning alterations, and anti-reflux medications. All showed improvement by their 4-week post-operative follow-up visit. The median age of the 24 patients at the time of surgery was 3 months, with a range from 2 weeks to 4 years. The median age of the patients found to have transient post-operative swallowing dysfunction was 1.5 months, with a range of 2 weeks to 4 months. There was no association between post-operative swallowing dysfunction and the surgical technique employed.

CONCLUSIONS

Supraglottoplasty in otherwise typically developing children carries a risk of transient swallowing dysfunction with a low risk of persistent dysfunction. Most patients can be assessed post-operatively via clinical swallow evaluation without requiring an instrumental swallow study.

Do you need to operate following recovery from complications of pediatric acute sinusitis?

OBJECTIVES

There are many studies that evaluate the role of surgery in the treatment of complications of pediatric acute sinusitis; however there are few studies, if any that report the incidence of surgery following recovery from acute complicated sinusitis. The goal of this study was to report the incidence and indications for surgical intervention after recovery from complications of pediatric acute sinusitis.

METHODS

We reviewed the records of all children admitted to a tertiary care children's hospital between January 2005 and September 2010 with a diagnosis of sinusitis and an orbital or intracranial complication. Eighty-six patients met inclusion criteria. Charts were reviewed for type of complication, initial treatment (medical or surgical), type of procedure, secondary procedures, age, and comorbidities. Statistical analysis was completed using independent samples student t-tests and Mann-Whitney tests.

RESULTS

A total of 86 patients with a mean age of 6.38 years (2 months to 18 years) were identified. Eighty patients had orbital complications while six presented with intracranial complications. Twenty-seven patients (31%) underwent sinus surgery during the acute phase of their illness whereas 59 patients (69%) were treated medically. After hospitalization and recovery for acute complicated sinusitis, surgery was performed on nine patients (mean age 4.86 years) within 1 month to 2 years post hospitalization. Of the nine patients who required secondary surgery following resolution of the initial complicated sinusitis, four patients were following initial surgical intervention and five patients had initially resolved their complication with medical therapy alone. Indications for subsequent surgery included failure of medical therapy for persistent rhinosinusitis (8 patients) and second complication (1 patient).

CONCLUSIONS

This study suggests that following resolution of complicated pediatric rhinosinusitis, very few patients may need further surgical intervention. Subsequent intervention is best guided by clinical judgment, symptoms during outpatient clinic visits, and failure of medical therapy.

Management and Treatment of Pediatric Rhinosinusitis

Program Description:

Pediatric chronic rhinosinusitis (PCR) without cystic fibrosis remains one of the most common complaints presenting to otolaryngologists. However, there is no standardized protocol in the work-up, diagnosis, imaging, and treatment of this disease process. This seminar will focus on diagnostic testing, including when to image and what allergy or immunology tests to order; pre-operative medical treatment options, including irrigations and diet modification; and review of best evidence for surgical management of PCR, including balloon dilation. We will also discuss the management of complications of acute pediatric rhinosinusitis and discuss our data about long-term impacts of surgical intervention.

Educational Objectives:

1) Apply the indications for CT imaging, the role of allergy and immunology testing, and the potential impact of non-surgical interventions in managing PCR. 2) Evaluate the evidence related to surgical treatment of PCR, including biopsy for primary ciliary dyskinesia, adenoidectomy, functional endoscopic sinus surgery, and balloon dilation. 3) Recognize the acute and long-term complications seen in pediatric rhinosinusitis and the short-term and long-term management of this disease.

Sympathetic neuropathy and dysphagia following doxycycline sclerotherapy

This case report demonstrates neurologic sequela following treatment with doxycycline sclerotherapy. A six-week-old child presented with respiratory distress from a macrocystic lymphatic malformation, extending from the skull base to the anterior mediastinum. Following doxycycline sclerotherapy, the airway symptoms resolved; however, the child developed silent aspiration and Horner's syndrome. Two months following treatment the patient resumed oral diet and at one year post-intervention there has been no recurrence of symptoms, with only mild ptosis remaining. While neuropathies following doxycycline sclerotherapy have been described, aspiration has never been documented. This case demonstrates a single patient's clinical course and resolution of their neuropathies.

Ulcerative lesions as a rare cause of laryngotracheitis in the pediatric population

OBJECTIVE

The goal of this study is to describe a unique finding of ulcerative lesions of the larynx in two pediatric patients presenting with prolonged acute laryngotracheitis and compare to previously described reports to determine the typical clinical picture, need for intervention, and management model.

METHODS

We present two cases of ulcerative lesions of the larynx in immunocompetent children, one with PCR positive HSV, which presented as severe croup requiring intensive care unit admission. Literature review was completed to assess for current knowledge of this entity. Our cases are discussed in the context of previously reported cases of HSV laryngotracheitis. Descriptive analysis was completed focusing on presentation, physical exam findings, treatment, length of therapy, and outcomes.

RESULTS

Literature review uncovered six case reports including 10 individual cases of prolonged croup with findings of HSV laryngitis and one retrospective review describing 15 cases of prolonged croup found to be caused by ulcerative laryngitis. All patients underwent direct laryngoscopy and bronchoscopy for evaluation. Analysis was completed comparing the studies to our patients with significant findings including high intubation rate of 77%, ulcerative stomatitis in 63%, and treatment with antiviral medication directed at HSV in 85% with improvement in symptoms.

CONCLUSION

It is important to consider HSV as a possible pathogen in cases of prolonged or atypical croup. Laryngoscopy should be used for diagnostic intervention and identification of ulcerative lesions. Stomatitis may be an indication for earlier direct inspection. Treatment with anti-viral therapy and with discontinuation or taper of steroid is suggested.

Use of coblation in resection of juvenile nasopharyngeal angiofibroma

We present a series of 4 patients with juvenile nasopharyngeal angiofibroma (JNA) who underwent Coblation-assisted endoscopic resection after preoperative embolization, and discuss the use and advantages of endoscopic Coblation-assisted resection of JNA. Our limited case series suggests that Coblation may be used in the resection of JNA after embolization in a relatively safe, efficient, and effective manner. Coblation allows for decreased bleeding, less need for instrumentation, and improved visualization. There are limited published data in the literature to date on the use of Coblation in endoscopic JNA resection. We describe its use in a more extensive tumor than those previously reported. Further studies are needed to fully define the safety and utility of Coblation technology for this application.

Socioeconomic implications of pediatric cervical methicillin-resistant Staphylococcus aureus infections

OBJECTIVE

To study cervical methicillin-resistant Staphylococcus aureus (MRSA) infections using a national database with the goal of providing normative data and identifying variations in resource utilization.

DESIGN

Retrospective review using a pediatric national data set (Kids' Inpatient Database 2009).

SUBJECTS

Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for both MRSA and specific neck and pharyngeal infections.

RESULTS

There were 26,829 admissions with MRSA; 3571 included a head and neck infection. The mean (SE) age at admission was 7.72 (0.20) years. Most patients (65.0%) were in the lower 2 socioeconomic quartiles; the most common payer was Medicaid (53.3%). The mean total charge per admission was $20,442. The mean (SE) length of stay (LOS) was 4.39 (0.15) days; there were significant differences among age (P < .001) and racial (P < .001) groups. A total of 1671 children underwent at least 1 surgical drainage procedure; there were statistically significant differences among racial (P < .001), age (P < .001), and socioeconomic (P = .048) groups. There were no regional variations in resource utilization when LOS, number of procedures, and total hospital charges were compared.

CONCLUSIONS

Cervical MRSA infections have a large socioeconomic impact across the nation. There are differences among the various races in resource utilization. Younger children have longer hospitalizations, are more likely to need surgery, and require more intubations. Children from the lowest socioeconomic group require surgery more frequently, but their LOS is not statistically different when compared with the other 3 groups. Knowledge of such characteristics for cervical MRSA infections in children can facilitate targeted clinical interventions to improve care of affected populations.

Initiation and use of propranolol for infantile hemangioma: report of a consensus conference

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available.

Surgical management of auricular infantile hemangiomas

OBJECTIVE

To report our experience with surgical management of auricular infantile hemangiomas and reconstruction of the affected ear.

DESIGN

Retrospective case series.

SETTING

Dedicated Birthmarks and Vascular Anomalies Center in a tertiary pediatric hospital.

PATIENTS

Ten patients with surgically treated, histopathologically confirmed auricular infantile hemangiomas.

MAIN OUTCOME MEASURES

Outcomes of surgical management.

RESULTS

The case series included 5 male and 5 female patients (age range, 4 months to 4 years). Indications for surgery were pain, bleeding, infection, and cosmetic deformity. Four patients had failed prior medical treatment, including pulsed dye laser, topical corticosteroids, and intralesional corticosteroids. Nine patients underwent single-stage resection. Otoplasty reconstruction was performed in 2 patients with hemangioma-induced deformities, while primary Z-plasty closure was performed in 2 patients with extensive lesions. No recurrence or complication has been reported to date.

CONCLUSIONS

Most infantile hemangiomas do not require treatment. Surgical excision of auricular infantile hemangiomas at any phase is effective in preventing fibrofatty scarring, reducing cartilage deformities, and treating complicated cases or patients who have failed medical management. Surgical excision with Z-plasty reconstruction is a viable option that should be considered to limit postoperative deformities.

Management of plastic bronchitis in a child with mild intermittent asthma

OBJECTIVES

We describe the clinical presentation of a 7 1/2-year-old boy with a history of mild intermittent asthma who presented with left lung collapse and was found to have plastic bronchitis.

METHODS

We reviewed the patient chart and imaging results and performed a literature review of plastic bronchitis and its management.

RESULTS

Bronchoscopy in our patient demonstrated a large white, friable, cast-like material that obstructed the entire left main stem bronchus and could not be easily suctioned. The cast was removed in a piecemeal fashion by means of serial rigid bronchoscopy over a 6-month period with use of both optical forceps and flexible suction catheters. Microscopic examination of the cast-like material showed a predominance of eosinophils along with neutrophils encased in proteinaceous material.

CONCLUSIONS

Plastic bronchitis in children is a rare condition that can mimic foreign body aspiration and can be associated with underlying pulmonary inflammatory disorders or cardiovascular disease. Aggressive bronchoscopic management of the airway obstruction and medical management of the underlying disease process are important for the successful treatment of plastic bronchitis.

Pediatric Otogenic Sinus Thrombosis and the Role of Anticoagulation

Objective: 1) Discuss the presentation, work up, and treatment of a series of pediatric patients presenting with otomastoiditis with sigmoid sinus thrombosis (OSST). 2) Review the literature in discussing surgical treatment and the role of anticoagulation for sinus thrombosis from complicated otomastoiditis.

Method: Retrospective case series of 3 patients with otomastoidits and lateral sinus thrombosis were included in the study. Type of anticoagulation used and both clinical and radiographic outcomes were compared. Pediatric literature review was conducted using Pubmed search terms “thrombosis and otitis media and anticoagulation” limited to English.

Results: Three patients were diagnosed with OSST. One patient presented with diplopia and otitic hydrocephalus. All patients were treated with anticoagulation following myringotomy with tubes and cortical mastoidectomy without thrombectomy. All patients were anticoagulated for 24 to 42 weeks with clinical recovery with resolution of thrombosis by MRI in less than 6 months. There were no major complications from anticoagulation use. Literature review of 50 patients with OSST showed that 60% had sigmoid aspiration or incision in addition to mastoidectomy, and only 64% of patients had anticoagulation. All patients had clinical recovery, with recanalization or resolution of clot in 16 patients.

Conclusion: The treatment of OSST is controversial. All patients presented had clinical recovery but 66% had anticoagulation and clot resolution in 19 out of 32. Two patients had hematoma with anticoagulation. This series and literature review highlights the controversy of surgical and medical management of OSST and the need for further investigation.

Infantile Hemangioma: Evolving Trends in Surgical Management

Objective: 1) Present outcomes of surgically treated infantile hemangioma, and describe changes in surgical management with the advent of changes in medical therapy. 2) Highlight the role of imaging in surgical planning. 3) Identify risk factors for surgical complications.

Method: Retrospective chart review of patients in a multidisciplinary clinic diagnosed with infantile hemangioma involving soft tissue and skin between 2008 and 2010. Data relating to demographics, indications for surgery, histopathology analysis, postoperative care, and complications were collected.

Results: Of 1050 subjects, 109 patients (10%) underwent surgical intervention, and 78% of the lesions were in the head and neck. Ulceration, bleeding, and deformity were the major surgical indications. Seven patients underwent staged excision. Magnetic resonance imaging was utilized in diagnostic workup and preoperative planning in 15 cases. Adjunctive medical therapy was safely used in 26% of the surgical cohort. Head and neck lesions were more likely to receive adjunctive therapy ( P = .007) and had a higher complication rate. Overall complication rate was lower (6%) compared with our 2005-2007 surgery cohort (1012 patients) with a complication rate of 17%.

Conclusion: Surgery continues to be a viable form of therapy for complicated infantile hemangiomas. Introduction of propanolol and vincrinstine for challenging lesions did not change the surgery rate but may partly explain the lower complication rate secondary to preoperative reduction of surgical bulk.

Pediatric Small Vessel AVMs Mistaken for Hemangioma

Objective: A majority of vascular anomalies in children are infantile hemangiomas (IH). However, some children with an atypical growth pattern can be suggestive of an AVM. This case series discusses the clinical presentation, diagnosis, radiology, pathology, and treatment of small vessel AVMs at a multidisciplinary vascular anomalies center.

Method: Retrospective case series of three patients. Chart review was obtained with IRB approval.

Results: Three patients presented with increasing head and neck masses at 12 months to 2.5 years. All patients had magnetic resonance imaging indicating likely infantile hemangioma. All patients underwent surgical excision, one requiring preoperative embolization. All pathology specimens were GLUT 1 negative and were diagnosed as small vessel arteriovenous malformations. Serial clinical photographs, imaging studies, and pathology will be presented.

Conclusion: Many pediatric vascular anomalies appear to be an IH, but atypical growth patterns should raise clinical suspicion of an AVM. Diagnostic error leads to inadequate treatment, disease progression, and increased morbidity. This series highlights the importance of clinical suspicion and a multidisciplinary team approach toward pediatric vascular anomalies.