Significant Declines in Juvenile-onset Recurrent Respiratory Papillomatosis Following Human Papillomavirus (HPV) Vaccine Introduction in the United States

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare and serious disease caused by human papillomavirus (HPV) presumably acquired during vaginal delivery. HPV vaccination of females through age 26 years, recommended in the United States since 2006, can prevent HPV transmission. We assessed trends in JORRP cases before and after HPV vaccine introduction in the United States.

METHODS

Case-patients were identified from 26 pediatric otolaryngology centers in 23 U.S. states. Demographics and clinical history were abstracted from medical records. Case-patients were grouped by year of birth, and birth-cohort incidences were calculated using number of births from either national or state-level natality data from the 23 states. We calculated incidence rate ratios (IRR) and 95% confidence intervals (CI) in 2-year intervals.

RESULTS

We identified 576 U.S. JORRP case-patients born in 2004-2013. Median age at diagnosis was 3.4 years (interquartile range: 1.9, 5.5). Number of identified JORRP case-patients declined from a baseline of 165 born in 2004-2005 to 36 born in 2012-2013. Incidence of JORRP per 100 000 births using national data declined from 2.0 cases in 2004-2005 to 0.5 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4); incidence using state-level data declined from 2.9 cases in 2004-2005 to 0.7 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4).

CONCLUSIONS

Over a decade, numbers of JORRP case-patients and incidences declined significantly. Incidences calculated using national denominator data are likely underestimates; those calculated using state-level denominator data could be overestimates. These declines are most likely due to HPV vaccination. Increasing vaccination uptake could lead to elimination of this HPV-related disease.

Juvenile-Onset Recurrent Respiratory Papillomatosis in the United States, Epidemiology and HPV Types-2015-2020

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare disease characterized by the growth of papillomas in the respiratory tract. In the United States, JORRP is not a nationally notifiable condition and current data are limited.

METHODS

Children with JORRP aged <18 years were enrolled from 26 pediatric otolaryngology centers in 23 US states from January 2015 through August 2020. Demographic, birth information, and maternal vaccination history were collected from a parent/guardian. Clinical history was abstracted from medical records. Papilloma biopsies were tested for 28 human papillomavirus (HPV) types. Mothers who delivered in 2006 or later were considered age-eligible for HPV vaccination if aged ≤26 years in 2006. We described characteristics of enrolled children and their birth mothers and analyzed disease severity by diagnosis age and HPV type using multiple logistic regression.

RESULTS

Among 215 children with JORRP, 88.8% were delivered vaginally; 64.2% were firstborn. Among 190 mothers, the median delivery age was 22 years. Among 114 (60.0%) age-eligible for HPV vaccination, 16 (14.0%) were vaccinated, 1 (0.9%) before delivery. Among 162 specimens tested, 157 (96.9%) had detectable HPV; all 157 had a vaccine-preventable type. Disease severity was associated with younger diagnosis age and HPV 11; adjusted analyses found only younger diagnosis age significant (adjusted odds ratio: 6.1; 95% confidence interval: 2.9, 12.8).

CONCLUSIONS

Children with JORRP were commonly firstborn and delivered vaginally to young mothers; most of the mothers reported no HPV vaccination before delivery. Vaccine-preventable HPV was identified in all specimens with detectable HPV. Increasing preexposure HPV vaccination could substantially reduce or eliminate JORRP in the United States.

Recurrent respiratory papillomatosis: A 2020 perspective

OBJECTIVE

Despite recent advancement recurrent respiratory papillomatosis (RRP) remains a rare but challenging benign airway neoplasm. In recent years there has been significant shifts in incidence of this disease due to changes in vaccination and prevention for human papilloma virus (HPV) and its related pathology. This review will highlight the epidemiology, prevention and treatment of RRP.

METHODS

The PubMed database was searched using relevant MeSH terms including "recurrent respiratory papillomatosis." The titles and abstracts were reviewed to assess relevance and unrelated articles were excluded. A full-text review for select articles was performed, the data and discussions were interpreted and synthesized to create a concise update on the management of RRP.

RESULTS

With the increasing utilization of the 9-valent and quadrivalent HPV vaccine in Australia, we have seen a significant decrease in the incidence of RRP. Preliminary data in the US shows a similar trend of decreased incidence after implementation of vaccination. Single dose Gardasil in developing countries has shown sustained immunization for at least 7 years. Preliminary clinical trials and retrospective studies have shown the HPV vaccine may have benefit as a treatment method in addition to prevention for HPV related diseases. Bevacizumab (Avastin), a VEGF monoclonal antibody, has shown promise as a systemic treatment for RRP. The Corona Virus Disease 2019 (COVID-19) pandemic has affected perioperative management of RRP.

CONCLUSION

RRP continues to decline in incidence since the implementation of HPV vaccination. Advancement in the medical management including Bevacizumab show promise as an additional option for the management of RRP.

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.

Management and Outcomes of Button Batteries in the Aerodigestive Tract: A Multi-institutional Study

OBJECTIVES/HYPOTHESIS

To describe the clinical presentation, management, and complications associated with button battery impaction in the aerodigestive tract in children.

STUDY DESIGN

Retrospective case series.

METHODS

This multi-institutional study, endorsed by the American Society of Pediatric Otolaryngology research consortium, is a retrospective medical record review, including all children at five tertiary-care institutions presenting with button batteries impacted in the aerodigestive tract between January 2002 and December 2014. Battery type/size, duration and location of impaction, presenting symptoms, treatment, complications, and outcomes were examined.

RESULTS

Eighty-one patients were included (64.2% male), with ingestion witnessed in 20 (24.7%). Median age at presentation was 3 years (range, 1 week-14 years). Median time from diagnosis to removal was 2.5 hours (range, 0.4-72 hours). Locations included the esophagus (n = 48), hypopharynx (n = 1), stomach (n = 6), nasal cavity (n = 22), and ear canal (n = 4). Most common symptoms for esophageal/hypopharyngeal impactions included dysphagia (26.5%), nausea/vomiting (26.5%), drooling (24.5%), cough (18.4%), and fever (18.4%). Most common symptoms for nasal impactions included epistaxis (54.6%), rhinorrhea (40.9%), nasal pain (27.3%), and fever (22.7%). Almost all esophageal impactions were from 3-V (89.5%), 20-mm (81.8%) lithium batteries. Severe esophageal complications included stricture (28.6%), perforation (24.5%), tracheoesophageal fistula formation (8.2%), pneumothorax (4.1%), and bilateral true vocal fold paresis (4.1%). Nasal complications included necrosis (59.1%), septal perforation (27.3%), and saddle nose deformity (4.5%). Duration of impaction correlated with an increased likelihood of persistent symptoms only for nasal batteries (P = .049).

CONCLUSIONS

Button batteries in the upper pediatric aerodigestive tract or ear canal should be considered a surgical emergency, requiring urgent removal and careful vigilance for complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E298-E306, 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.

Update on Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) remains a challenging disease afflicting children and adults, resulting in an estimated $120 million per year in United States healthcare-related costs, with annual costs per patient approaching $60,000. Although the prevalence of RRP has declined, RRP remains the most common benign laryngeal neoplasm in children. RRP is unique in its high rate of multisite recurrence, its high burden on patient quality of life, and its high associated healthcare costs. This article summarizes current understanding of the natural history and quality of life burden of RRP, and basic science advancements in prevention and treatment.

An evidence based protocol for managing neonatal middle ear effusions in babies who fail newborn hearing screening

OBJECTIVES

To evaluate the prevalence of middle ear disease in infants referred for failed newborn hearing screening (NBHS) and to review patient outcomes after intervention in order to propose an evidence-based protocol for management of newborns with otitis media with effusion (OME) who fail NBHS.

METHODS

85 infants with suspected middle ear pathology were retrospectively reviewed after referral for failed NBHS. All subjects underwent a diagnostic microscopic exam with myringotomy with or without placement of a ventilation tube in the presence of a middle ear effusion and had intra-operative auditory brainstem response (ABR) testing or testing at a later date.

RESULTS

At the initial office visit, a normal middle ear space bilaterally was documented in 5 babies (6%), 29/85 (34%) had an equivocal exam while 51/85 (60%) had at least a unilateral OME. Myringotomy with or without tube placement due to presence of an effusion was performed on 65/85 (76%) neonates. Normal hearing was established in 17/85 (20%) after intervention, avoiding the need for any further audiologic workup. Bilateral or unilateral sensorineural hearing loss (SNHL) or mixed hearing loss was noted in 54/85 (64%) and these children were referred for amplification. Initially observation with follow up outpatient visits was initiated in 27/85 (32%) however, only 3/27 (11%) resolved with watchful waiting and 24/27 (89%) ultimately required at least unilateral tube placement due to OME and 14/24 (59%) were found to have at least a unilateral mixed or SNHL.

CONCLUSIONS

An effective initial management plan for children with suspected middle ear pathology and failed NBHS is diagnostic operative microscopy with placement of a ventilation tube in the presence of a MEE along with either intra-operative ABR or close follow-up ABR. This allows for the identification and treatment of babies with a conductive component due to OME, accurate diagnosing of an underlying SNHL component and for prompt aural rehabilitation.

Rethinking surgical technique and priorities for pediatric tonsillectomy

The past 100years have witnessed dramatic shifts in the concept of ideal surgical goals and operative technique in tonsil surgery. Surgeons are reviving a technique of intracapsular tonsillectomy with increasing precision thanks to modern technology. With intracapsular tonsillectomy, pediatric patients recover faster, use less pain medication, and have a lower risk of dehydration and hemorrhage. Various considerations will dictate the adoption of this technology in the coming years. This current review explores concepts and controversies surrounding tonsillectomy with a focus on quality improvement.

E-cigarettes: An update on considerations for the otolaryngologist

PURPOSE

We provide an update in the literature and national regulations regarding electronic cigarettes with special attention to the pediatric population.

BACKGROUND

Electronic nicotine delivery systems (ENDS) are handheld battery operated devices that vaporize nicotine-containing liquids for inhalation. Use of these products has dramatically increased over the last several years, particularly among the youth. ENDS are being marketed with advertising techniques and flavors which appeal to the adolescent and young adult population. More reports of accidental pediatric exposures are being documented, as are suicides from abuse of liquid nicotine. Federal regulation has only now become required of these devices.

CONCLUSION

Use of e cigarettes among adolescents increases each year. Government oversight is needed to protect our children from the re-normalization of tobacco. Otolaryngologists should be prepared to counsel their patients and families regarding the latest in ENDS use.

Unique challenges of obtaining regulatory approval for a multicenter protocol to study the genetics of RRP and suggested remedies

Objective

Investigations that seek to generalize findings or to understand uncommon diseases must be conducted at multiple centers. This study describes the process of obtaining regulatory approval for a minimal risk genetic study in a multi-center setting as undertaken by the Recurrent Respiratory Papillomatosis (RRP) Task Force.

Study Design and Setting

Sequential cohort of American children's hospitals. A single protocol was submitted to each Institutional Review Board (IRB).

Results

Documentation was prepared for 14 IRBs over 2.5 years. The median time between enlistment and approval at the first 8 sites was 15 months. Institutions varied considerably in their requirements and in the issues that were raised. Protocols were submitted sequentially and accumulated experience was used in the preparation of applications to subsequent IRBs. Nevertheless, there was no correlation between the accumulated experience and the number of issues that were raised.

Conclusion

Despite uniform federal standards, all local IRBs required unique and individualized submissions. For multicenter studies, investigators should seriously consider the establishment of cooperative authorization agreements. On a simpler level, a standardized format for applications needs to be adopted nationwide. EBM rating: B-3b

Post-Tonsillectomy Morbidity and Quality of Life in Pediatric Patients with Obstructive Tonsils and Adenoid: Microdebrider vs Electrocautery

OBJECTIVES: To prospectively compare outcomes in children over age 2 with obstructive adenotonsillar hypertrophy when tonsillectomy is performed utilizing an intracapsular microdebrider technique versus low-wattage electrocautery technique.

STUDY DESIGN AND SETTING: Prospective, single-blind, randomized controlled trial at a tertiary care children's hospital.

RESULTS: Among the 300 children, those treated with the microdebrider resumed normal activity faster, with a median recovery of 2.5 days, and stopped taking pain medication sooner, with the median time to the last dose of 4 days. The microdebrider group were 3 times more likely to no longer need pain medications at 3 days postoperatively and 2.5 times less likely to be still needing pain medication 7 days postoperatively. They were twice as likely to be at a normal activity level by 3 days postoperatively and were less likely to still not have attained normal activity and normal diet after 7 days. There was no difference between groups in median days to return to normal diet (3.0 to 3.5 days). At 1-month follow-up, children in the microdebrider group were 5 times more likely to have residual tonsil tissue.

CONCLUSIONS: Intracapsular tonsillectomy in children with obstructive adenotonsillar hypertrophy results in improved peri-operative outcomes. Residual tonsil tissue is more common with use of the microdebrider; however, the incidence of future obstruction or infection is unknown.

EBM rating: A-1b

Identifying musical difficulties as they relate to congenital amusia in the pediatric population

INTRODUCTIONS/OBJECTIVES

Approximately 4% of the population fails to develop basic music skills and can be identified as "amusic". Congenital amusia (CA), or "tone deafness", is thought to be a hereditary disordera predominantly affecting the perception and production of music. The gold standard for diagnosis is the Montreal Battery for Evaluation of Amusia (MBEA). This study aims to pinpoint factors in the history that may help identify amusic children and to determine if amusic pediatric patients can be identified using a widely available, shorter test validated in adults.

METHODS

Subjects ages 7-17 years were recruited to take an online test, validated against the MBEA, for CA. The sections tested recognition of "off-beat" (OB), "mistuned" (MT), and "out-of-key" (OOK) conditions. Parents filled out a questionnaire regarding the subject's past medical, educational, musical exposure, and family history.

RESULTS

Of 114 subjects recruited, complete data was available on 105 with a mean age of 12.5 years. According to adult criteria, 63/105 (60%) of subjects scored in the "amusic" range. Children >10 years of age scored significantly higher on the off-beat section (p=0.001) and total scores (p=0.025). Subjects who were born prematurely scored significantly lower (p=0.045). Children whose father had difficulties with music scored significantly lower on the off-beat section (p=0.003) and total scores (p=0.008).

CONCLUSIONS

CA is a disorder that has implications for quality of life. Earlier identification may help elucidate the pathogenesis of the condition and, in the future, the institution of prompt treatment. Further studies are needed to identify the most appropriate and convenient tests, as well as the optimal timing of testing, for reliably diagnosing CA in children.

E-cigarettes: Considerations for the otolaryngologist

PURPOSE

To review the literature regarding electronic cigarettes and discuss potential implications and need for advocacy for the pediatric otolaryngologist.

BACKGROUND

Electronic cigarettes (e-cigarettes) are battery-operated devices that deliver nicotine-containing vapors via inhalation. Research on the health related consequences of e-cigarettes is ongoing and safety has yet to be established. E-cigarettes are not presently under the regulation of any national governing body with wide accessibility to minors. Use of these products has substantially increased since arrival to the market, particularly within the adolescent population. These products are marketed via various platforms including television, Internet and social media. Hundreds of flavors are offered and e-cigarettes are packaged in various colors. Not only are the ill health effects and addictive quality of nicotine concerning, these products have the potential to serve as a gateway for minors to tobacco use.

APPLICATIONS

The relationship between tobacco use, secondhand smoke exposure and otolaryngology specific diseases has well been defined. As use of electronic cigarettes increases, pediatric otolaryngologists should be aware of the ongoing literature regarding these products and to be prepared to counsel families accordingly.

CONCLUSIONS

The use of e-cigarettes among teenagers, potential implications of secondhand vapor exposure from parents and friends, and concerns this may encourage adolescents to utilize conventional tobacco products needs to be considered.

Intraoperative Use of QuikClot During Adenotonsillectomy: A Prospective Pediatric Trial

BACKGROUND

Achieving hemostatic control after intracapsular adenotonsillectomy with minimal cauterization may potentially lead to improved outcomes with respect to return to normal diet, normal activity, and less use of narcotic pain medications.

METHODS

A prospective, nonrandomized, consecutive series of children with obstructive tonsils and adenoids at a tertiary children's hospital was undertaken.

RESULTS

One hundred consecutive children (52 boys/48 girls) ages 0-16 (mean=4.8, SD=3.7, median=4.0) years were recruited with complete data available on all 100. Mean total procedure time was 19.8 (SD=4.3, median=19.5) minutes, including mean total cauterization time of 155.3 (SD=59.7 seconds, median=143.0) (adenoids: mean=60.9, SD=31.5, median=53.0; tonsils: mean=94.5, SD=41.9, median=82.0) minutes. Mean estimated blood loss was 29.4 (SD=40.9, median=25.0) ml. There were no major complications (0/100 episodes of bleeding or dehydration after surgery). Mean return to normal diet was 3.4 (SD=2.2, median=3.0) days; mean return to normal activity was 2.8 (SD=2.1, median=3.0) days, and mean days to no further narcotics was 3.0 (SD=2.3, median=2.0) days. Mean days to complete recovery (normal diet, normal activity, and no narcotics) was 4.5 (SD=2.1, median=4.0, range: 1-10). Total cautery time was significantly correlated with time to complete recovery (P<.05).

CONCLUSIONS

Intracapsular microdebrider tonsillectomy with adenoidectomy utilizing QuikClot to enhance the hemostasis results in recovery times better than previously reported for this common operation in children.

Adenotonsillectomy vs Observation for Management of Mild Obstructive Sleep Apnea in Children

Objective

To determine the impact of adenotonsillectomy vs observation on quality of life (QOL) in children with mild obstructive sleep apnea (OSA).

Study Design

Prospective, nonrandomized trial.

Setting

Tertiary children’s hospital.

Subjects and Methods

Sixty-four children (ages 3-16 years) with mild OSA (apnea hypopnea index between 1 and 5 on polysomnogram) completed the study. Caregivers chose between management options of adenotonsillectomy and observation and completed validated QOL instruments (OSA-18 and Children’s Health Questionnaire) at baseline, early, and late follow-ups. The primary outcome measure was QOL.

Results

Thirty patients chose adenotonsillectomy, while 34 were observed. Total OSA-18 scores at baseline were significantly poorer ( P = .01) in the surgery group (72.3) compared with the observation group (58.5). Four months following surgery, OSA-18 scores improved by 39.1 points over baseline ( P = .0001), while there was no change for the observation group ( P = .69). After 8 months, OSA-18 scores remained improved in the surgery group, and observation group scores improved by 13.4 points over baseline ( P = .005). While OSA-18 scores at the late follow-up visit were poorer in the observation group, the difference was not statistically significant ( P = .05). Six observation patients opted for adenotonsillectomy during the study.

Conclusion

Quality of life significantly improves in children with mild OSA after adenotonsillectomy. In children with mild OSA who are observed, QOL improvements at early follow-up are less pronounced, but significant improvements in QOL are evident after 8 months. QOL instruments may be useful tools to help providers determine which children with mild OSA may benefit from early intervention.

Avenues to Leadership: Opportunities at Every Level

Program Description:

This miniseminar is designed to help physicians in the Academy find ways to become leaders in their own environments. The panelists will include leaders within national organizations such as the AAO-HNS, ACGME, and ACS, as well as local leaders, including a department chair and residency program director. Emphasis will be placed on career crossroads and how to navigate them. Several of the panelists are women and will comment on experiences unique to female leaders in our field.

Educational Objectives:

1) Recognize individualized ways to become leaders in various environments. 2) Characterize the role of medical leaders in our departments, institutions, clinical specialties, and national organizations. 3) Apply leadership principles to everyday practice.

Clinical Pearls in Pediatric Otolaryngology: A Video Forum

Program Description:

This video-based forum will provide audience members with state of the art concepts in pediatric otolaryngology. The speakers consist of: Carlton Zdanski: Transoral Robotic Surgery in Children: Indications and Results; Christopher Hartnick: Bevacizumab (Avastin) injection for pediatric RRP; Craig Derkay: Modifications of the Seldinger technique to secure the difficult pediatric airway; David White: Endoscopic division of the sternocleidomastoid muscle for treatment of torticollis; Ken Kazahaya: Endoscopic assisted otologic surgery; Michael Rutter: Tracheotomy tube fenestration; Sanjay Parikh: Diagnosis of sleep induced laryngomalacia; Soham Roy: Radiofrequency ablation of pediatric oral cavity lesions; Steven Goudy: Video-assisted pharyngeal surgery.

Educational Objectives:

1) Consider contemporary airway management ideas for tracheotomy tubes, recurrent papillomatosis, and laryngomalacia. 2) Describe novel endoscopic laryngopharyngeal techniques with robotics, radiofrequency, and video-assistance. 3) Implement novel endoscopic otologic and neck techniques.

Off-Label Uses of Drugs and Technology: What’s the Stigma?

Program Description:

The practice of otolaryngology is rapidly evolving with new technologies and pharmaceuticals introduced into use at an exponential rate. While most new interventions are Food and Drug Administration approved, some rely on their success in other fields of medicine and are applied into our field as experimental or are used in good faith with anecdotal benefits. The purpose of this multi-expert panel is to share the ethical considerations and controversies of such tools, with a special emphasis on the pathway for approval by the hospital as well as credentialing, off-label use of injectables and topical medications, and application of robotics in otolaryngology.

Educational Objectives:

1) Describe the process of introducing off-label medications, devices, and technologies into everyday practice. 2) List some commonly used topical and injectable medications and their off-label use in the various fields of otolaryngology. 3) Recognize the limitations that are inherent to the introduction of such innovations.

The Financial Value of Fellowship Training in Otolaryngology

Objective

To evaluate the financial impact of pursuing a fellowship in otolaryngology.

Study Design

Retrospective financial analysis using American Academy of Otolaryngology—Head and Neck Surgery survey data.

Subjects and Methods

The American Academy of Otolaryngology—Head and Neck Surgery report, entitled Socioeconomic Study among Members April 2011, gives a financial profile of respondents who reported their primary area of specialization as either general otolaryngology or a specific area of subspecialization. Weighted averages were calculated from the reported data. The weighted averages were used to calculate a net present value (NPV) over a 30-year contiguous career.

Results

The NPV for general otolaryngology was $4.73 million. The NPV for the following subspecialties in relation to general otolaryngology were (in hundred thousands) as follows: otolaryngologic allergy (−$1153), sleep medicine (−$677), otology/neurotology (−$339), laryngology (−$288), head and neck (−$191), pediatric otolaryngology (−$176), facial plastic surgery (−$139), skull base surgery ($122), rhinology ($285), and allergy and immunology ($350). Ninety-four percent of general otolaryngology respondents were in private practice. Most subspecialists worked in an academic setting.

Conclusion

Fellowship training in otolaryngology will affect career earnings of prospective fellows. The overall financial impact of fellowship training, calculating in the delay in receiving a full clinical salary, should be factored into the decision to pursue fellowship training.

Prevalence of ventilation tubes in children with a tracheostomy tube

OBJECTIVES

To estimate the prevalence of operative ear disease in pediatric patients with tracheostomy tubes, as well as to identify risk factors predictive of operative otologic interventions in this patient cohort.

METHODS

We hypothesize that the prevalence of operative middle ear disease in patients with a tracheostomy tube is greater than that of the population at large. To validate our anecdotal observations, we queried the CHCA hospital database (PHIS) regarding the association between tympanostomy tube placements in children with tracheostomies. To further investigate, a retrospective chart review was undertaken at our regional tertiary care children's hospital to determine the frequency at which tympanostomy tubes were placed in children who have a tracheostomy. Risk factors were analyzed, applying independent samples t-tests and Pearson's Chi-square test. Univariate and multivariate logistic regression models were constructed to estimate odds ratios (OR) and 95% confidence intervals (CI) for predictors of operative ear disease. Institutional review board (IRB) approval was obtained.

RESULTS

Of a population of 181 patients with tracheostomies, 37 (or 20%, 95% CI 15-26%) have undergone placement of ventilation tubes in the past 3 years. No statistically significant difference was noted with regards to gender or race. The operative group had an average age of 23.0 months at the time of tracheostomy, compared to 52.5 months in the non-operative group (p=0.0022). In addition, home living situation, term birth, and craniofacial abnormalities were more frequently observed in the operative versus the non-operative group. Multivariate logistic regression models revealed the same factors as predictors of operative ear disease.

CONCLUSION

The presence of a tracheostomy is associated with an increased risk of requiring ventilation tube placement over the population at large. Risk factors for operative middle ear disease among these children include age at time of the tracheostomy, craniofacial abnormalities, term birth, and home living situation.

Current use of intralesional cidofovir for recurrent respiratory papillomatosis

OBJECTIVES/HYPOTHESIS

The authors sought to define the indications, administration, and adverse events associated with intralesional cidofovir use for recurrent respiratory papillomatosis (RRP).

STUDY DESIGN

Cross-sectional study.

METHODS

A 21-question online survey was distributed to 115 selected adult and pediatric laryngeal surgeons internationally. Results were used to draft statements of best practice, which were approved by the full membership of the RRP Task Force.

RESULTS

Eighty-two surgeons, who altogether presently manage 3,043 patients with RRP, responded to the survey. Seventy-four surgeons previously used cidofovir, reporting 1,248 patients in the last decade (estimated 801 adults and 447 children). Single indications for adjuvant cidofovir included six or more surgeries per year, increasing frequency of surgery, and extralaryngeal spread (in children). Most adult surgeons use 20 to 40 mg in <4 mL; pediatric surgeons use <20 mg in <2 mL. Scheduled administration following an initiation trial of five injections is common; cidofovir is discontinued following a complete response. Most surgeons biopsy routinely, use special informed consent, and are willing to participate in multi-institutional clinical trials on cidofovir uses, efficacy, and safety.

CONCLUSIONS

Eighteen statements were approved by the RRP Task Force after discussion of the survey results. Intralesional cidofovir may be initiated if surgical debulking is required every 2 to 3 months. The concept of an adjuvant regimen with regular biopsy is favored. Administration should remain below established safe limits of dosing (3 mg/kg) and volume. Informed consent, including discussion of off-label use and acute kidney injury in children, is important. A special consent form sample is included. There remains a need for high-quality data.

Quality of Internet information in pediatric otolaryngology: a comparison of three most referenced websites

OBJECTIVE

Patients commonly refer to Internet health-related information. To date, no quantitative comparison of the accuracy and readability of common diagnoses in Pediatric Otolaryngology exist.

STUDY AIMS

(1) identify the three most frequently referenced Internet sources; (2) compare the content accuracy and (3) ascertain user-friendliness of each site; (4) inform practitioners and patients of the quality of available information.

METHODS

Twenty-four diagnoses in pediatric otolaryngology were entered in Google and the top five URLs for each were ranked. Articles were accessed for each topic in the three most frequently referenced sites. Standard rubrics were developed to include proprietary scores for content, errors, navigability, and validated metrics of readability.

RESULTS

Wikipedia, eMedicine, and NLM/NIH MedlinePlus were the most referenced sources. For content accuracy, eMedicine scored highest (84%; p<0.05) over MedlinePlus (49%) and Wikipedia (46%). The highest incidence of errors and omissions per article was found in Wikipedia (0.98±0.19), twice more than eMedicine (0.42±0.19; p<0.05). Errors were similar between MedlinePlus and both eMedicine and Wikipedia. On ratings for user interface, which incorporated Flesch-Kinkaid Reading Level and Flesch Reading Ease, MedlinePlus was the most user-friendly (4.3±0.29). This was nearly twice that of eMedicine (2.4±0.26) and slightly greater than Wikipedia (3.7±0.3). All differences were significant (p<0.05). There were 7 topics for which articles were not available on MedlinePlus.

CONCLUSIONS

Knowledge of the quality of available information on the Internet improves pediatric otolaryngologists' ability to counsel parents. The top web search results for pediatric otolaryngology diagnoses are Wikipedia, MedlinePlus, and eMedicine. Online information varies in quality, with a 46-84% concordance with current textbooks. eMedicine has the most accurate, comprehensive content and fewest errors, but is more challenging to read and navigate. Both Wikipedia and MedlinePlus have lower content accuracy and more errors, however MedlinePlus is simplest of all to read, at a 9th Grade level.

Biofilms in Otolaryngology: What Does This Mean to the Clinician?

Program Description: Virtually all microbes live in biofilm communities. Within these communities, the microbes assume differing specialized roles which confer survival advantages on the community. These communities cause chronic and device-associated infections. The role of biofilms in the persistence of chronic, mucosal-based ENT-related infections was first recognized in otitis media. Within the field of pediatric otolaryngology, biofilms have now been shown to play a role in many infections, including: recurrent acute otitis media, otitis media with effusion, cholesteatoma, chronic tonsillitis, chronic rhinosinusitis, and infections of tracheostomies, endotracheal tubes, tympanostomy tubes, and cochlear implants. The recognition that chronic ear, nose, and throat bacterial infections are biofilm-related has been the impetus for the development of new technologies for the study of biofilms and their prevention and treatment. Understanding that chronic bacterial infections are biofilm-related is fundamental to developing rationale strategies for treatment and prevention.

Educational Objectives: 1) Appreciate the current state of understanding regarding biofilms in middle ear effusions and recurrent acute otitis media. 2) Understand the contributions that biofilms make toward chronic infections of the tonsils and adenoids. 3) Understand the near and long-term possibilities in treatment and prevention of pediatric otolaryngology infections associated with biofilms.

Extracts from the Cochrane Library: "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children"

The Cochrane Corner is a quarterly section in the journal that highlights systematic reviews relevant to otolaryngology–head and neck surgery, with invited commentary to aid clinical decision making. This installment features an updated Cochrane review "Grommets (Ventilation Tubes) for Hearing Loss Associated with Otitis Media with Effusion in Children" that reinforces the modest benefits demonstrated in the original review published in 2005.

Obstructive sleep disorders in Prader-Willi syndrome: The role of surgery and growth hormone

OBJECTIVE

To review the effectiveness and safety of surgical intervention for obstructive sleep apnea in Prader-Willi syndrome.

BACKGROUND

The muscle hypotonia and obesity associated with Prader-Willi syndrome (PWS) result in a high rate of obstructive sleep apnea (OSA). The use of growth hormone therapy in these patients has been associated with sudden death, raising concerns that such treatment may exacerbate obstructive sleep apnea. As a result, it has been suggested that children with PWS be evaluated for OSA and indications for adenotonsillectomy prior to instituting growth hormone therapy. The true effectiveness of surgical intervention in these cases, however, remains in doubt.

METHODS

Retrospective review of patients with a diagnosis of PWS who underwent adenoidectomy or adenotonsillectomy from January 2001 to July 2009 at a regional, tertiary care children's hospital. Patients underwent pre-operative and post-operative polysomnography. Differences between pre-operative and post-operative body-mass index (BMI), apnea-hypopnea index (AHI), and median oxygen saturation and oxygen saturation nadir were analyzed.

RESULTS

Five patients were identified during the study period. Three patients underwent adenotonsillectomy, 1 patient adenoidectomy alone, and another adenotonsillectomy with uvulopalatopharyngoplasty (UPPP). While median AHI was found to have decreased from 16.4 to 4.4, no statistically significant change could be demonstrated (p=0.274). Mean O(2) and nadir O(2) saturation also improved, but without reaching statistical significance. No intra-operative complications were noted.

CONCLUSIONS

Our series, and other small case series, have demonstrated that complete resolution of sleep apnea in PWS patients is difficult to obtain with upper airway surgery alone. It is suggested that children with PWS being considered for growth hormone therapy undergo assessment for OSA by polysomnography. Patients identified with OSA should be referred for management by tonsillectomy and/or continuous positive airway pressure (CPAP) and then reassessed for residual airway obstruction prior to instituting hormonal therapy.

Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: Comparing three tonsillectomy techniques

Objective: To compare the rates of major complications (postoperative hemorrhage requiring return to the operating room or cauterization in the emergency department and dehydration requiring intravenous fluids or readmission) in a large cohort of children undergoing adenotonsillectomy by three different techniques.

Study Design: Case series with chart review, case-controlled study.

Setting: Regional children's hospital.

Subjects and Methods: Subjects comprised patients aged 1 to 18 years undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy by microdebrider, coblator, or Bovie over a 36-month period. Major complications identified were compared to two case-matched controls to try to identify patients at risk for major postoperative complications.

Results: The overall complication rate was 80 of 4776 (1.7 ± 0.4% [percent ± 95% confidence interval]). Of the 3362 patients who received either an adenotonsillectomy or tonsillectomy alone, 80 had a complication (2.3 ± 0.5%). Major complication rates differed among tonsil removal techniques: 34 of 1235 (2.8 ± 0.9%) coblation; 40 of 1289 (3.1 ± 0.9%) electrocautery; six of 824 (0.7 ± 0.7%) microdebrider ( P < 0.001). Postoperative hemorrhage occurred in older children (8.5 vs 5.5 years; P < 0.001), while age did not influence postsurgical dehydration (5.33 vs 5.49 years). The case-control portion of the study did not find any reliable way to identify patients at risk for complications during adenotonsillectomy. Identity of the surgeon was not a confounding independent variable, nor was participation by resident surgeons.

Conclusion: In this “real life” teaching hospital surgical setting in which three different techniques of tonsillectomy are routinely performed by a variety of resident and attending surgeons, microdebrider intracapsular tonsillectomy is associated with lower rates of post-tonsillectomy hemorrhage and dehydration when compared to coblation and electrocautery complete tonsillectomy technique.

Role of the pediatric otolaryngologist in diagnosis and management of children with mucopolysaccharidoses

OBJECTIVE

Mucopolysaacharidoses (MPS) represent a spectrum of disorders characterized by the genetic deficiency of specific lysosomal enzymes occurring in as many as 1 in 10,000 live births and resulting in the accumulation of glycosaminoglycans within cells throughout the body. Children have highly variable, multi-systemic involvement that nearly always involves manifestations of the head and neck including recurrent otitis, hearing loss, upper airway obstruction, and characteristic coarse facial features. This places the otolaryngologist in a prime position for early recognition and initiation of treatment. We sought to examine our own experience in dealing with this diverse and often quite devastating clinical entity.

METHODS

Retrospective chart review of children with mucopolysaccharidoses seen in our tertiary care pediatric otolaryngology clinic accompanied by review of the literature.

RESULTS

Nine children were identified--five with Hurler syndrome, three with Hunter syndrome, and one with Maroteaux-Lamy syndrome. The median age of diagnosis/genetics referral was 15 months, while median age of presentation to an otolaryngologist was 12 months. Three patients were referred for genetics evaluation based upon initial evaluation/suspicion by an otolaryngologist. Two were diagnosed early because of an affected older sibling. All patients in the series had varying degrees of hearing loss, recurrent otitis, chronic effusions or abnormal facial features, and all patients required placement of at least one set of ventilation tubes.

CONCLUSIONS

Otolaryngologists have an opportunity to play an increasingly integral role in the multidisciplinary approach to the diagnosis and management of many children with mucopolysaccharidoses. Clinical suspicion, early recognition, and prompt diagnosis of these challenging disorders is crucial, as outcomes of treatment in many cases appear time-sensitive, with better results being achieved when intervention is initiated at a younger age or prior to progression of the disease.

Pharmacotherapy of recurrent respiratory papillomatosis: an expert opinion

BACKGROUND

Recurrent respiratory papillomatosis is caused by the human papillomavirus types (HPV) 6 and 11. It affects both children and adults. In a small number of cases, the disease can be very aggressive causing significant morbidity and possibly death. Surgical therapy is the primary treatment but in patients with aggressive disease, adjunctive therapy is initiated. The majority of these adjuncts center on immunomodulation, disruption of molecular signaling cascades or interruption of viral replication to help decrease the severity of the disease. Recently, a preventative vaccine has become available but data on its effectiveness will be at least a decade away. In the mean time, researchers are examining other vaccination strategies in the fight against HPV disease.

OBJECTIVE

We will review the following pharmacotherapies used in the adjunct treatment of RRP: interferon, acyclovir, ribivirin, cidofovir, COX-2 inhibitors, retinoids, anti-reflux medications, zinc, indole-3-carbinol, therapeutic/preventative vaccines.

METHODS

This is a review paper. Utilizing Medline and Pubmed from 1966 to present, the key words as well as the above listed adjunct treatments were searched for relevant papers.

CONCLUSION

The evidence supporting each of these adjuncts varies with a majority having only case reports or cases-series to support their use. However, there is hope on the horizon with regard to the HPV vaccine and its potential to prevent future transmission of this disease.

Extracts fromThe Cochrane Library: Intranasal corticosteroids for moderate to severe adenoidal hypertrophy

The “Cochrane Corner” is a quarterly section in the Journal that highlights systematic reviews relevant to otolaryngology–head and neck surgery, with invited commentary to aid clinical decision making. This installment features a Cochrane Review entitled “Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy,” which finds limited evidence of a short-term improvement in nasal symptoms with a reduction of adenoid size.

Age of child, more than HPV type, is associated with clinical course in recurrent respiratory papillomatosis

Background

RRP is a devastating disease in which papillomas in the airway cause hoarseness and breathing difficulty. The disease is caused by human papillomavirus (HPV) 6 or 11 and is very variable. Patients undergo multiple surgeries to maintain a patent airway and in order to communicate vocally. Several small studies have been published in which most have noted that HPV 11 is associated with a more aggressive course.

Methodology/Principal Findings

Papilloma biopsies were taken from patients undergoing surgical treatment of RRP and were subjected to HPV typing. 118 patients with juvenile-onset RRP with at least 1 year of clinical data and infected with a single HPV type were analyzed. HPV 11 was encountered in 40% of the patients. By our definition, most of the patients in the sample (81%) had run an aggressive course. The odds of a patient with HPV 11 running an aggressive course were 3.9 times higher than that of patients with HPV 6 (Fisher's exact p = 0.017). However, clinical course was more closely associated with age of the patient (at diagnosis and at the time of the current surgery) than with HPV type. Patients with HPV 11 were diagnosed at a younger age (2.4y) than were those with HPV 6 (3.4y) (p = 0.014). Both by multiple linear regression and by multiple logistic regression HPV type was only weakly associated with metrics of disease course when simultaneously accounting for age.

Conclusions/Significance Abstract

The course of RRP is variable and a quarter of the variability can be accounted for by the age of the patient. HPV 11 is more closely associated with a younger age at diagnosis than it is associated with an aggressive clinical course. These data suggest that there are factors other than HPV type and age of the patient that determine disease course.

Microdebrider intracapsular tonsillectomy

With a continued desire to reduce the morbidity of tonsil surgery, otolaryngologists have begun to use powered microdebriders to perform partial intracapsular tonsillectomies. This technique has an advantage over conventional tonsillectomy of leaving a biological dressing or residual tonsillar tissue and capsule to protect the underlying musculature with its vessels and nerves. The literature has shown that partial intracapsular tonsillectomy is equally effective at relieving patient's symptoms of obstruction when compared to conventional tonsillectomy and that it appears to reduce the complications of postoperative pain, dehydration, and bleeding. Patients are able to return to normal activity and diet faster as the healing process is accelerated. This article reviews the published data on microdebrider-assisted partial intracapsular tonsillectomy with a discussion of its advantages, potential limitations and areas of future research.

Prevention of recurrent respiratory papillomatosis: role of HPV vaccination

Recurrent respiratory papillomatosis is a rare, but devastating, cause of airway lesions in children and adults. This disease is caused by human papilloma virus subtypes 6 and 11. At this time there are two vaccines in late stages of development seeking Food and Drug Administration (FDA) approval to prevent cervical cancer, which is also caused by human papilloma virus. One of these vaccines has been developed to stimulate immunity to the most common subtypes that cause cervical cancer but also includes those responsible for recurrent respiratory papillomatosis. With the possibility this could drastically reduce the incidence of RRP, the otolaryngology community should advocate for implementation of a vaccine program that provides effective prevention of HPV infection with subtypes 6 and 11.

Outcomes in children with perforated tympanic membranes after tympanostomy tube placement: results using a pilot treatment algorithm

PURPOSE

The objective of this study was to examine the success of a pilot treatment algorithm for tympanic membrane perforations in children after tympanostomy tube placement.

MATERIALS AND METHODS

A retrospective chart review of children with diagnosed tympanic membrane perforations after tympanostomy tube placement from 1998 to 2003 at a tertiary care children's hospital was performed. The patients had been treated according to an algorithm used by 2 pediatric otolaryngologists for management of tympanic membrane perforations: observation vs myringoplasty. Success rates were examined.

RESULTS

Ninety-five children were identified, 27% of whom had nonhealing perforations after tube extrusion; 73% of the perforations were caused by a retained tube. The median duration of tube retention was 48 months, ranging from 13 to 120 months. After the treatment protocol, 76% of the patients underwent gelatin film or paper patch myringoplasty, 23% had adipose myringoplasty, and 1% were observed. Overall, 91% had healed perforations after the first intervention. Among those requiring a second intervention, the sizes of initial perforations were between 15% and 40%, with postrepair perforation sizes between 5% and 40%. In addition, 75% of those requiring a second intervention underwent tympanoplasty repair and 25% had fat patch myringoplasty. None required a third intervention.

CONCLUSIONS

Our treatment algorithm for children with tympanic membrane perforations after tympanostomy tube placement appears to be successful and is an excellent model for other clinicians.

Four mutations in Epidermodysplasia verruciformis 1 (EVER1) gene are not contributors to susceptibility in RRP

OBJECTIVE

Epidermodysplasia verruciformis is a skin disease characterized by abnormal susceptibility to human papilloma viruses. Recently four mutations in the Epidermodysplasia verruciformis 1 gene (EVER1, also known as TMC6) have been associated with the disease. Because of the phenotypic similarity between Epidermodysplasia verruciformis and recurrent respiratory papillomatosis, we decided to investigate whether any of these mutations accounts for the susceptibility to human papilloma viruses in subjects with recurrent respiratory papillomatosis (RRP).

METHODS

Allele-specific PCR and restriction fragment length polymorphisms (RFLPs) were employed for genotyping a cohort of 101 patients with recurrent respiratory papillomatosis.

RESULTS

None of these four mutations were found in the studied subjects.

CONCLUSION

The absence of these mutations in RRP patients might indicate that EVER 1 alleles are not associated with susceptibility to RRP, or that other, as yet unidentified, mutations in the Epidermodysplasia verruciformis 1 gene, might account for the susceptibility to RRP.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a frustrating and challenging disease for surgeons, patients, and patients' families. Although the voice and airway manifestations are managed surgically, a "cure" for this disease remains elusive. In this edition of the "Seminar Series," we endeavor to review the current literature regarding the epidemiology, etiology, clinical manifestations, and surgical and medical treatments of this disorder. The key to future management of recurrent respiratory papillomatosis may lie in its prevention, if current efforts to develop an effective vaccine come to fruition.

HspE7 treatment of pediatric recurrent respiratory papillomatosis: final results of an open-label trial

OBJECTIVES

We sought to evaluate the effectiveness of HspE7, a recombinant fusion protein of Hsp65 from Mycobacterium bovis BCG and E7 protein from human papillomavirus 16, to improve the clinical course of pediatric patients with recurrent respiratory papillomatosis.

METHODS

An open-label, single-arm intervention study was conducted in 8 university-affiliated medical centers. Twenty-seven male and female patients with recurrent respiratory papillomatosis, ages 2 to 18 years, were enrolled and followed up to 60 weeks. Before enrollment, these patients required surgery on average every 55 days. After a baseline debulking surgery, the patients received HspE7 500 microg subcutaneously monthly, for 3 doses over 60 days. The primary end point was the length of the interval from the last surgery during the treatment period until the first debulking surgery in the posttreatment period, compared with the median intersurgical interval (ISI) of the 4 surgeries before the treatment.

RESULTS

The mean of the first posttreatment ISI increased 93% (from 55 days to 106 days; p < .02). The median ISI for all surgeries after treatment was similarly prolonged (mean, 107 days; p < .02), indicating a sustained treatment effect, and was associated with a significant decrease in the number of required surgeries (p < .003). Unexpectedly, the treatment effect was most striking in the 13 female patients, who had statistically significant increases in both the first posttreatment ISI (142%; p < .03) and the median ISI (147%; p < .03). The most common adverse events were mild-to-moderate injection site reactions.

CONCLUSIONS

Treatment with HspE7 appears to significantly improve the clinical course in pediatric patients with RRP insofar as it reduces the frequency of required surgeries. These results warrant a confirmatory phase III trial.

Pediatric sinusitis: when do we operate?

PURPOSE OF REVIEW

The role of surgery in the treatment of pediatric sinusitis is still in evolution. This review of recent literature highlights developments in the study of pediatric sinusitis, particularly as it pertains to surgical intervention.

RECENT FINDINGS

There is growing support in the literature for adenoidectomy as a first-line surgical intervention for chronic rhinosinusitis in children when maximal medical management fails. Maxillary sinus aspiration or middle meatal culture can be performed at the same sitting to facilitate directed antibiotic therapy. Intravenous antibiotics seem to be a promising alternative to functional endoscopic sinus surgery (FESS), especially in younger children. Current literature continues to support FESS as a safe and effective treatment for pediatric sinus disease. Previous notions that FESS may inhibit midfacial growth have been challenged by several recent studies. There is no clear consensus regarding timing of FESS for chronic rhinosinusitis. However, the current literature seems to support FESS when maximal medical therapy, adenoidectomy, and culture-directed systemic antibiotics have all failed with persistence of sinonasal disease, when anatomic abnormalities predispose to chronic rhinosinusitis by obstructing normal sinonasal drainage pathways, in sinonasal polyposis to facilitate application of topical steroids, as an adjunct to desensitization in aspirin-sensitive patients, when orbital or intracranial complications of sinonasal disease occur, and in selected cystic fibrosis patients to improve quality of life and facilitate application of topical antibiotics with activity against Pseudomonas aeruginosa.

SUMMARY

Although the current literature lends some additional clarity to the indications for surgical intervention in pediatric chronic rhinosinusitis, additional research is still needed to elucidate appropriate timing for surgery and more specific indications.

Analysis of a staging assessment system for prediction of surgical interval in recurrent respiratory papillomatosis

INTRODUCTION

A staging system for assessment of recurrent respiratory papillomatosis (RRP) has been in use over the last 3 years for 17 patients at our children's hospital.

OBJECTIVE

To evaluate a staging system for assessment of RRP on the basis of the predictive value on the surgical interval of: anatomic staging system score, urgency of intervention, voice quality, and stridor. To assess effect on surgical interval of the age of patient at time of surgery and use of adjuvant therapy. To develop a model based on the staging criteria to predict need for adjuvant therapy.

DESIGN

Validation cohort.

SETTING

Academic children's hospital.

RESULTS

Estimated time to surgery decreased by "x days": "independent variable" "(95% CI)" as follows. Four days: each 1 point in total anatomical score (0.2, 8); 120 days: total anatomical score >20 (37,203); 143 days: urgent versus scheduled surgery (42, 243); 100 days: aphonic versus normal voice (-211, 343); 31 days: abnormal versus normal voice (-281, 343); 125 days: stridor at rest versus no stridor (-31, 281); 109 days: stridor with activity versus no stridor (19, 198); 26 days: each 1 year decrease in age (22, 30). Adjuvant therapy delays next surgery by 32 days (-4, 69) and average scores decreased while on adjuvant therapy.

CONCLUSIONS

Elements of our proposed staging system are effective in prediction of surgical interval with statistical significance achieved for total anatomical scores, urgency of intervention and stridor with activity versus no stridor. This study is pilot in nature and provides a framework upon which future studies can be based. The analysis of a larger, more severity diverse population could yield results which lead to a model capable of effectively predicting future surgical interval based on a weighted prediction score calculated from age, comorbidities, anatomic staging score, and clinical staging score.