Preoperative Imaging and Surgical Findings in Pediatric Frontonasal Dermoids

OBJECTIVE

To review cases of congenital frontonasal dermoids to gain insight into the accuracy of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in predicting intracranial extension.

METHODS

This retrospective study included all patients who underwent primary excision of frontonasal dermoids at an academic children's hospital over a 23-year period. Preoperative presentation, imaging, and operative findings were reviewed. Receiver operating characteristic (ROC) statistics were generated to determine CT and MRI accuracy in detecting intracranial extension.

RESULTS

Search queries yielded 129 patients who underwent surgical removal of frontonasal dermoids over the study period with an average age of presentation of 12 months. Preoperative imaging was performed on 122 patients, with 19 patients receiving both CT and MRI. CT and MRI were concordant in the prediction of intracranial extension in 18 out of 19 patients. Intraoperatively, intracranial extension requiring craniotomy was seen in 11 patients (8.5%). CT was 87.5% sensitive and 97.4% specific for predicting intracranial extension with an ROC of 0.925 (95% CI [0.801, 1]), whereas MRI was 60.0% sensitive and 97.8% specific with an ROC of 0.789 (95% CI [0.627, 0.950]).

CONCLUSION

This is the largest case series in the literature describing a single institution's experience with frontonasal dermoids. Intracranial extension is rare and few patients required craniotomy in our series. CT and MRI have comparable accuracy at detecting intracranial extension. Single-modality imaging is recommended preoperatively in the absence of other clinical indications.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1961-1966, 2024.

Delaying Invasive Treatment in Unilateral Head and Neck Lymphatic Malformation Improves Outcomes

OBJECTIVES

Large (De Serres stage [IV-V]) head and neck lymphatic malformations (HNLMs) often have multiple, high-risk, invasive treatments (ITs) to address functional compromise. Logically reducing HNLM ITs should reduce treatment risk. We tested whether delaying HNLM ITs reduces total IT number.

MATERIALS

Consecutive HNLM patients (n = 199) between 2010 and 2017, aged 0-18 years.

METHODS

ITs (surgery or sclerotherapy) were offered for persistent or dysfunction causing HNLMs. Treatment effectiveness categorized by IT number: optimal (0-1), acceptable (2-5), or suboptimal (>5). Clinical data were summarized, and outcome associations tested (χ² ). Relative risk (RR) with a Poisson working model tested whether HNLM observation or IT delay (>6 months post-diagnosis) predicts treatment success (i.e., ≤1 IT).

RESULTS

Median age at HNLM diagnosis was 1.3 months (interquartile range [IQR] 0-45 m) with 107/199(54%) male. HNLM were stage I-III (174 [88%]), IV-V (25 [13%]). Initial treatment was observation (70 [35%]), invasive (129 [65%]). Treatment outcomes were optimal (137 [69%]), acceptable (36 [18%]), and suboptimal (26 [13%]). Suboptimal outcome associations: EXIT procedure, stage IV-V, oral location, and tracheotomy (p < 0.001). Stage I-III HNLMs were initially observed compared with stage I-III having ITs within 6 months of HNLM diagnosis, had a 82% lower relative treatment failure risk ([i.e., >1 IT], RR = 0.09, 95% CI 0.02-0.36, p < 0.001). Stage I-III HNLMs with non-delayed ITs had reduced treatment failure risk compared with IV-V (RR = 0.47, 95% CI 0.33-0.66, p < 0.001).

CONCLUSION

Observation and delayed IT in stage I-III HNLM ("Grade 1") is safe and reduces IT (i.e., ≤1 IT). Stage IV-V HNLMs ("Grade 2") with early IT have a greater risk of multiple ITs.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:956-962, 2023.

Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database

OBJECTIVE

Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism.

STUDY DESIGN

Retrospective multi-institutional cohort study.

SETTING

Tertiary care pediatric hospital systems throughout North America.

METHODS

Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models.

RESULTS

In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism.

CONCLUSION

These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

Clinical Outcomes of Diffuse Sclerosing Variant Papillary Thyroid Carcinoma in Pediatric Patients

OBJECTIVES/HYPOTHESIS

The diffuse sclerosing variant of papillary thyroid carcinoma (DSV) may be more aggressive than conventional well-differentiated non-DSV related papillary thyroid carcinomas (N-PTC).

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective review of clinical outcomes for patients 21 years of age or younger who underwent initial surgery for PTC at a single institution from January 1, 2005 to April 1, 2020. Genomic analysis was performed using targeted next-generation sequencing. Data were analyzed using Fischer's exact test and Kaplan-Meier curve log-rank test.

RESULTS

Our cohort consisted of 72 patients, nine with DSV and 63 with N-PTC. Age at diagnosis was comparable (15.4 vs. 16.2 years, respectively, P = .46). DSV were more likely to be in the high-risk American Thyroid Academy pediatric risk group (100% vs. 41.3%, P = .004), to present with regional cervical lymph node metastases (100% vs. 60.3%, P = .036), and to present with distant metastases (67% vs. 22%, P = .005). No mortality seen in either group over 27.5 (interquartile range 14.8, 46.00) months average follow-up. Throughout the follow-up period, DSV were more likely to experience progression than N-PTC (hazard ratio = 5.7 [95% confidence interval 1.7-20.0; P = .0056]). In a subset of 19 patients with aggressive disease who had molecular testing as part of clinical care we detected RET fusions in nearly all DSV compared to a minority of N-PTC (83% vs. 15.4%, P = .0095).

CONCLUSIONS

Pediatric patients with DSV have more advanced disease at diagnosis and are more likely to experience progression of disease compared to patients with N-PTC. The prevalence of RET fusions in our cohort recapitulates the frequency of this alteration described in prior studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

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

Importance

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

Observations

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

Conclusions and Relevance

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

Impact of Eliminating Local Anesthesia on Immediate Postoperative Analgesia in Pediatric Ambulatory Adenotonsillectomy

Our goal was to standardize intraoperative analgesic regimens for pediatric ambulatory tonsillectomy by eliminating local anesthetic use and to determine its impact on postoperative pain measures, while controlling for other factors.

METHODS

We assembled a quality improvement team at an ambulatory surgery center. They introduced a standardized anesthetic protocol, involving American Society of Anesthesiologists Classification 1 and 2 patients undergoing adenotonsillectomy. Local anesthesia elimination was the project's single intervention. We collected pre-intervention data (79 cases) from July 5 to September 17, 2019 and post-intervention data (59 cases) from September 25 to December 17, 2019. The intervention requested that surgeons eliminate the use of local anesthetics. The following outcomes measures were evaluated using statistical process control charts and Shewhart's theory of variation: (1) maximum pain score in the post-anesthesia care unit, (2) total post-anesthesia care unit minutes, and (3) postoperative opioid rescue rate.

RESULTS

No special cause variation signal was detected in any of the measures following the intervention.

CONCLUSIONS

Our data suggest that eliminating intraoperative local anesthetic use does not worsen postoperative pain control at our facility. The intervention eliminated the added expenses and possible risks associated with local anesthetic use. This series is unique in its standardization of anesthetic regimen in a high-volume ambulatory surgery center with the exception of local anesthesia practices. The study results may impact the standardized clinical protocol for pediatric ambulatory adenotonsillectomy at our institution and may hold relevance for other centers.

Active Observation as an Alternative to Invasive Treatments for Pediatric Head and Neck Lymphatic Malformations

OBJECTIVES

An increasing number of treatment modalities for lymphatic malformations are being described, complicating therapeutic decisions. Understanding lymphatic malformation natural history is essential. We describe management of head and neck lymphatic malformations where decisions primarily addressed lesion-induced functional compromise (ie, breathing, swallowing) to identify factors associated with invasive treatment and active observation. We hypothesize that non-function threatening malformations can be observed.

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective case series of consecutive head and neck lymphatic malformation patients (2000-2017) with over 2 years of follow-up. Patient characteristics were summarized and associations with invasive treatment (surgery or sclerotherapy) tested using Fisher's exact. In observed patients, factors associated with spontaneous regression were assessed with Fisher's exact test.

RESULTS

Of 191 patients, 101 (53%) were male, 97 (51%) Caucasian, and 98 (51.3%) younger than 3 months. Malformations were de Serres I-III 167 (87%), or IV-V 24 (12%), and commonly located in the neck (101, 53%), or oral cavity (36, 19%). Initial treatments included observation (65, 34%) or invasive treatments such as primary surgery (80, 42%), staged surgery (25, 13%), or primary sclerotherapy (9, 5%). Of 65 initially observed malformations, 8 (12%) subsequently had invasive treatment, 36 (58%) had spontaneous regression, and 21 (32%) elected for no invasive therapy. Spontaneous regression was associated with location in the lateral neck (P = .003) and macrocystic malformations (P = .017).

CONCLUSION

Head and neck lymphatic malformation treatment selection can be individualized after stratifying by stage, presence of functional compromise, and consideration of natural history. Recognizing the spectrum of severity is essential in evaluating efficacy of emerging treatments, as selected malformations may respond to observation.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1392-1397, 2021.

Pediatric Otolaryngology Divisional and Institutional Preparatory Response at Seattle Children's Hospital after COVID-19 Regional Exposure

Coronavirus disease 2019 (COVID-19) is a novel coronavirus resulting in high mortality in the adult population but low mortality in the pediatric population. The role children and adolescents play in COVID-19 transmission is unclear, and it is possible that healthy pediatric patients serve as a reservoir for the virus. This article serves as a summary of a single pediatric institution's response to COVID-19 with the goal of protecting both patients and health care providers while providing ongoing care to critically ill patients who require urgent interventions. A significant limitation of this commentary is that it reflects a single institution's joint effort at a moment in time but does not take into consideration future circumstances that could change practice patterns. We still hope dissemination of our overall response at this moment, approximately 8 weeks after our region's first adult case, may benefit other pediatric institutions preparing for COVID-19.

Preoperative Facial Nerve Mapping to Plan and Guide Pediatric Facial Vascular Anomaly Resection

Importance

Facial vascular anomalies are surgical challenges due to their vascularity and facial nerve distortion. To assist facial vascular anomaly surgical treatment, presurgical percutaneous facial nerve stimulation and recording of compound motor action potentials can be used to map the facial nerve branches. During surgery, the nerve map and continuous intraoperative motor end plate potential monitoring can be used to reduce nerve injury.

Objective

To investigate if preoperative facial nerve mapping (FNM) is associated with intraoperative facial nerve injury risk and safe surgical approach options compared with standard nerve integrity monitoring (NIM).

Design, Setting, and Participants

This investigation was a historically controlled study at a tertiary vascular anomaly center in Seattle, Washington. Participants were 92 pediatric patients with facial vascular anomalies undergoing definitive anomaly surgery (from January 1, 1999, through January 1, 2015), with 2 years' follow-up. In retrospective review, a consecutive FNM patient cohort after 2005 (FNM group) was compared with a consecutive historical cohort (1999-2005) (NIM group).

Main Outcomes and Measures

Postoperative facial nerve function and selected surgical approach. For NIM and FNM comparisons, statistical analysis calculated odds ratios of nerve injury and operative approach, and time-to-event methods analyzed operative time.

Results

The NIM group had 31 patients (median age, 3.3 years [interquartile range, 2.2-11.4 years]; 20 [65%] male), and the FNM group had 61 patients (median age, 4.4 years [interquartile range, 1.5-11.0 years]; 26 [43%] male). In both groups, lymphatic malformation resection was most common (19 of 31 [61%] in the NIM group and 32 of 61 [52%] in the FNM group), and the median anomaly volumes were similar (52.4 mL; interquartile range, 12.8-183.3 mL in the NIM group and 65.4 mL; interquartile range, 18.8-180.2 mL in the FNM group). Weakness in the facial nerve branches at 2 years after surgery was more common in the NIM group (6 of 31 [19%]) compared with the FNM group (1 of 61 [2%]) (percentage difference, 17%; 95% CI, 3%-32%). Anterograde facial nerve dissection was used more in the NIM group (27 of 31 [87%]) compared with the FNM group (28 of 61 [46%]) (percentage difference, 41%; 95% CI, 24%-58%). Treatment with retrograde dissection without identification of the main trunk of the facial nerve was performed in 21 of 61 (34%) in the FNM group compared with 0 of 31 (0%) in the NIM group. Operative time was significantly shorter in the FNM group, and patients in the FNM group were more likely to complete surgery sooner (adjusted hazard ratio, 5.36; 95% CI, 2.00-14.36).

Conclusions and Relevance

Facial nerve mapping before facial vascular anomaly surgery was associated with less intraoperative facial nerve injury and shorter operative time. Mapping enabled direct identification of individual intralesional and perilesional nerve branches, reducing the need for traditional anterograde facial nerve dissection, and allowed for safe removal of some lesions after partial nerve dissection through transoral or direct excision.

Chronic Sinusitis as a Manifestation of Primary Immunodeficiency in Adults

Twenty-three adult patients evaluated at a university medical center for severe refractory sinusitis were found to have a primary immunodeficiency on the basis of total immunoglobulin, IgG subclass, and vaccine response determinations. The most common finding was IgG3 deficiency with antibody hyporesponsiveness to pneumococcal vaccine. Treatment options included prophylactic antibiotics and aggressive management of associated allergies with intravenous immunoglobulin reserved for severely affected patients who failed more conservative therapy.

Recurrent Thyroglossal Duct Cysts: A 23-Year Experience and a New Method for Management

Objectives:

We present an experience in the management of primary and recurrent thyroglossal duct cysts (TGDCs) and describe a novel method for recurrent TGDC removal.

Methods:

We performed a retrospective review of TGDC surgery at Children's Hospital in Seattle from 1980 to 2003. The surgical techniques for primary and recurrent TGDCs and the factors associated with TGDC recurrence were evaluated and analyzed.

Results:

During the study period, 231 patients underwent 296 TGDC surgeries. Thirty-four of the 231 patients (15%) underwent a total of 88 procedures for recurrent TGDCs. Successful procedures used for secondary TGDC management included central neck dissection with directed base of tongue (BOT) excision in 6 of 9 patients (67%), secondary Sistrunk operation with limited BOT resection in 12 of 27 patients (44%), revision Sistrunk operation with BOT dissection in 7 of 11 patients (64%), and suture-guided transhyoid pharyngotomy in 8 of 8 patients (100%). Ten of the 231 patients (4%) had initial TGDC incision and drainage and then underwent a total of 21 procedures, excluding the incision and drainage. The factors associated with TGDC recurrence were inaccurate initial diagnosis (17 of 34 or 50%), infection (5 of 34 or 15%), unusual TGDC presentation (5 of 34 or 15%), and lack of BOT musculature removal (7 of 34 or 20%). The level of surgeon training affected the surgical outcome.

Conclusions:

Successful TGDC treatment requires consideration of factors associated with recurrence. Recurrent TGDCs can be treated by several methods, including suture-guided transhyoid pharyngotomy.

First branchial cleft anomalies: otologic manifestations and treatment outcomes

OBJECTIVE

This study describes the presentation of first branchial cleft anomalies and compares outcomes of first branchial cleft with other branchial cleft anomalies with attention to otologic findings.

STUDY DESIGN

Case series with chart review.

SETTING

Pediatric tertiary care facility.

METHODS

Surgical databases were queried to identify children with branchial cleft anomalies. Descriptive analysis defined sample characteristics. Risk estimates were calculated using Fisher's exact test.

RESULTS

Queries identified 126 subjects: 27 (21.4%) had first branchial cleft anomalies, 80 (63.4%) had second, and 19 (15.1%) had third or fourth. Children with first anomalies often presented with otologic complications, including otorrhea (22.2%), otitis media (25.9%), and cholesteatoma (14.8%). Of 80 children with second branchial cleft anomalies, only 3 (3.8%) had otitis. Compared with children with second anomalies, children with first anomalies had a greater risk of requiring primary incision and drainage: 16 (59.3%) vs 2 (2.5%) (relative risk [RR], 3.5; 95% confidence interval [CI], 2.4-5; P<.0001). They were more likely to have persistent disease after primary excision: 7 (25.9%) vs 2 (2.5%) (RR, 3; 95% CI, 1.9-5; P=.0025). They were more likely to undergo additional surgery: 8 (29.6%) vs 3 (11.1%) (RR, 2.9; 95% CI, 1.8-4.7; P=.0025). Of 7 persistent first anomalies, 6 (85.7%) were medial to the facial nerve, and 4 (57.1%) required ear-specific surgery for management.

CONCLUSIONS

Children with first branchial cleft anomalies often present with otologic complaints. They are at increased risk of persistent disease, particularly if anomalies lie medial to the facial nerve. They may require ear-specific surgery such as tympanoplasty.

First Branchial Cleft Anomalies: Otologic Manifestations and Treatment Outcomes

Objectives:

(1) Describe a presentation of first branchial cleft anomalies. (2) Compare outcomes of first branchial cleft to other branchial cleft anomalies with attention to otologic findings.

Methods:

For this case-controlled study, databases at Seattle Childrens Hospital were queried by International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes for pediatric branchial cleft cases from 2004 to 2013. Inferential analysis was performed using unpaired t test. Measurements of risk were calculated using Fisher’s exact test.

Results:

The query identified 104 subjects; 24 (23.1%) of whom had first branchial cleft anomalies, the remaining 80 (76.9%) had second or third branchial cleft anomalies. First branchial cleft anomalies were diagnosed at an older age, 2.65 years (SD = 3.3) versus 1.66 years (SD = 4), P value .28 (not significant). They also presented with a range of otologic findings, including otorrhea (25%), otitis media (29.2%), tympanic membrane web (26.1%), and cholesteatoma (16.7%). They had greater risk of requiring primary incision and drainage: 14 (58.3%) versus 3 (3.8%), odds ratio (OR) 15.12, 95% confidence interval (CI) [3.8, 88.9], P value <.0001. They were also more likely to have recurrent disease: 7 (29.1%) versus 3 (3.8%), OR 7.6, 95% CI [1.59, 49.1], P value .008. They were more likely to undergo additional surgery: 6 (26.1%) versus 4 (5%), OR 4.91, 95% CI [1.07, 25.72], P value .04, often related to residual ear disease.

Conclusions:

Children with first branchial cleft anomalies present with a range of otologic manifestations that increase the risk of persistent disease and that may require specific treatment such as tympanoplasty.

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

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

Transoral approach for direct and complete excision of vallecular cysts in children

OBJECTIVE

To review the presentation, evaluation, and treatment of children with vallecular cysts and introduce a new technique of transoral excision for this entity.

METHODS

Retrospective case series of children diagnosed with vallecular cyst between 2001 and 2008 at a single tertiary care children's hospital. Data collected, including age at diagnosis, presenting symptoms, additional diagnoses, diagnostic modality, prior and subsequent surgical therapy, length of hospital stay, length of follow-up, and recurrence were analyzed with descriptive statistics.

RESULTS

Seven children (mean age 198 days, range 2 days to 2.9 years) were included in this series. Five children presented with respiratory distress and/or swallowing difficulties. Vallecular cyst was diagnosed by initial flexible fiberoptic laryngoscopy (5/7), MRI (1/7), and intubating laryngoscopy (1/7). All children underwent complete cyst excision via transoral surgical approach. Two children underwent additional supraglottoplasty for concomitant laryngomalacia, one of whom underwent tracheotomy for persistent respiratory distress and vocal cord immobility. The average length of hospital stay postoperatively was 9.5 days, and four patients stayed less than 2 days. No patients experienced recurrence of the vallecular cyst at last follow-up (range 4-755 days, mean 233 days).

CONCLUSIONS

Vallecular cysts are rare but should be considered in children with respiratory distress and dysphagia. Awake, flexible fiberoptic laryngoscopy with particular attention to the vallecular region should be performed on any child presenting with these symptoms. Direct, transoral approach for excision of the vallecular cyst is our preferred method of treatment with no recurrences to date.

Redefining Pediatric Rhinosinusitis

Program Description: Over a decade has passed since the last comprehensive definition of pediatric rhinosinusitis was developed by an expert panel. In this miniseminar, international leaders in the field of pediatric rhinology will provide the latest evidence and experience regarding the definition of pediatric rhinosinusitis. Specifically, panelists will provide state-of-the-art concepts regarding pediatric rhinosinusitis including contributing factors such as allergy, antigens, fungus, biofilms, and reflux. The panel will discuss the differences between acute and chronic pediatric rhinosinusitis and provide the audience with guidelines for the clinical evaluation of both. Finally, with the use of case presentations, the panel will discuss contemporary medical and surgical interventions for acute and chronic pediatric rhinosinusitis.

Educational Objectives: 1) Understand the current definitions of acute and chronic pediatric rhinosinusitis. 2) Understand contributing factors to pediatric rhinosinusitis including allergy, fungus, biofilms, and reflux. 3) Understand contemporary treatment options for acute and chronic pediatric rhinosinusitis.

Pediatric Sinusitis: Drugs and Devices

Program Description: Pediatric sinusitis is a major source of patient referrals for the otolaryngologist. The issue of diagnosis and treatment differs from the adult with regard to pathophysiology, management, and patient cooperation. This seminar will focus on the current state of drugs and devices used to diagnose and treat pediatric sinusitis. The seminar will begin with the use of devices in children to diagnose chronic rhinosinusitis or differentiate rhinitis from sinusitis. Discussion will include the use of pediatric office endoscopy, endoscopic-guided cultures, CT scanning, pH probe testing and other devices. We will also discuss how they should be used in the office on children. The seminar will then progress to the use of drugs and devices in the management and treatment of pediatric sinusitis. This discussion will include adenoidectomy and associated devices, culture techniques, balloon sinus surgery, and associated minimally invasive devices as well as traditional endoscopic surgical techniques. Further discussion will focus on various endoscopic surgical drugs and devices applied to the pediatric patient both intraoperative and postoperative. Drugs discussed for the treatment and management of pediatric sinusitis will include intravenous antibiotics, topical aerosol therapy, mucolytic agents, steroids, and intranasal packing and stents. Presentations will also occur on the pediatric patient with special issues and sinusitis such as immunologic deficiencies and cystic fibrosis. This will be a presentation based on the current literature, extensive clinical experience and case studies. Panel discussions and opinion by pediatric otolaryngologist with extensive experience will be a major part of this seminar.

Educational Objectives: 1) Discuss and present drugs and medical devices currently used to diagnose and treat pediatric sinusitis. 2) Present current medical devices and techniques used to treat pediatric sinusitis in the operative setting. 3) Present current drugs and devices used to manage children with sinusitis and related medical disorders.

Diagnosis and treatment of primary immunodeficiency disease: the role of the otolaryngologist

OBJECTIVE

The objective of the study was to review the diagnosis and treatment of primary immunodeficiency disease (PID) and the role of otolaryngologists in the management of PID.

METHODS

A search was conducted of PubMed and the Web sites of organizations for PID patients for literature pertaining to the diagnosis and treatment of PID, with an emphasis on the role of otolaryngologists. The reference lists of selected articles were reviewed for additional articles.

RESULTS

Patients with PID commonly present with respiratory tract infections (eg, recurrent ear, nose, or throat infections) and chest disease. Diagnostic delays or inadequate treatment of PID may lead to significant morbidity and premature mortality. Immunoglobulin (Ig) replacement is the cornerstone of therapy for most patients with PID. Although intravenous Ig is the most popular route of administration in the United States, subcutaneous Ig administration may be appropriate for patients with poor venous access, those who are unable to tolerate intravenous Ig, or those who prefer the independence and flexibility of self-administration.

CONCLUSIONS

Recognition and diagnosis of PID by otolaryngologists are critical to optimizing patient outcomes. Several therapeutic regimens for Ig replacement are now available that offer patients increased flexibility and independence.

How airway venous malformations differ from airway infantile hemangiomas

OBJECTIVE

To compare airway infantile hemangiomas (IHs) and venous malformations (VMs) clinically, radiographically, endoscopically, and histologically.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care pediatric hospital.

PATIENTS

The study included patients seen in the Vascular Anomaly Clinic, Seattle Children's Hospital, Seattle, Washington, between 2001 and 2008.

METHODS

All patients with airway vascular anomalies were identified by searching the Vascular Anomaly Quality Improvement Database and hospital discharge data. The data, which were analyzed with descriptive statistics and the Fisher exact test, included presenting age, sex, presenting signs, lesion site, and radiographic, endoscopic, and histologic findings..

RESULTS

Seventeen patients with airway lesions were identified, 6 with VMs and 11 with IHs. Patients with VMs presented at a mean (SD) age of 11.3 (13.7) months (age range, 3-39 months), while those with IHs presented at 3 (1.8) months of age (age range, 1-6 months) (P = .03). The patients with IHs were predominantly female (9 of 11 [81%]), while no sex difference was noted among the patients with VMs (3 of 6 [50%]). All patients with IHs presented with stridor and cutaneous lesions, whereas patients with VMs more often presented with hemoptysis or dysphagia (P = .001). Computed tomographic angiograms demonstrated enhancing endolaryngeal lesions in all IHs, while VMs enhanced poorly. Endoscopically, IHs were transglottic, while VMs were postcricoid or epiglottic (P < .001). Histologically, immunostained lesions showed submucosal lobules of capillaries lined by GLUT-1 (glucose transporter isoform 1)-positive endothelium in IHs, whereas VMs consisted of loosely organized venous channels that lacked GLUT-1 staining.

CONCLUSION

Patients with airway IHs and VMs differ in presenting age and signs, sex, airway lesion location, enhancement on computed tomographic angiograms, and histologic appearance.

Initial Experience With a Multidisciplinary Strategy for Initiation of Propranolol Therapy for Infantile Hemangiomas

Objectives. To outline a safe, standardized protocol for outpatient initiation of propranolol therapy for infantile hemangiomas.

Study Design. Retrospective review.

Setting. Academic tertiary care pediatric hospital.

Subjects and Methods. Forty-nine infantile hemangioma patients were offered propranolol therapy and included in the study. Any patients requiring hospital admission were excluded. Screening consisted of cardiology evaluation, including electrocardiography and, when indicated, echocardiography. Target initiation dose was 2 to 3 mg/kg/d divided into 3 doses. Blood pressure and heart rate were initially monitored at baseline and 1 and 2 hours in clinic following initial dosing. A 3-hour time point was later added. Families received standardized instructions regarding home heart rate monitoring, side effects, and fasting.

Results. Outpatient propranolol therapy was safely initiated in 39 of 44 patients (89%). Five patients required brief admission: 1 with clinical signs/symptoms of heart failure, 3 having airway involvement, and 1 for social reasons. Propranolol administration transiently reduced blood pressure; the maximal decrease occurred at 2 hours, prompting addition of a 3-hour time point to ensure recovery. No patients exhibited symptomatic hypotension, bradycardia, or heart failure.

Conclusions. In most children with infantile hemangiomas, propranolol therapy can be safely initiated as an outpatient. Careful cardiovascular evaluation by an experienced clinician is essential for pretreatment evaluation, inpatient admission (when necessary), blood pressure and heart rate monitoring following initial dosing, and parent education. This standardized multidisciplinary outpatient initiation plan reduces the cost of initiating therapy compared with inpatient strategies while still providing appropriate monitoring for potential treatment complications. Further evaluation of propranolol therapy efficacy at the current dosing and duration of treatment continues.

Endoscopie posterior cricoid split and rib grafting in 10 children

OBJECTIVE

To report our experience with endoscopic posterior cricoid split and rib graft insertion (EPCS/RG) in children with posterior glottic (PGS) and subglottic stenosis (SGS).

DESIGN

Retrospective analysis of case series, with 1 to 2 year follow-up.

SETTING

Tertiary-care pediatric referral center.

PATIENTS

Ten consecutive patients undergoing EPCS/RG.

INTERVENTION

EPCS/RG is a new procedure that expands the posterior glottic opening by dividing the posterior cricoid lamina endoscopically with a laser and inserting a rib cartilage graft through the laryngoscope.

MAIN OUTCOME MEASURES

Laryngeal function and hospital stay.

RESULTS

Successful decannulation in two of two patients with PGS and one of five patients with PGS and SGS without further surgery. Of the four not initially decannulated, two were decannulated with adjunctive procedures, and the other two can now tolerate tracheostomy capping for extended periods of time. We achieved improvement in exercise tolerance in three nontracheotomy-dependent patients. For those with established tracheotomies, median hospital stay was 3 days and intensive care unit care was unnecessary. There were no major complications or deterioration of voice or feeding.

CONCLUSIONS

EPCS/RG appears to be safe and effective in the management of PGS in selected pediatric patients. This minimally invasive procedure has advantages over traditional open approaches and destructive endoscopic techniques (cordotomy and arytenoidectomy). The role of EPCS/RG alone in the face of severe grades of SGS appears to be limited.

Lymphatic malformations: Current cellular and clinical investigations

Objective: Summarize current knowledge of lymphatic malformation development, biology, and clinical outcome measures.

Methods: Panel presentation of lymphatic malformation biology and measurement of head and neck malformation treatment outcomes.

Results: Characterization of lymphatic malformation endothelial and stromal cells may lead to biologically based treatment. Traditionally, lymphatic malformation treatment outcomes have been measured according to reduction of malformation size. Currently, methods to measure functional outcomes following lymphatic malformation treatment are lacking. This is particularly apparent when the malformation directly involves the upper aerodigestive tract.

Conclusions: The etiology and pathogenesis of head and neck lymphatic malformations are poorly understood, but understanding is improving through ongoing investigation. Reduction of lymphatic malformation size is generally possible, but further work is necessary to optimize methods for measuring therapeutic outcomes in problematic areas.

Epiglottitis due to nontypeable Haemophilus influenzae in a vaccinated child

Once a prevalent disease, acute epiglottitis in children has become a rare entity. The introduction of the Haemophilus influenzae type b vaccine has had a dramatic impact on the number of invasive infections caused by this organism. However, physicians must be aware that epiglottitis may result from vaccine failures or from infection with other pathogenic organisms. Vaccinated children with epiglottitis present in a similar fashion to those who are not vaccinated. We present a rare case of acute epiglottitis in a fully vaccinated child due to nontypeable H. influenzae and discuss the clinical presentation and management.

Proposal for Staging Airway Hemangiomas

OBJECTIVE: To describe a method of airway infantile hemangioma staging using standardized assessment of airway narrowing, and hemangioma location and volume, as determined with endoscopy and CT angiography.

STUDY DESIGN: Case series with chart review.

SETTING: Tertiary pediatric hospital, 2003-2008.

SUBJECTS AND METHODS: Subjects included airway hemangioma patients evaluated at a tertiary pediatric hospital. Data collected were age at first symptoms, diagnostic evaluation, percent airway compromise, and estimated hemangioma volume. Data were analyzed with descriptive and Fisher exact statistics.

RESULTS: Twelve patients were identified and seven had complete data sets. Mean age at first symptoms was 1.9 months (SD 1.09 months, range 0.5-4 months). Evaluation consisted of nasopharyngoscopy, microlaryngoscopy, CT angiography, and/or MRI. Mean laryngeal airway narrowing was estimated at 63.75 percent (SD 19.0%, range 40%-90%). Total hemangioma volume was less in patients with isolated (focal) endolaryngeal hemangiomas compared with airway hemangiomas associated with extralaryngeal (segmental) hemangiomas. Airway hemangioma stages were stage one (5 of 12; 41.6%), stage two (6 of 12; 50.0%), and stage three (1 of 12; 8.3%).

CONCLUSION: This method of airway hemangioma staging may be applicable to treatment planning and used to measure treatment outcomes.

Airway procedures and hemangiomas: treatment patterns and outcome in U.S. pediatric hospitals

OBJECTIVE

Characterize and compare care in children with hemangiomas, who do or do not undergo airway procedures.

METHODS

National retrospective cohort study of patients aged 0-18 with hemangiomas, from 33 freestanding United States pediatric hospital discharge records, 2001-2005. The main outcome measures were therapy, readmission and mortality.

RESULTS

Of 2890 patients diagnosed with hemangiomas, 337 (12%) underwent airway procedures. Most airway procedures were for patients between ages 1 and 11 months. Patients with hemangiomas and airway procedures had more steroid use (80%), increased readmission (30%), and increased mortality (2%) compared to hemangioma patients without airway procedures. Procedures (i.e. laser, open surgery, tracheotomy) and age over 4 months in airway procedure patients were associated with decreased readmission. Increased readmissions were associated with systemic steroid administration.

CONCLUSION

Hemangioma patients who undergo airway procedures experience increased medical and surgical therapy compared to those who do not. Readmission is increased in patients with hemangiomas and airway procedures, but surgical intervention and age greater than 4 months decreased readmission.

Endoscopic electrocauterization of pyriform fossa sinus tracts as definitive treatment

OBJECTIVE

To (1) update the technique of endoscopic electrocauterization of patients with pyriform fossa sinus tracts and (2) evaluate its effectiveness as a definitive treatment.

METHODS

Retrospective case series with nine patients (age range, 3.3-16.1 years) who were diagnosed with pyriform fossa sinus tracts between 2000 and 2007 at a single tertiary care children's hospital and underwent endoscopic electrocauterization of the sinus tract. Data collected including age of diagnosis, presenting symptoms, time from presentation to diagnosis, diagnostic studies, prior and subsequent treatments, length of hospital stay, and recurrence, were reviewed and analyzed with descriptive statistics.

RESULTS

All nine patients presented with recurrent left or midline neck masses or abscesses. Seven patients (78%) had at least one previous incision and drainage procedures for abscess treatment. All patients had a computed tomography scan with findings suspicious for left-sided pyriform fossa sinus tract. The diagnosis was confirmed with laryngoscopy. For seven patients (78%), endoscopic electrocauterization was definitive treatment with no recurrences to date. Two patients (22%) had recurrent left neck abscesses after endoscopic treatment; these patients ultimately underwent excision of sinus tract with left thyroid lobectomy without complications or further recurrences.

CONCLUSIONS

Endoscopic electrocauterization of pyriform fossa sinus tracts is a safe and definitive treatment for most patients. We advocate this minimally invasive procedure as first line of treatment for pyriform fossa sinus tracts, reserving open excision with or without thyroid lobectomy for failures.

PHACES syndrome: otolaryngic considerations in recognition and management

OBJECTIVES

To describe the otolaryngic manifestations of PHACES and evaluate current diagnostic and management principles for these patients.

METHODS

A retrospective review was performed within a tertiary children's hospital. Children with segmental facial hemangiomas of infancy and one extracutaneous manifestation comprising PHACES (posterior fossa malformation, arteriovenous malformations, cardiac/aortic defects, eye anomalies, and sternal defect) were identified. Otolaryngic problems were evaluated with physical examination, audiogram, swallow evaluation, polysomnography, and laryngoscopy. Extracutaneous manifestations were diagnosed using radiology, echocardiogram, and EEG. Treatment for cutaneous and airway hemangiomas included oral and intralesional steroids, CO(2) or pulse-dye laser, tracheotomy, and surgical excision. Management of extracutaneous problems was system-dependent.

RESULTS

Of 246 children with segmental facial hemangiomas of infancy evaluated since January 2000, 5 girls (2.0%) met diagnostic criteria for PHACES. Mean age at last follow-up was 2.6 years (range 0.4-5.8). Each child had one extracutaneous manifestation of aortic anomaly (2/5), sternal clefting (2/5), and brain malformation (1/5). Otolaryngic abnormalities included middle ear atelectasis (1/5), tympanic membrane hemangiomas with conductive hearing loss (3/5), skin and cartilage ulceration (2/5), dysphagia (4/5), and airway hemangiomas with stridor (3/5). Three children received oral steroids and required pulse-dye laser for cutaneous hemangiomas of infancy. One child underwent tracheotomy. Additional interventions included tympanostomy tubes and resection of nasal hemangioma.

CONCLUSIONS

Diagnosis of PHACES requires awareness of the association of facial hemangiomas of infancy with systemic and airway problems. Otolaryngology-related manifestations of PHACES are not commonly described, and management should be tailored to the individual patient.

Facial nerve anatomy, dissection and preservation in lymphatic malformation management

OBJECTIVE

To describe facial nerve anatomy and surgical techniques used for safe lymphatic malformation resection of malformation involving the facial nerve.

METHODS DESIGN

retrospective case series.

SETTING

tertiary pediatric hospital.

SUBJECTS

record review of lymphatic malformation patients after facial nerve dissection, from 1996 to 2005. Data collected included: facial nerve function, relationship of lymphatic malformation to facial nerve, facial nerve anatomy, dissection extent and clinical outcome.

RESULTS

Sixteen patients who met inclusion criteria underwent a total of 21 facial nerve dissections. Mean age at dissection was 48 months (range 1-72 months). Mean follow-up was 38 months (range 8-144 months). Pre-operative lymphatic malformation stage by patient: II=7/16, III=4/16, IV=2/16 and V=3/16. Higher stage lymphatic malformations required more extensive dissections (p=0.026). Pre-operative facial nerve function was House-Brackmann grade (HBG)-1 in 20, and HBG-6 in 1. Eight months postoperatively, facial nerve function was HBG-1 in 18, HBG-2 in 1, and HBG-6 in 2. The facial nerve was surrounded by lymphatic malformation in 10/21, deep to the lymphatic malformation in 5/21, superficial to the lymphatic malformation in 4/21, and not identified in 2/21. Imaging studies predicted facial nerve position in 15/21 procedures. Antegrade nerve dissection was performed in 10/21, retrograde in 7/21 and not done in 2/21. Abnormally elongated facial nerve was identified in 11/21 cases and required more extensive dissection (p=0.040). Facial nerve monitoring was used in 15/21 dissections. Clinical outcomes were felt to be good in 19/21 dissections.

CONCLUSIONS

In lymphatic malformation surgery, the facial nerve is often abnormally elongated and encompassed by malformation. Pre-operative imaging, facial nerve identification and dissection allow excellent postoperative facial nerve function.

Clinical and radiographic findings in children with spontaneous lymphatic malformation regression

Objective

Evaluate clinical and radiographic characteristics of spontaneously regressing lymphatic malformations (“lesions”).

Subjects and Methods

Retrospective review of 104 consecutive patients with cervicofacial lesions, with 1-year follow-up. Data collected: patient's age; lesion stage, location, radiographic characteristics; treatment. Data analysis using descriptive and Fischer exact tests.

Results

Spontaneously regressing lesions were identified in 13 of 104 (12.5%) patients. Five of 13 had in utero lesions, which persisted at birth; presenting age in the remaining eight patients was 2 to 138 months. Lesions regressed within 2 to 7 months. Lesion stage: I (7 of 13), II (2 of 13), III (4 of 13). Lesion location: left neck (9 of 13), right neck (4 of 13), posterior neck (10 of 13). All 13 resolving lesions were macrocystic with fewer than five septations in 11 of 13. Comparison of a resolving lesion cohort with a nonresolving lesion cohort demonstrated that disappearing lesions are more likely to have fewer than five septae and to be macrocystic ( P < 0.05). Treatment was none in seven of 13, antibiotics in four of 13, and redundant skin excision in two of 13.

Conclusion

Spontaneous lesion regression can occur, and these lesions have distinct features. Lesions with these characteristics can be observed.

Lymphocytopenia in Children With Lymphatic Malformation

OBJECTIVE

To determine whether an immunologic abnormality exists in patients with lymphatic malformation (LM).

DESIGN

Retrospective case series.

SETTING

Tertiary care pediatric hospital.

PATIENTS

Twenty-one consecutive patients (11 male and 10 female) undergoing LM treatment.

INTERVENTIONS

Clinical data (ie, age, clinical LM stage, radiographic appearance, and histologic findings) were correlated with complete blood cell count and detailed lymphocyte differential. Complete blood cell counts and lymphocyte subsets were measured in 21 and 18 patients, respectively.

RESULTS

The average age at the time of testing was 67 months (range, 1-231 months). The patients were categorized according to LM stage, including 4 (19%) with stage 1, 4 (19%) with stage 2, 4 (19%) with stage 3, 7 (33%) with stage 4, and 2 (10%) with stage 5 disease. Radiographic LM appearance was macrocystic in 6 patients (29%), mixed macrocystic and microcystic in 8 (38%), and microcystic in 7 (33%). Complete blood cell count data demonstrated lymphocytopenia in 6 patients (29%). The results of the lymphocyte subset tests showed concomitant T-, B-, and natural killer (NK)-cell deficiency in 6 (33%) of 18 patients. All 6 patients with T-cell lymphocytopenia had normal neutrophil and platelet counts. Spearman rank and chi(2) analyses showed that LM stage 4 or 5 and microcystic LM were significantly associated with lymphocytopenia (P = .002 and P = .008, respectively). Histologic analysis did not demonstrate increased lymphocytes in any LM specimens.

CONCLUSION

We found T, B, and NK lymphocytopenia in patients with large bilateral or microcystic LM. Although the relationship between lymphocytopenia and infection was not addressed in this study, the recognition of lymphocytopenia in patients with LM may have important clinical and prognostic implications.

Hemangiomas of Infancy

Ulceration is a common complication of hemangiomas of infancy and presents a therapeutic dilemma for the head and neck-facial plastic surgeon. Multiple therapies are available, further complicating treatment of patients. We review the common characteristics of ulcerated hemangiomas and discuss the treatment modalities available. We present case reports to illustrate management options and a stepwise algorithm for treatment of ulcerated hemangiomas.

Diagnostic and Surgical Challenges in the Pediatric Skull Base

Advances in management of adult skull base pathologies are increasingly being applied in children. Pediatric patients present special challenges because of their smaller anatomy, but potential gains in reduced morbidity make improvements in skull base approaches well worth pursuing.

Head and Neck Endocrine Surgery in Children

OBJECTIVES

To characterize children undergoing parathyroid, thyroid, and thyroglossal duct cyst surgery in 1997 and 2000 using a nationally representative discharge database to determine whether rates and outcomes of these surgical treatments vary by age, sex, and health care system attributes.

DATA SOURCE

The 1997 and 2000 Kids' Inpatient Database, available through the Agency for Healthcare Research and Quality.

STUDY SELECTION

All patients 18 years and younger undergoing head and neck endocrine (HNE) procedures were included.

DATA EXTRACTION

The sampling scheme of this database allowed for calculation of national and regional estimates using Stata 7.0.

DATA SYNTHESIS

An estimated 2077 and 1871 inpatient pediatric HNE procedures were performed nationally in 1997 and 2000, respectively. Most were performed at general (nonpediatric) teaching hospitals. There were an estimated 1102 thyroglossal duct cyst excisions, making this the most common HNE procedure and diagnosis. Thyroid lobectomy was the second most common HNE surgical treatment. Thyroid malignant neoplasm (usually treated by total thyroidectomy) was the second most common diagnosis. Neck dissections were performed in 32% of patients with thyroid malignant neoplasm. These HNE procedures accounted for more than 28 million dollars in hospital charges in 1997 and nearly 38 million dollars in 2000.

CONCLUSIONS

Surgical treatment trends for pediatric HNE procedures remained stable between 1997 and 2000. Thyroglossal duct cyst excision and thyroid lobectomy are the most common procedures. There were regional differences in the rates of most HNE surgical treatments. In addition, hospital charges increased between 1997 and 2000.

Pediatric Admissions and Procedures for Lymphatic Malformations in the United States: 1997 and 2000

OBJECTIVE

To describe the incidence of discharges for lymphatic malformation (LM) and the various treatments rendered for this condition in a nationwide sampling of pediatric discharges from 1997 and 2000.

DATA SOURCE

The 1997 and 2000 Kid's Inpatient Database (KID), available through the Agency for Healthcare Research and Quality (AHRQ).

DATA EXTRACTION

The sampling scheme of this database allowed for calculation of national and regional estimates using STATA 8.2.

DATA SYNTHESIS

There were an estimated 3200 admissions for the treatment of pediatric LM in 1997 and 2000 combined. These admissions were most common in urban teaching institutions (69% in 1997 and 81% in 2000). The mean age at admission was 3.7 years, while the median was 1 year. The most common procedure performed in these children was surgical excision of the malformation. Over half of these were done in children under age 2. Airway endoscopy was the second most common procedure. Sclerotherapy was infrequently performed. The estimated national hospital charges for these admissions were $26 million in 1997 and $35 million in 2000.

CONCLUSIONS

This analysis reveals a national perspective on the total number of pediatric admissions for LM and their associated inpatient procedures. Treatment trends for pediatric LM have remained relatively stable between 1997 and 2000, but hospital charges have increased.

Laryngeal anatomic differences in pediatric patients with severe laryngomalacia

OBJECTIVES

To compare the aryepiglottic (AE) length in pediatric patients who have severe laryngomalacia (SL) and are undergoing aryepiglottoplasty with the AE length of a convenience sample of control patients without laryngomalacia.

DESIGN

Prospective case-control study.

SETTING

A tertiary-care pediatric hospital.

RESULTS

The mean AE fold length-glottic length ratio for patients with SL (0.380) was significantly lower than the mean ratio for controls (0.535) (P = .004 in 2-sample t test with unequal variance). For patients with SL, the aryepiglottoplasy procedure resulted in an average AE length increase-glottic length ratio of 0.330. Seven of the patients with SL were also diagnosed as having an underlying neurologic condition, and 18 had a diagnosis of gastroesophageal reflux disease. Two patients with SL required a tracheotomy for treatment of persistent airway obstruction.

CONCLUSIONS

In this series, patients with SL had lower AE fold length-glottic length ratios and more frequent occurrence of neuromuscular tone abnormalities (especially gastroesophageal reflux) than controls. These 2 findings may be related in that low intrauterine tone might contribute to anatomic underdevelopment.

Plastic laryngeal foreign bodies in children: a diagnostic challenge

OBJECTIVE

To review Children's Hospital and Regional Medical Center experience with pediatric airway foreign bodies, and examine the incidence and treatment of laryngeal foreign bodies. To determine if plastic laryngeal foreign bodies present differently than other laryngeal foreign bodies.

METHODS

A retrospective review of all cases of children (1874 patients) undergoing direct laryngoscopy and/or bronchoscopy from 1st January 1997 to 9th September 2003 at a tertiary care children's hospital. Patients with endoscopically documented laryngeal foreign bodies were identified and the medical record reviewed in more detail. Patient age, gender, foreign body location, foreign body type, duration of foreign body presence, radiographic findings, endoscopic findings and treatment complications were recorded.

RESULTS

One hundred and five aspirated foreign bodies were identified. The nine laryngeal foreign bodies included five clear plastic radiolucent items, two radiolucent food items, and two sharp radioopaque pins. Time to diagnosis and treatment was on average 11.6 days with 17.6 days for thin/plastic foreign bodies and 1.6 days for metal/food foreign bodies.

CONCLUSION

Laryngeal foreign bodies represent a small portion of all pediatric airway foreign bodies. Difficulty in identifying laryngeal foreign bodies, especially thin, plastic radiolucent foreign bodies can delay treatment. Thin plastic foreign bodies can present without radiographic findings, can be difficult to image during endoscopy and can be particularly difficult to diagnose. A history of choking and vocal changes is associated with laryngeal foreign bodies. Laryngeal foreign bodies should be in the differential diagnosis of all children presenting with atypical upper respiratory complaints especially if a history suggestive of witnessed aspiration and dysphonia can be obtained.

Three-dimensional CT angiography imaging of vascular tumors of the head and neck

OBJECTIVE

To evaluate the utility of three-dimensional (3D) computerized tomography angiography (CTA) in head and neck vascular anomalies.

DESIGN

Prospective case series.

METHODS

A consecutive series of cases of patients with distinct types of vascular anomalies (i.e. hemangioma, arteriovenous malformation, venous malformation and lymphatic malformation) were obtained through CT multislice scanner and analyzed with Vitrea 2 software (Vital Images Inc., Plymouth, MN).

RESULTS

CTA was safe and successful in describing 3D vascular anatomy of a variety of vascular lesions.

CONCLUSIONS

Three-dimensional CTA allows detailed description of vascular lesions of the head and neck and offers another effective means of imaging these complex lesions.

Effects of inhalant anesthesia: tympanometry validation (R98/217)

OBJECTIVES

The purpose of this study was to determine the best time to assess middle ear status with tympanometry for tympanometric instrument validation. The research question addressed three logical times for tympanometric reading prior to myringotomy.

METHODS

Fifty-one children, ranging in age from nine months to 10 years, were recruited for this investigation. Participants underwent inhalant anesthesia for myringotomy and grommet placement with or without adenoidectomy and/or tonsillectomy. Tympanometry data was analyzed across three time periods.

RESULTS

Findings indicated that tympanometric readings prior to anesthesia produced the most accurate results.

CONCLUSIONS

Implicated in findings, in order to ensure that tympanometric instruments are reliable, typanometric measurements should be taken prior to the administration of any anesthesia.

Management of lymphatic malformations

PURPOSE OF REVIEW

Innovative otolaryngologists, plastic surgeons, craniofacial surgeons, pediatric surgeons, radiologists, anesthesiologists, neonatologists, obstetricians, and scientists have continued to advance our understanding of the etiology, diagnosis, and treatment of lymphatic malformations. This article reviews the publications over the past 2 years with respect to these advances.

RECENT FINDINGS

Fast-sequence MRI limits motion artifacts and allows prenatal MR to be used as a complementary study to ultrasound in the evaluation of large congenital neck masses. Three-dimensional ultrasonography may also be helpful in evaluating prenatal lymphatic malformations. Fluorescence in situ hybridization techniques can be used to evaluate lymphatic malformations for prenatal chromosomal analysis with emphasis on chromosomes 13, 18, 21, X, and Y. The sclerosing agent OK-432 is effective for macrocystic lymphatic malformations but showed less promise for microcystic lesions, mixed lesions, and lesions outside the head and neck region. Somnoplasty shows promise for reduction of tongue lymphatic malformations. Surgical excision, staged when necessary, continues to be integral to management in many cases.

SUMMARY

Basic science research has furthered understanding of lymphatic malformations. Clinical research has expanded and refined our diagnostic and therapeutic options for patients with these lesions. Further identification of genes selectively expressed by lymphatic endothelium should facilitate identification of usable vascular markers that can enable analysis of the underlying biology, physiology, pathology, and treatment of the lymphatic system and its malformations.

Klippel-Trenaunay-Weber syndrome with labyrinthine bony overgrowth and mixed hearing loss, a case report

Klippel-Trenaunay syndrome (KTS) is a congenital disorder characterized by a triad of (1) capillary malformations, (2) venous malformations, and (3) soft tissue or bony hypertrophy. There exists one report of a patient with KTS and an associated sensorineural hearing loss. We describe an adolescent girl with KTS and AV fistulas who was found to have a bony overgrowth extending from the cochlea into the middle ear cavity and an ipsilateral mixed hearing loss. In both of these patients, there were obvious KTS deformities involving the face. We suggest conducting hearing screening in patients with KTS and obvious head involvement.