Surgical repair of massive hemorrhage secondary to button battery ingestion causing aortoesophageal fistula.

BACKGROUND: In pediatrics, foreign body ingestion poses unique challenges. Each case is unique given variability in timing, type, and size of object, compounded by underlying comorbidities and age. In the mid-1990s, mortality and morbidity associated with button battery (BB) ingestion (BBI) emerged corresponding to modification in battery fabrication towards higher voltage, large-diameter lithium cells. AIMS: To describe the case and management of a BBI in a pediatric patient necessitating the use of cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA). MATERIALS AND METHODS: A 17-month-old female presented with the sudden loss of consciousness at home. Chest X-ray revealed an esophageal foreign body suspicious for BBI. A massive upper gastrointestinal bleeding was temporized with packing. The patient was urgently taken to the operating room for sternotomy, establishment of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), removal of BB, repair of the left common carotid artery, esophageal, and tracheal injuries. DISCUSSION: Successful management of BBI requires coordinated care and a multidisciplinary approach. A high degree of clinical suspicion for BBI is imperative to facilitate early aggressive interventions. Lateral and anteroposterior chest films should be obtained in any suspected BBI. CONCLUSION: This case demonstrates the utility of CPB and DHCA where control of bleeding secondary to BBI is not otherwise possible.

Development of a patient reported outcome instrument for chronic sialadenitis.

BACKGROUND: Sialendoscopy assisted treatments are a minimally invasive management modality for chronic sialadenitis. Clinicians report improved patient quality of life (QoL) following sialendoscopy assisted treatments, but there exist gaps in current literature about patient reported outcomes (PROs). PROs are outcome measures developed based on patient perceptions. OBJECTIVE: The objective of this study was to create a PRO instrument for chronic sialadenitis, to assess the efficacy of sialendoscopy assisted treatments in improve patients' QoL. DESIGN: This four-phase qualitative study employed grounded theory methodology and a modified Delphi technique. In Phase I, ten patients were interviewed to identify the QoL domains impacted by chronic sialadenitis. In Phase II, these QoL domains were presented to a focus group of different chronic sialadenitis patients, who were asked to rank them by order of importance. A conceptual framework of QoL domains impacted by chronic sialadenitis was created based on patient consensus. Itemization of the PRO questionnaire was done by a focus group of four Otolaryngologists in phase III. Lastly, the questionnaire was completed in Phase IV by cognitive interviewing of five new chronic sialadenitis patients; ensuring ease of understanding and clarity. RESULTS: Patients identified 15 domains of QoL impacted by chronic sialadenitis, divided into three sub-scales: physical symptoms, psychosocial symptoms, and activity restriction. These domains provided the basis for creation of a 22-item PRO questionnaire, with a Likert-type response scale. CONCLUSION: Clinical application of the novel questionnaire produced by this study will allow for a patient-centered assessment of the patient reported effectiveness of sialendoscopy assisted therapies for management of chronic sialadenitis. Level of evidence Level V.

Validity of laryngomalacia classification systems: A multi-institutional agreement study.

OBJECTIVES: To determine the agreement of paediatric otolaryngologists on classifying laryngomalacia (LM). DESIGN: Intra- and interobserver agreement study of two classification systems. SETTING: Three tertiary referral paediatric centres. PARTICIPANTS: Three paediatric otolaryngologists, who were blinded to any clinical details, interpreted the videos of children diagnosed with LM using the Holinger and Olney classifications independently. They rated the videos twice with a washout period of at least 2 weeks. THE MAIN OUTCOME MEASURES: Inter- and intra-observer agreement measured by overall Fleiss kappa and unweighted Cohen's kappa coefficients. The secondary outcome measures were inter- and intra-observer agreement on the individual anatomical subunits of the supraglottis affected by LM, characterised by the subcategories of the classifications. RESULTS: Video records of infants and children <18 years who had an endoscopic diagnosis of LM from 2012 to 2017 were retrospectively chosen for inclusion (n = 73). The overall Fleiss kappa coefficient was 0.25 (95% CI 0.18-0.32) amongst the raters using the Holinger classification and 0.31 (95% CI 0.21-0.42) for the Olney classification. Intra-observer agreement using the Holinger classification was 0.30 (95% CI 0.18-0.42), 0.62 (95% CI 0.23-0.85) and 0.84 (95% CI 0.75-0.94], whilst the Olney classification yielded values of 0.41 (95% CI 0.26-0.56), 0.51 (95% CI 0.29-0.63) and 0.63 (95% CI 0.48-0.78). CONCLUSIONS: The agreement on types of LM between expert observers is modest using the Holinger and Olney classifications. This has significant implications for accurately diagnosing LM and exposes potential obstacles against credible pooling of data and extrapolation of information.

Magnetic Apposition across the Epiglottis: Radiographic and Operative Correlation of a Rare Hypopharyngeal Foreign Body.

Background and Aim. Rare-earth magnet ingestions are a subset of foreign body ingestions and can result in significant morbidity secondary to pressure necrosis. These magnets are best visualized radiographically, typically located in the gastrointestinal tract. However, unusual locations of magnetic adherence may include the hypopharynx along the epiglottis, where only 2 previous cases have been reported. Clinicians should be aware of the potential dangers of rare-earth magnet ingestion and consider atypical locations of attachment in the appropriate clinical setting. Case Presentation. We present an interesting case of a fourteen-year-old female patient who presents with witnessed ingestion of multiple rare-earth magnets. Soft-tissue neck radiographs demonstrate two adjacent rounded radiopaque densities in the hypopharynx. Intraoperative images confirmed the radiographic findings and identified two magnetic balls stuck along the dorsal and ventral aspect of the epiglottis without evidence of pressure necrosis. CONCLUSION: This is the first published case of magnetic foreign body adherence to the epiglottis in the Radiology literature. Awareness and recognition of the unique radiographic findings of this rare entity can help clinicians streamline timely management.

Formal mentorship in a surgical residency training program: a prospective interventional study.

BACKGROUND: Otolaryngology-Head and Neck surgery resident physicians (OHNSR) have a high prevalence of burnout, job dissatisfaction and stress as shown within the literature. Formal mentorship programs (FMP) have a proven track record of enhancing professional development and academic success. More importantly FMP have an overall positive impact on residents and assist in improving job satisfaction. The purpose of the study is to determine the effects of a FMP on the well-being of OHNSR. METHODS: A FMP was established and all OHNSR participation was voluntary. Eight OHNSR participated in the program. Perceived Stress Survey (PSS) and the Maslach Burnout Inventory (MBI) were administered at baseline and then at 3, 6, 9, and 12 month intervals. World Health Quality of Life-Bref Questionnaire (WH-QOL) was administered at baseline and at 12 months. RESULTS: Baseline statistics found a significant burden of stress and burnout with an average PSS of 18.5 with a high MBI of 47.6, 50.6, and 16.5 for the emotional, depersonalization, and personal achievement domains respectively. Quality of life was also found to be low with a WH-QOL score of 71.9. After implementation of the FMP, PSS was reduced to 14.5 at 3 months (p = 0.174) and a statistically significant lower value of 7.9 at 12 months (p = 0.001). Participants were also found to have lower emotional scores (14.9, p < 0.0001), levels of depersonalization (20.1, p < 0.0001), and higher personal achievement (42.5, p < 0.0001) on MBI testing at 12 months. Overall quality values using the WH-QOL was also found to be significantly improved (37.5, P = 0.003) with statistically significant lower scores for the physical health (33.9, p = 0.003), psychological (41.1, p = 0.001), social relationship (46.9, p = 0.019), and environment (53.5, p = 0.012) domains. CONCLUSION: This is the first study to show that FMP can potentially alleviate high levels of stress and burnout within a surgical residency program and achieve higher levels of personal satisfaction as well as overall quality of life.

Does drug-induced sleep endoscopy change the surgical decision in surgically naïve non-syndromic children with snoring/sleep disordered breathing from the standard adenotonsillectomy? A retrospective cohort study.

BACKGROUND: Adenotonsillectomy is the most commonly performed operation for pediatric snoring/sleep disordered breathing (S/SDB). However, 20-40% of patients will fail to improve. Drug-induced sleep endoscopy (DISE) may provide a more individualized surgical plan and limit unsuccessful surgeries. The aim of this study was to assess the impact of DISE on surgical decision-making in surgically naïve children with S/SDB. METHODS: A retrospective observational cohort study was undertaken at the Stollery Children's Hospital. Patients 3-17 years of age who underwent DISE-directed surgery for S/SDB between January 2009 and December 2015 were eligible. We excluded other indications for tonsillectomy and syndromic children. The primary outcome was the level of agreement between a DISE-based surgical decision and the reference standard based on the American Academy of Pediatrics (AAP) guidelines via un-weighted Cohen's kappa. Secondary outcomes included the frequency and type of alternate surgical targets identified by DISE. The agreement on tonsil size between in-office physical assessment and DISE was also calculated. The effectiveness of DISE-directed surgery on postoperative S/SDB was not investigated. RESULTS: Five hundred fifty-eight patients were included. DISE changed the surgical plan in 35% of patients. Agreement between DISE-based and AAP clinical practice guidelines-based management was low (κ = 0.354 +/- 0.021 [95% CI 0.312-0.395]). An alternate diagnosis or surgical target was identified by DISE in 54% of patients. There was moderate agreement on tonsil size (κ = 0.44 [0.33-0.55]) between DISE and in-office clinical assessment. CONCLUSIONS: This is a first phase diagnostic study, which demonstrates that DISE affects decision-making in surgically naïve children with S/SDB in up to 35% of patients. It has utility in individualizing first stage surgical treatments as well as identifying alternate targets for further surgical or medical therapy, while potentially limiting unsuccessful surgeries. Further studies to examine the effect of DISE on surgical outcomes are required.

Variables associated with repeated ventilation tube insertion in healthy non-syndromic children.

OBJECTIVES: The objectives of this study was to determine variables associated with rVT insertions for rAOM and/or OME in otherwise healthy children. METHODS: This was designed as a retrospectively controlled cohort study. Patients were identified from a prospectively collected surgical database. Eligible subjects were those who had undergone rVT and a consecutive concurrent control group who received only one ventilation tube (VT). Exclusion criteria included craniofacial abnormalities and syndromes. Demographics, tympanic membrane characteristics, parental smoking, breast-feeding history, large day-care attendance, and soother use was collected. RESULTS: Over a period of 10 years, 59 patients underwent rVT (5.6%). 180 children who underwent VT were included in the control group. There was no difference in gender distribution (p=1, 1.73:1 vs. 1.76:1), mean age (p=0.69, 4.7±3.33 vs. 4.4±3.17) or chronic rhinitis (p=0.36, OR 1.376, 95% CI: 0.69-2.74). The rVT group was associated significantly more with a smoking parent (p=0, OR 61.8, 95% CI 21.26-176.07), large day care attendance (p=0, OR 23.39, 95% CI: 8.637-57.54), breast feeding <3months (p=0, OR -0.074, 95% CI: 0.028-0.331), soother use (p=0, OR 21.49, 95% CI: 7.81-55.87), and tympanic membrane atelectasis (p<0.0005). The same factors were also found to be significant upon multiple regression analysis (p<0.05). CONCLUSIONS: Otherwise healthy children with rAOM and/or OME are at a greater risk of rVT if they attend large day cares, were not breast fed for ≥3 months, if their tympanic membranes were atelectatic and most significantly if their parents smoke.

Correlations between acoustic rhinometry, subjective symptoms, and endoscopic findings in symptomatic children with nasal obstruction.

IMPORTANCE: Nasal obstruction is common in children and difficult to quantify objectively. Symptom quantification is paramount for surgical and medical decision making. Acoustic rhinometry is a relatively new technique aimed at the objective assessment of nasal obstruction. There is no standardized method for the objective assessment of the pediatric nasal airway. OBJECTIVE: To explore the correlations between acoustic rhinometry (AR), subjective symptoms, and endoscopic findings in children presenting with nasal obstruction. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, exploratory, diagnostic study of prospectively collected data from a multidisciplinary airway clinic (pulmonology, orthodontics, and otolaryngology) database at a tertiary academic referral center. Data were collected over a 2-year period (2010-2012) from 65 nonsyndromic children (38 boys) 7 years and older (mean [SD] age, 10.3 [2.5] years [range, 7-14 years]), presenting with persistent nasal obstructive symptoms for at least 1 year, without signs and symptoms of sinus disease. INTERVENTIONS: We collected patient demographics and medical history information including allergy, asthma, and sleep-disordered breathing. Subjective nasal obstruction was scored using a visual analog scale (VAS). Sleep-disordered breathing was assessed using overnight pulse oximetry. The adenoid size, septal position, and visual severity of chronic rhinitis (endoscopic rhinitis score [ERS]) were rated on nasal endoscopy by 2 independent reviewers and validated by agreement. Acoustic rhinometry (AR) was undertaken before and after use of a decongestant. MAIN OUTCOMES AND MEASURES: Correlation and multiple regression analyses were performed to explore interrelationships between subjective nasal obstruction VAS, AR, and nasal endoscopy. RESULTS: Among the 65 patients, 28 (43%) had symptoms of sleep-disordered breathing, 14 (22%) had allergic rhinitis, 10 (15%) had asthma, 27 (41%) had grade 3 or 4 adenoidal obstruction, 28 (43%) had an ERS of 2, 6 (9%) had an ERS of 3, and 19 (29%) had septal deviation. Significant correlations were found between subjective nasal obstruction VAS score and ERS (r = -0.364, P = .003), ERS and minimal cross-sectional area before decongestion (r = -0.278, P = .03), and adenoid size and calculated nasal resistance after decongestion (r = 0.430, P < .001). Multiple regression analysis showed that the ERS was the only significant predictor of VAS score (ß of -22.089; 95% CI, -35.56 to -8.61 [P = .002]). No predictors were identified for AR variables. CONCLUSIONS AND RELEVANCE: Among the evaluated tools, endoscopy appears to be the most reliable tool to estimate the degree of subjective nasal symptoms.