Tracheomalacia is associated with lower FEV1 and Pseudomonas acquisition in children with CF.

BACKGROUND: Tracheomalacia (TM) occurs in approximately 1 in 2,100 children. Because the trachea develops abnormally in animal models of cystic fibrosis (CF), we hypothesized this may also occur in children with CF, increasing their risk of TM. PURPOSE: To examine the prevalence and clinical consequences of TM in children with CF. METHODS: We studied children with CF born between 1995 and 2012. TM was defined as dynamic collapse of the trachea, and the severity was recorded as described in the chart. The effect of TM on patient outcomes, including FEV1 , CT changes, and acquisition of CF pathogens, was assessed using a longitudinal patient dataset. RESULTS: Eighty-nine percent of children with CF had at least one bronchoscopy (n = 97/109). Fifteen percent of these children had TM described in any bronchoscopy report (n = 15/97). Of the patients with TM, eight had meconium ileus (P = 0.003) and all were pancreatic insufficient. Pseudomonas aeruginosa infection occurred 1.3 years earlier among children with TM (P = 0.01). Starting FEV1 values by age 8 were diminished by over 18% of predicted for patients with TM. Life-threatening episodes of airway obstruction occurred in 3 of 15 patients with CF and TM, including one leading to death. Gender, prematurity, and hepatic disease were not associated with TM. No difference was observed in the frequency of bronchiectasis. CONCLUSIONS: TM is significantly more common in infants and children with CF than in the general population and is associated with airway obstruction and earlier Pseudomonas acquisition.

Subtotal petrosectomy and mastoid obliteration in adult and pediatric cochlear implant recipients.

OBJECTIVE: To investigate the effect of subtotal petrosectomy and mastoid obliteration (SPMO) on the overall success of adult and pediatric cochlear implant (CI) recipients. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care referral center. PATIENTS: Thirty-nine ears in 36 patients (23 adults and 13 children) received both surgeries between 1990 and 2012. INTERVENTION: CI candidates underwent SPMO to permit implantation and minimize the risks of infectious complications in the recipient ear. SPMO was performed before (69.3%), at the time of (25.6%), and after CI (5.13%). Mastoids were obliterated with fat (30.8%), muscle (66.7%), and bone pate (2.56%). MAIN OUTCOME MEASURE: Feasibility, complications, and success of SPMO and CI were assessed with standard statistical analysis and Fisher's exact test with 2-sided p values. RESULTS: Ear disease was definitively managed, and CI was successfully placed in all but one case. Complications including abscess (n = 3), subcutaneous emphysema (n = 1), ear canal granulation formation (n = 1), and electrode extrusion (n = 1) occurred in 15.4% of patients. Predisposing syndromes were present in children more often than adults (43.8% versus 13.0%, p = 0.0598). Adults more often than children had previous mastoid surgery for middle ear disease (30.4% versus 0.0%, p = 0.0288). CIs were placed under local anesthetic and sedation (n= 3) and after radiation treatment for nasopharyngeal cancer (n = 2) in adult ears. CONCLUSION: SPMO is an effective and safe procedure for definitively managing middle ear disease and implanting adult and pediatric CI candidates.

Sialoendoscopy for the treatment of pediatric salivary gland disorders.

OBJECTIVE: To show that sialoendoscopy is both a safe and effective alternative to traditional treatments for juvenile recurrent parotitis and sialolithiasis. DESIGN: Retrospective medical chart review. SETTING: Two major pediatric tertiary care centers. PATIENTS: Eighteen pediatric patients. INTERVENTIONS: A total of 33 sialendoscopic procedures on 27 glands. MAIN OUTCOME MEASURES: Indications for surgery, age at onset of symptoms, age at procedure, sex, intraoperative findings, complications, recurrences, need for additional procedures, and follow-up interval. RESULTS: Juvenile recurrent parotitis was the most common indication for sialendoscopy (12 of 18) followed by sialolithiasis (4 of 18). Ten of 12 patients with juvenile recurrent parotitis were asymptomatic after 1 or 2 sialendoscopies (8 patients and 2 patients, respectively). There were 6 minor complications. Three patients ultimately required gland excision for disease management. CONCLUSION: Sialoendscopy is safe and effective as a treatment for pediatric salivary gland disorders.

Dynasplint for the management of trismus after treatment of upper aerodigestive tract cancer: a retrospective study.

In order to evaluate the Dynasplint Trismus System (DTS) for the relief of trismus secondary to the treatment of head and neck cancer, we conducted a retrospective chart review of patients who had undergone DTS therapy during a 1-year period. Our inclusion criteria were cancer of the upper aerodigestive tract; treatment with radiation, chemotherapy, and/or surgery; and a maximal incisal opening (MIO) of less than 30 mm. MIO and the rate of improvement of trismus ("gain") were measured at selected intervals. Twenty-six patients met our study criteria; their pretherapy mean MIO was 19.3 mm. At the time of their most recent measurement, the mean MIO had increased to 25.5 mm-a measured gain of 32%. Although the initial rate of gain was 0.36 mm/day during the first 6 weeks, improvement leveled off over time, and the overall rate of gain was 0.16 mm/day. We conclude that the DTS is effective in increasing the mandibular range of motion at a rate of change that is maximized during initial treatment.

The management of myringotomy tubes in pediatric cochlear implant recipients.

OBJECTIVE: To investigate the impact of myringotomy tubes (MTs) on outcomes for pediatric cochlear implant (CI) recipients. DESIGN: Retrospective case-control chart review. SETTING: Tertiary care pediatric hospital. PATIENTS: Sixty-two patients received an MT before CI (mean [SD] age at initial CI, 3.20 [2.45] years). Seventy-eight ears received CIs and MTs. INTERVENTION: The MTs were removed and allowed to extrude before CI (59% [n = 46]) or kept in place until CI (41% [n = 32]). MAIN OUTCOME MEASURES: Otorrhea, persistent tympanic membrane (TM) perforation, and need for additional procedures were recorded. Statistical analysis was performed with the Fisher exact test. RESULTS: Forty ears (51%) required more than 1 set of MTs. Ten ears (22%) in which the MTs were removed before CI required a separate MT after CI compared with 6 ears (19%) in which the MTs remained in place until CI (P = .78). The MTs that were present during CI were either removed with myringoplasty (31% [n = 10]) or retained after surgery (69% [n = 22]). All TMs in which the tubes were removed before or during CI healed. There were 3 persistent TM perforations that required surgical treatment. There were no cases of meningitis and no removals of CIs because of infection. CONCLUSIONS: Myringotomy tubes do not appear to adversely affect the final outcomes of pediatric CI recipients and can be managed similarly to MTs in other otitis media-prone children. They may be left in place in children who continue to experience recurrent acute otitis media or removed in children who no longer need them.

Sternberg's canal: fact or fiction?

BACKGROUND: Sternberg's (lateral craniopharyngeal) canal was originally described in anatomic studies as a membranous space in the lateral wall of the sphenoid sinus. The canal has been etiologically associated with lateral sphenoid sinus "spontaneous" cerebrospinal fluid (CSF) leaks. A patent Sternberg's canal has been reported in up to 4% of adults, and persistent vestiges have been reported in up to 30%. However, no modern studies analyzing high-resolution CT scans have been published. METHODS: A consecutive analysis of 1000 high-resolution CT scans of sphenoid bones was performed. Scans were analyzed for a lateral recess, bony defects, arachnoid pits, and holes possibly representing Sternberg's canal. Data were compared with a case series of lateral sphenoid CSF leaks. RESULTS: Average patient age was 38.7 years (10-92 years). A sphenoid lateral recess was present in 35.3% (17.4% bilateral) of cases. Arachnoid pits were present on the floor of the middle cranial fossa in 23.4% of cases. Seven skull base defects were identified. Only one traveling medial to V2 resembled the description of Sternberg's canal. In contrast, a case series of 25 patients with lateral sphenoid sinus CSF leaks all had a lateral recess, defects, and arachnoid pits lateral to V2 (p < 0.00001). CONCLUSION: Sternberg's canal as historically defined is not nearly as prevalent as previously reported. Furthermore, the presence of arachnoid pits in all sphenoid CSF leaks and the predominant leak location lateral to the sites of fusion of ossification centers suggests that the leaks are acquired. Contributing factors may include arachnoid pits/weaknesses in the skull base and intracranial hypertension.

Zygomatic-maxillary buttress reconstruction of midface defects with the osteocutaneous radial forearm free flap.

BACKGROUND: The purpose of this study was to evaluate morbidity, functional, and aesthetic outcomes in midface zygomatic-maxillary buttress reconstruction using the osteocutaneous radial forearm free flap (OCRFFF). METHODS: A retrospective review of 24 consecutive patients that underwent midface reconstruction using the OCRFFF was performed. All patients had variable extension of maxillectomy defects that requires restoration of the zygomatic-maxillary buttress. After harvest, the OCRFFF was fixed transversely with miniplates connecting the remaining zygoma to the anterior maxilla. The orbital support was given by titanium mesh when needed that was fixed to the radial forearm bone anteriorly and placed on the remaining orbital floor posteriorly. The skin paddle was used for intraoral lining, external skin coverage, or both. The main outcome measures were flap success, donor-site morbidity, orbital, and oral complications. Facial contour, speech understandability, swallowing, oronasal separation, and socialization were also analyzed. RESULTS: There were 6 women and 18 men, with an average age of 66 years old (range, 34-87). The resulting defects after maxillectomy were (according to the Cordeiro classification; Disa et al, Ann Plast Surg 2001;47:612-619; Santamaria and Cordeiro, J Surg Oncol 2006;94:522-531): type I (8.3%), type II (33.3%), type III (45.8%), and type IV (12.5%). There were no flap losses. Donor-site complications included partial loss of the split thickness skin graft (25%) and 1 radial bone fracture. The most significant recipient-site complications were severe ectropion (24%), dystopia (8%), and oronasal fistula (12%). All the complications occurred in patients with defects that required orbital floor reconstruction and/or cheek skin coverage. The average follow-up was 11.5 months, and over 80% of the patients had adequate swallowing, speech, and reincorporation to normal daily activities. CONCLUSIONS: The OCRFFF is an excellent alternative for midface reconstruction of the zygomatic-maxillary buttress. Complications were more common in patients who underwent resection of the orbital rim and floor (type III and IV defects) or external cheek skin.

Fistula analysis after radial forearm free flap reconstruction of hypopharyngeal defects.

OBJECTIVE/HYPOTHESIS: To evaluate risk factors and management options for fistula formation after hypopharyngeal reconstruction using the radial forearm free flap reconstruction. STUDY DESIGN: Retrospective cohort study. METHODS: Patients undergoing radial forearm free flap for hypopharyngeal reconstruction were retrospectively reviewed. A total of 104 patients underwent this procedure between 2001 and 2007. Fistulas were classified as mild or severe depending on the response to conservative management. Demographics, operative details, pathology, and postoperative course were recorded as the prognostic variables. Univariate analysis and a logistic regression model were used to identify associated factors. RESULTS: Pharyngocutaneous fistula developed in 30 (28.8%) patients. Recurrence, cancer stage, cancer location, type of ablative surgery, and the addition of other oncologic procedures were identified as significant predictors of fistula formation. Fistula significantly increases hospital stay and recipient site complications such as flap survival, infection, and bleeding. Functional results such as diet, deformity, and socialization were also negatively affected by fistula development. One third of the cases responded to conservative management, and 20 cases required a surgical procedure to definitively close the fistulous track. CONCLUSIONS: Fistula formation remains a significant cause of morbidity associated with hypopharyngeal-reconstruction. Postoperative course and successful preventive strategies are discussed.

Stereomicroscopic fluorescence imaging of head and neck cancer xenografts targeting CD147.

PURPOSE: To demonstrate that systemically administered fluorescently labeled anti-CD147 antibody can detect head and neck squamous cell carcinoma xenografts in vivo. EXPERIMENTAL DESIGN: In vivo immunodeficient murine model. RESULTS: Peak tumor fluorescence was visualized by near infrared stereomicroscopy in SCC-1 tumors at 24 hours after systemic injection of anti-CD147:Cy5.5 bioconjugate. SCC-1 xenografts demonstrated significantly higher fluorescent intensity after administration of CD147:Cy5.5 (48 au, p < 0.0001) compared to IgG1k:Cy5.5 isotype control antibody (9 au). FaDu tumors overexpressing CD147 (FaDu/E) demonstrated higher fluorescence (53 au) compared to control vector transfected cells (FaDu, 33 au, p < 0.0001) which was higher than CD147 knockdown cells (FaDu/siE, 5 au, p < 0.0001). METHODS: To determine if fluorescently labeled anti-CD147 antibody was specific for tumors in vivo, anti-CD147 and non-specific IgG1k antibody were labeled with a near infrared fluorophore (Cy5.5) and administered systemically to immunodeficient mice bearing SCC-1 xenografts. Imaging was performed over a 72 hour period using brightfield and fluorescent (685-735 nm) stereomicroscopy. To determine if fluorescence varied with receptor expression, SCID mice were xenografted with cell lines expressing variable amounts of CD147: FaDu (control vector transfected), FaDu/siE (siRNA CD147 knockdown) or FaDu/E (CD147 overexpressing) cells. CONCLUSIONS: This data suggests fluorescently labeled anti-CD147 may have clinical utility in detection of HNSCC.