Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy.

Importance: Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy. Objective: To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy. Design, Setting, and Participants: Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019. Main Outcomes and Measures: Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated. Results: A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger. Conclusions and Relevance: Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.

Otolaryngology Service Usage in Children With Cleft Palate.

OBJECTIVES: To determine the usage of otolaryngology services by children with cleft palate at a pediatric tertiary care facility. DESIGN: Retrospective case series. SETTING: Specialty clinic at a pediatric tertiary care hospital. PATIENTS: Children born between January 1, 1999, and December 31, 2002, with the diagnosis of cleft palate or cleft lip and palate. A total of 41 female and 48 male patients were included. MAIN OUTCOME MEASURES: Total number of otolaryngology clinic visits and total number of otolaryngologic surgeries (tympanostomy tube placements and other otologic or upper airway procedures). RESULTS: In the first 5 years of life, these children utilized an average of 8.2 otolaryngology clinic visits (SD = 5.0; range: 1-22) and underwent 3.3 tympanostomy tube surgeries (SD = 2.0; range: 0-10). Seventy-three had their first tube placed at the time of palate repair, and 4 at the time of lip repair. Fifty-one (57.3%) required other otologic or upper airway procedures, including tonsillectomy and/or adenoidectomy (27 children), removal of tympanostomy tubes (24 children), tympanomastoidectomy (3 children), and tympanoplasty (14 children). Of the children who underwent other procedures, they underwent a mean of 1.67 (SD = 0.84; range: 1-4) surgeries. CONCLUSIONS: Children with cleft palate are at increased risk for eustachian tube dysfunction, frequently utilize otolaryngology care, and typically receive multiple sets of tympanostomy tubes. This study found that children with cleft palate receive on average of approximately 3 sets of tympanostomy tubes, and the majority required another otologic or upper airway surgery.

Perioperative Hearing Evaluations for Patients Undergoing Tympanostomy Tube Placement.

Importance: Obtaining hearing thresholds is an important step in the evaluation of a child with otitis media because decreased hearing in the presence of a chronic middle ear effusion factors into the decision to place tympanostomy tubes (TTs). Objective: To provide evidence regarding appropriate use of perioperative hearing evaluations in conjunction with TTs. Design, Setting, and Participants: Case series with medical record review of all patients aged 0 to 24 years who received TTs at a tertiary pediatric care facility from June 1, 2010, through June 1, 2011. Medical records were abstracted by 1 researcher for surgical, audiometric, tympanometric, clinical, and patient demographic data. The data analysis was performed between December 1, 2014, and June 1, 2015. Main Outcomes and Measures: Audiometric data were examined to determine the number of patients with hearing loss preoperatively and postoperatively, with the intention to describe the population with no prior hypothesis regarding results. Results: Of 2274 patients identified, 910 (40.0%) were female. Median (interquartile range) age at TT placement was 2.62 (1.48-4.94) years. A total of 1757 (77.3%) underwent audiometric evaluation preoperatively, 1742 (76.6%) postoperatively, and 1395 (61.3%) both preoperatively and postoperatively; 170 (7.5%) had no audiometric testing. Within 1 year after surgery, 271 (11.9%) of patients had evidence of nonfunctional tubes. Postoperatively, 19.9% (347 of the 1742 patients who received a postoperative evaluation) had hearing loss. In all, 89 (3.9%) patients had a permanent sensorineural hearing loss, and 15 (0.66%) had a persistent conductive hearing loss. Conclusions and Relevance: A postoperative audiometric examination should be performed in children who have hearing loss when evaluated before TT placement to determine whether resolution of the hearing loss was obtained.

Vestibular evoked myogenic potential testing for the diagnosis of conductive hearing loss: survey of pediatric otolaryngologists' knowledge and beliefs.

OBJECTIVES: To assess physicians' knowledge and beliefs regarding vestibular evoked myogenic potential (VEMP) testing in children. METHODS: A survey was delivered via email in html format to 1069 members of the American Academy of Otolaryngology--Head and Neck Surgery who identified as pediatric otolaryngologists. Study data were collected and managed using the Research Electronic Data Capture (REDCap) tools. RESULTS: 443 (41.4%) physicians opened the email. 190 (42.9% of opens) initiated the survey, of which 117 (61.9%) fully completed the survey of the physicians who responded to a question regarding knowledge of VEMP, 16% of respondents had never heard of the test. 16% of participants would use it in the setting of diagnosing pediatric conductive hearing loss. Responses regarding the youngest age at which VEMP is possible ranged from younger than 6 months through greater than 13 years of age. Beliefs regarding utility and reliability of VEMP varied, with 'unsure' as the most frequent response. Additionally, only 26% of pediatric otolaryngologists indicated some access to the test. CONCLUSION: The knowledge and availability of VEMP testing in the pediatric otolaryngology community varies widely.

Clinical uses of cervical vestibular-evoked myogenic potential testing in pediatric patients.

To demonstrate the feasibility and clinical significance of cervical vestibular-evoked myogenic potential (cVEMP) test in pediatric patients.Retrospective review study was conducted in a pediatric tertiary care facility. A total of 278 patients were identified with adequate data, including medical notes, results of cVEMP, and imaging studies.Among the total of 278 pediatric patients, only 3 children were not able to finish the cVEMP test successfully. In about 90% of the cases, the cVEMP test was requested to investigate a patient's hearing loss and/or vestibular complaints. Over 90% of the cVEMP tests were ordered by specialists such as pediatric otolaryngologists or otologists. Obtained cVEMP results provided useful information in clinical diagnosis and management in all cases.It is feasible to conduct cVEMP testing in children, including infants, and cVEMP testing can provide valuable information in the diagnosis and management of hearing loss and vestibular impairment. This simple and noninvasive test should be embraced by pediatric professionals.

Crural attachment to promontory case report: implications for stapes development.

Understanding of the embryologic origin of the stapes remains controversial. Theories diverge upon whether the entirety of the stapes arises from a single source versus the footplate and suprastructure arising from distinct sources. A 12-year-old boy with left-sided conductive hearing loss had computed tomography of the temporal bone, revealing an inferiorly displaced left stapes, and a nonspecific density in the left Prussak's space. Exploratory tympanotomy revealed the crura of the stapes to be attached to the promontory. The stapes footplate was located in the oval window and was mobile.

Sarcoidosis of the pinnas in a 17-year-old.

A 17-year-old girl presented with persistent swelling and erythema of the midportion of the helix of the pinnas, with no associated history of pain, fever, or hearing loss. The area was erythematous, with crusting and a minimal amount of pus. Her otologic examination was otherwise normal. A culture grew Staphylococcus (nonaureus). Over a 9-month period, she had flair-ups of the lesions with minimal response to topical and oral antibiotics. A dermatology consultation was obtained, and she was started on topical steroids, with no clinical improvement. She then developed raised erythematous lesions. Blood work showed no obvious immune disorder or evidence of an infectious process. A full-thickness skin biopsy was then taken, and pathologic examination found noncaseating granulomatous dermatitis; the histopathologic diagnosis was sarcoidosis. The patient was then referred to rheumatology for further evaluation and treatment. Although sarcoidosis is rare in the pediatric population, skin lesions that do not respond to medical therapy should be considered for biopsy.

Persistent conductive or mixed hearing loss after the placement of tympanostomy tubes.

OBJECTIVE: Described is a case series of clinical findings in children with persistent conductive or mixed hearing loss following tympanostomy tube placement for serous otitis media. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary pediatric hospital. SUBJECTS/METHODS: Medical records of thirty-nine children who were referred for either conductive or mixed hearing loss post-tympanostomy tube placement were reviewed for clinical histories, physical examinations, audiological evaluations, diagnostic studies, consultations, and surgical findings. Approval was obtained from the Boston Children's Hospital Institutional Review Board. RESULTS: Causes of hearing loss included ossicular abnormalities, cochlear abnormalities, 'third window' effects, cholesteatomas, genetic syndromes, and unknown causes. In four patients with isolated mild low-frequency conductive hearing loss, the cause was the presence of functional tubes. All patients diagnosed with a genetic syndrome had bilateral hearing loss. Patients with mixed hearing loss were diagnosed with cochlear abnormalities, 'third window' effects, or genetic syndromes. Computed tomography led to diagnosis in sixteen of twenty-five patients. Vestibular-evoked myogenic potential testing suggested a diagnosis in three of four patients. CONCLUSION: In children with persistent hearing loss following tympanostomy tube placement, identifying the laterality and type of hearing loss appears to be of importance in diagnosis. Patients with bilateral hearing loss should be considered for genetic testing, given the possibility of a syndrome. Patients identified with a mixed hearing loss should be evaluated for inner ear anomalies. Patients with mild, low-frequency hearing losses should be monitored audiologically and investigated further only if the hearing loss progresses and/or there is no resolution following tube extrusion.