Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database.

OBJECTIVES: This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO). DESIGN: Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012. SETTING: Inpatient database from the United States. PARTICIPANTS: Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic. INTERVENTIONS: Mandibular distraction osteogenesis. MAIN OUTCOME MEASURES: Length of hospital stay, adjunct airway and nutritional interventions and disposition. RESULTS: The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32). CONCLUSIONS: Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.

Association of Pediatric Patient Demographic Factors and Scar Anatomic Features With Scar Outcomes After Surgical Repair of Cleft Lip.

IMPORTANCE: Scar outcomes following cleft lip repair are an important component of pediatric patient and family satisfaction and indicate the need for future surgical interventions. OBJECTIVE: To assess the association of pediatric patient demographic factors and scar anatomic features with scar outcomes following cleft lip surgical repair. DESIGN, SETTING, AND PARTICIPANTS: A case-control study was conducted involving 58 pediatric patients who underwent surgical repair of a cleft lip from October 31, 2008, to August 4, 2016, at a tertiary care pediatric specialty hospital. Data on patient demographic factors, cleft type, and the surgical technique used were collected and analyzed from June 11, 2009, to November 21, 2017. Scar outcomes were subjectively rated by 3 physicians at 6-month and 12-month postoperative intervals. MAIN OUTCOMES AND MEASURES: Overall scar outcomes at 6-month and 12-month postoperative intervals were based on rating of scar appearance, color, width, height, and alignment by using a subjective, 5-point scar-assessment scale in which 1 indicated the poorest aesthetic appearance and 5, the ideal aesthetic appearance. RESULTS: A total of 58 pediatric patients who underwent cleft lip repair were evaluated; mean (SD) age at time of repair, 4.8 (3.0) months. Of these, 44 (76%) were male and 14 (24%) were female, 37 (64%) were white, 11 (19%) were black, 7 (12%) were Hispanic, 2 (3%) were Asian, and 1 (2%) was of another race/ethnicity. Scores on the Cohen κ interrater test indicated either a substantial or almost perfect strength of agreement among the physicians grading the scar outcomes. At 12 months, patients with black skin type had worse overall scar outcomes than patients with white skin type (odds ratio [OR], -0.31; 95% CI, -1.15 to -0.14; P = .03). A depressed scar height (OR, -0.54; 95% CI, -1.32 to -0.49; P < .001), and hypopigmented scar color (OR, -0.45; 95% CI, -1.34 to -0.32; P = .002) were associated with worse scar outcomes at 12 months following surgery. The overall median lip scar outcome significantly improved between the 6-month and 12-month follow-up assessments (scar-assessment scale score, 3.3; interquartile range [IQR], 2.7-4.0 vs 4.0; IQR, 3.3-4.3; P < .001). No association was observed between the anatomic type and severity of the cleft lip and scar outcomes (unilateral vs bilateral cleft, complete vs incomplete or microform cleft, and lip height ratio of the unilateral noncleft to cleft lip). CONCLUSIONS AND RELEVANCE: This study's findings suggest that, compared with white pediatric patients, black pediatric patients exhibited worse overall scar outcomes. A depressed scar and a hypopigmented scar also were associated with overall worse scar appearance after surgical repair. Cleft lip scar outcomes were not significantly associated with the type and severity of the cleft lip.

Congenital Vallecular Cyst as a Cause of Neonatal Stridor and Apnea.

An infant who presents with stridor and apnea constitutes a challenge for emergency physicians in terms of diagnosis and management. Among the rarest of causes for these symptoms, congenital vallecular cysts can cause devastating outcomes if left undiagnosed. Reported here is a case of intermittent episodes of stridor and apnea in a 4-day-old neonate with a previously undiagnosed vallecular cyst. The process by which the infant was stabilized, correctly diagnosed, and successfully treated for a life-threatening airway obstruction is explained. After a discussion of vallecular cysts, methods for preparing for and executing proper airway management in an infant who presents with apnea and stridor are considered.

Hearing loss in children with growth hormone deficiency.

OBJECTIVE: Although insulin-like growth factor 1 (IGF-1) has been shown to be important for inner-ear development in animal models, little is known about the otologic and audiologic findings of children with growth hormone deficiency (GHD). The goal of this study is to evaluate the prevalence, type, and severity of hearing impairment in children with GHD. METHODS: Audiologic, otologic, and demographic data were recorded for children with a diagnosis of GHD in the AudGen database. Data for each patient were selected based on the first encounter with available complete audiometric data or the first encounter with a type of hearing loss documented. The patients were then stratified by type and severity of hearing loss, and otologic issues were documented. A separate cohort comprised of children with GHD without hearing loss was compared as a control. RESULTS: 209 children with GHD met inclusion criteria. 173 (83%) of these patients had hearing loss. 79% of losses were bilateral and 21% were unilateral (309 total ears with hearing loss). 293 of the 309 ears with hearing loss had audiograms with ear-specific thresholds; 47 had conductive, 24 had sensorineural, 65 had mixed and 157 had undefined hearing loss with incomplete audiograms. Pure-tone averages (PTA) were higher among patients with mixed hearing loss compared to patients with all other loss types. CONCLUSION: Hearing loss is prevalent in children with GHD with a predisposition to be bilateral. These findings suggest the need for increased awareness and routine hearing screening for patients with GHD. Further studies may elucidate the etiology of the hearing impairment in children with GHD to better aid pediatricians, endocrinologists, otolaryngologists and audiologists when assessing and managing these children.

PANDAS: A systematic review of treatment options.

INTRODUCTION: Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) is a rare but important condition for pediatric otolaryngologists to recognize. Several treatment options exist including tonsillectomy, antibiotic treatment/prophylaxis, intravenous immunoglobulin (IVIG), and psychiatric medications/therapy. METHODS: A systematic review of the PubMed, EMBASE, and Scopus databases was performed searching for articles that focused exclusively on the aforementioned treatment modalities in the PANDAS population. Review articles, single patient case reports, and studies examining the natural history or diagnostic strategies were excluded. RESULTS: Five articles regarding tonsillectomy treatments with level of evidence (LOE) 4 were found but no clear benefit could be determined. Three articles were selected involving the use of antibiotic therapy. One prospective study and one double-blind randomized control trial (DB RCT) supported the use of antibiotics but a separate DB RCT showed no benefit. Two selected articles described the use of IVIG: one unblinded RCT and one retrospective study. One prospective study on cognitive-behavioral therapy (CBT) showed benefit in PANDAS. CONCLUSION: There is a paucity of high-level studies regarding this rare disorder and no hard treatment recommendations can be made. Tonsillectomy should only be performed in those who are surgical candidates based on current published guidelines. Antibiotics are an option but provide uncertain benefit. CBT remains a low-risk option. Studies support the use of IVIG, however more investigation is needed prior to widespread adoption of this treatment given its potential risks.

Objective Outcomes of Supraglottoplasty for Children With Laryngomalacia and Obstructive Sleep Apnea: A Meta-analysis.

IMPORTANCE: Surgical intervention is the main treatment alternative for patients with severe laryngomalacia. Supraglottoplasty offers effective treatment results not only for laryngomalacia but also for concurrent obstructive sleep apnea (OSA). OBJECTIVE: To quantify the objective outcomes of supraglottoplasty for laryngomalacia with OSA via polysomnography data in the pediatric population. DATA SOURCES: A comprehensive literature search of the PubMed database was performed on May 20, 2015, using the search terms supraglottoplasty, epiglottoplasty, aryepiglottoplasty, laryngomalacia, obstructive sleep apnea, Apnea-Hypopnea Index (AHI), children, and polysomnography. There were no date restrictions. STUDY SELECTION: The literature search identified English-language studies that used polysomnography to evaluate patients with laryngomalacia and OSA after supraglottoplasty. Two reviewers screened titles and abstracts of the studies. The full texts of the studies were examined to assess their relevance to the meta-analysis. DATA EXTRACTION: Numerical polysomnography data were extracted and compared among studies where appropriate. A fixed- or random-effects model was used, when appropriate, to analyze the data and calculate effect sizes. RESULTS: Four studies were included in various subsets of the meta-analysis. After supraglottoplasty, the Apnea-Hypopnea Index (AHI) improved by a mean of 12.5 points in 4 studies (95% CI, -21.14 to -3.78; P = .005), oxygen saturation as measured by pulse oximetry nadir by 9.49 in 4 studies (95% CI, 4.87-14.12; P < .001), and Obstructive AHI by 21 points in 2 studies (95% CI, -50.3 to -8.29; P = .16). Twenty-nine of 33 children (88%) had residual disease. Patients 7 months and older had significant improvement in the AHI (P = .03). CONCLUSIONS AND RELEVANCE: Supraglottoplasty is an effective treatment modality for patients with laryngomalacia and OSA with objectively measurable benefits; however, patients will frequently have residual disease. Additional polysomnography after treatment is advised to ensure adequate resolution of the disorder.

The impact of adenoid size on rate of revision sphincter pharyngoplasty.

OBJECTIVES/HYPOTHESIS: Determine the impact of adenoid size and prior adenoidectomy on outcomes of sphincter pharyngoplasty. STUDY DESIGN: Retrospective review. METHODS: Retrospective review of patients 18 years of age or younger, who underwent sphincter pharyngoplasty for velopharyngeal insufficiency (VPI) from 2007 to 2012. Nasal endoscopy and nasometry testing were administered pre- and postoperatively. Preoperative adenoid size was scored by two blinded otolaryngologists. Primary outcome measures were sphincter pharyngoplasty revision rate, achievement of normal resonance, and degree of improvement in nasometry scores. RESULTS: Eighty-six patients were included in this study. The overall rate of revision sphincter pharyngoplasty was 28%. Patients with mild adenoid hypertrophy underwent less revision surgery (14%) than patients with moderate to severe adenoid hypertrophy (38%, P = .046). Subgroup analysis was performed based on prior repair of cleft or submucous cleft palate and history of 22q11 microdeletion. Smaller adenoids were associated with lower surgical revision rates in patients who did not have a history of cleft palate or 22q11 microdeletion (P = .014 and .018, respectively). Adenoid size did not impact revision rates in patients with repaired cleft palates or those with 22q11 microdeletions. CONCLUSIONS: Smaller or absent adenoids are associated with lower rates of revision surgery after sphincter pharyngoplasty in children with VPI. Patients with VPI and bulky adenoids, who do not have a history of cleft palate or 22q11 microdeletion, should be considered for adenoidectomy prior to sphincter pharyngoplasty.

Balloon laryngoplasty for pediatric laryngeal stenosis: case series and systematic review.

OBJECTIVES/HYPOTHESIS: The aim of this study was to systematically review available literature on the outcomes of children treated with balloon laryngoplasty (BLP) as a primary or adjuvant treatment for subglottic or laryngeal stenosis, as well as briefly report on a new series of 60 children treated at the Medical University of South Carolina from 2007 to 2013. STUDY DESIGN: Review of published case series and retrospective chart review. METHODS: A literature search was performed in PubMed and MEDLINE to identify trials that reported clinical outcomes of BLP in human patients under the age of 18 with subglottic or laryngeal stenosis. Single case reports and series studying the dilation of tracheal or bronchial stenosis alone were excluded. Hospital billing codes were used to identify appropriate patients for retrospective chart review. A successful outcome for chart review was determined to be decannulation of previous tracheostomy or avoidance of open laryngotracheoplasty or tracheostomy. RESULTS: Seven studies published between 1991 and 2012 met inclusion criteria and reported outcomes with success defined through improvement of symptoms, decrease in Myer-Cotton level of stenosis, decannulation, or avoidance of reconstructive procedures. Including 60 children from our institution, 202 patients between 1 day and 22 years of age (average 35 months) underwent 457 dilations, with an average of 2.26 dilations per patient (2.25 in our population). The overall success rate was 64% (77% in our population). No complications were reported with subglottic or laryngeal dilations. CONCLUSIONS: BLP is a highly effective, low-risk alternative or adjunct to traditional reconstructive procedures in children with subglottic or laryngeal stenosis. LEVEL OF EVIDENCE: 4.

Nasal cavity dimensions in congenital pyriform aperture stenosis.

OBJECTIVE: To determine the dimensions of the nasal cavity in infants with congenital pyriform aperture stenosis (CPAS). STUDY DESIGN: The nasal cavities of seven children with CPAS were identified and were compared to the nasal cavities of 13 neonates (<30 days old) who had received CT scans for other indications. METHODS: The width of the nasal cavities was measured at the pyriform aperture, choana, and at two standardized points along the lateral nasal wall (LW-1 and LW-2) between the pyriform aperture and choana. RESULTS: Comparison between neonates with and without CPAS demonstrates significant narrowing of the nasal cavity (not just the pyriform aperture) in infants with CPAS. Significantly smaller nasal width was noted at pyriform aperture, LW-1, and LW-2 (p<0.01, p<0.01, p=0.02). No significant narrowing was seen at the choana. CONCLUSION: These findings suggest that CPAS is associated with narrowing of the anterior 75% of the nasal cavity. This has implications for surgical management because simple pyriform aperture ostectomy may not be sufficient to relieve symptoms of obstruction.

A trial of drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing.

OBJECTIVES/HYPOTHESIS: To determine the reliability and validity of drug-induced sleep endoscopy (DISE) for patients undergoing surgery for sleep-disordered breathing (SDB). STUDY DESIGN: Non-randomized, prospective clinical trial. METHODS: Patients with sleep-disordered breathing were evaluated for multi-level upper airway surgery by awake and drug-induced sleep endoscopy to identify levels and degree of airway collapse. The reliability of a drug-induced sleep endoscopy rating index was assessed by comparing scores of three blinded investigators. The validity was assessed by comparison of drug-induced sleep endoscopy index scores from awake and drug-induced sleep endoscopy; correlation between drug-induced sleep endoscopy scores and Apnea-Hypopnea Index; and determination whether drug-induced sleep endoscopy affected the original surgical plan. RESULTS: Thirty-eight patients (22 M, 16 F) underwent preoperative assessment with awake and drug-induced sleep endoscopy. Drug-induced sleep endoscopy was successfully performed in all but one patient (97%) who became combative during propofol infusion. Using an internal airway grading scale, drug-induced sleep endoscopy demonstrated more severity of collapse than awake endoscopy (P = 0.0001). The surgical plan was changed after drug-induced sleep endoscopy in 23 (62%) cases and unchanged in 14 (38%). The majority (73%) had multi-segmental airway collapse with fewer having single-level palatal (16%) or tongue base (11%) collapse. Scoring of drug-induced sleep endoscopy videos demonstrated good intrarater (κ 0.61) and interrater (κ 0.65) correlation. CONCLUSIONS: Drug-induced sleep endoscopy provides more clinical information to assess airway function and collapse than awake endoscopy alone and assists in the surgical planning. Additional investigation is needed to standardize drug-induced sleep endoscopy techniques, training, and interpretation.

Adenoid ciliostimulation in children with chronic otitis media.

OBJECTIVE: Adenoid hypertrophy and chronic adenoiditis are associated with an increased incidence of chronic otitis media. This study intends to determine the relationship between chronic otitis media and dynamic ciliary beat frequency in children undergoing adenoidectomy. STUDY DESIGN: Prospective, controlled study. SETTING: Pediatric tertiary care hospital. SUBJECTS AND METHODS: Children undergoing adenoidectomy were enrolled. Patients were stratified according to their indication for surgery, including adenotonsillar hypertrophy with obstructive sleep apnea, chronic otitis media with effusion, or recurrent episodes of acute otitis media. Adenoids were harvested using the curette. Tissue was sectioned and allowed to equilibrate in basal media for 24 hours. Cilia-bearing tissue was then stimulated using isoproterenol or methacholine. Ciliary beat frequency was serially reordered and analyzed using the Sisson-Ammons Video Analysis software program. RESULTS: Baseline ciliary beat frequency was similar in all groups (N = 47, total). Using isoproterenol, children with chronic otitis media with effusion demonstrated a blunted dynamic ciliary response at 2 and 3 hours relative to control (P = .0176 and P = .0282). Methacholine-stimulated ciliary beat frequency was not different between each group. CONCLUSION: At 2 and 3 hours following isoproterenol stimulation, there was a significant blunting of dynamic ciliary beat frequency in children with chronic otitis media with effusion. This ciliary dysfunction may provide a physiological explanation related to chronic adenoiditis in children with chronic otitis media.

Ultrasound characterization of middle ear effusion.

PURPOSE: To further enhance and assess the ability to characterize middle ear effusion (MEE) using non-invasive ultrasound technology. MATERIALS AND METHODS: This is a prospective unblinded comparison study. Fifty-six children between the ages of 6 months and 17 years scheduled to undergo bilateral myringotomy with pressure equalization tube placement were enrolled. With the child anesthetized, the probe was placed into the external ear canal after sterile water was inserted. Ultrasound recordings of middle ear contents were analyzed by computer algorithm. Middle ear fluid was collected during myringotomy and analyzed for bacterial culture and viscosity. RESULTS: Ultrasound waveforms yielded a computer algorithm interpretation of middle ear contents in 66% of ears tested. When a result was obtained, the sensitivity and specificity for successfully characterizing middle ear fluid content as either void of fluid, thick fluid (mucoid), or thin fluid (serous or purulent) were at least 94%. Mucoid effusions had higher measured viscosity values (P=.002). Viscosity measures were compared to culture result, and those with low viscosity (thin consistency) had a higher likelihood of having a positive culture (P=.048). CONCLUSION: The device sensitivity and specificity for fluid detection were 94% or greater among interpretable waveforms (66% of those tested). Although this technology provides important information of the middle ear effusion presence and characteristic, further technological improvements are needed.

Cigarette smoke inhibits dynamic ciliary beat frequency in pediatric adenoid explants.

OBJECTIVE: Environmental tobacco smoke exposure in children increases the incidence of upper respiratory infections, chronic sinusitis, and chronic otitis media. This study investigated the effects of ex vivo and in vitro smoke exposure on dynamic ciliary beat frequency (CBF) in pediatric adenoid explants. STUDY DESIGN: Blinded and controlled prospective study. SETTING: Tertiary care pediatric hospital. SUBJECTS AND METHODS: Fifty-five children undergoing adenoidectomy for obstructive sleep apnea and adenotonsillar hypertrophy were enrolled in this study. Adenoids were surgically removed using currettage. Hair was collected for nicotine analysis. Tissue was sectioned into 1-mm strips and allowed to equilibrate in DMEM/F12 with 2% fetal bovine serum for 24 hours. Cilia-bearing explant tissues were treated with either DMEM/F12 media, 5% cigarette smoke extract (CSE), or 10% CSE for 24 hours. Cilia were then stimulated using either isoproterenol (10(-9) M) or methacholine (10(-6)M), and CBF was serially recorded using the Sisson-Ammons Video Analysis (SAVA) software. RESULTS: Children with hair nicotine levels ≥ 1 ng/mg consistent with secondhand smoke exposure display blunted dynamic CBF response ex vivo. Explants incubated with CSE in vitro demonstrate significant impairment of isoproterenol and methacholine-induced CBF. CONCLUSION: CBF of adenoid explants increases when stimulated with isoproterenol and methacholine. Ex vivo and in vitro smoke exposure blunted ciliostimulation of CBF in adenoid explants. Smoke exposure impairs ciliary function in the pediatric airway and could potentially contribute to disorders such as chronic rhinosinusitis and chronic otitis media.

Risk factors for supraglottoplasty failure.

OBJECTIVE: To review outcomes after supraglottoplasty for laryngomalacia and identify risk factors for supraglottoplasty failure. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Retrospective case series evaluating patient outcomes after supraglottoplasty at an academic medical center between 2004 and 2010. Surgical failure was defined as need for revision surgery, tracheostomy tube placement, or gastrostomy tube insertion. Multivariable logistic regression was performed to identify risk factors for failure. RESULTS: The authors identified 95 children who underwent supraglottoplasty. After excluding patients with inadequate follow-up data, 74 patients were included. On the basis of chart review, 12 (16%) of those patients were defined as failures according to the criteria above. Age, history of prematurity (<34 weeks' gestational age), weight, growth curve percentile, neurologic/developmental problems, genetic syndrome, cardiac abnormality, synchronous airway lesions, and surgical technique were considered in risk factor analysis. Multivariable logistic regression was performed, revealing history of prematurity to be the only independent risk factor for failure (odds ratio = 4.85; 95% confidence interval, 1.07-22.1; P = .041). CONCLUSIONS: Outcomes after supraglottoplasty were comparable to previous reports in the literature. History of prematurity should be considered a risk factor for surgical failure.

Postoperative massive tongue edema in craniosynostotic children.

OBJECTIVE: Although rarely encountered in the clinical setting, massive tongue edema is a known phenomenon that can occur in craniosynostotic children in the postoperative period. In 1998, Kunhert described an encounter with an adolescent patient with Crouzon syndrome who required craniectomy for complications associated with Chairi malformation [1]. Following her procedure she had rapid tongue edema which was felt to be secondary to obstruction of the venous drainage of the tongue. Despite extensive workup and unsuccessful medical attempts to reduce the swelling, she was extubated with rapid resolution of the tongue edema [1]. METHODS AND RESULTS: In our facility, two children with underlying craniofacial diagnoses underwent elective surgical procedures. During their postoperative course, they encountered postoperative massive tongue swelling which ultimately required tracheotomy to relieve the compression and upper airway obstruction. CONCLUSION: We describe the clinical manifestations, treatment, and postoperative outcomes identified in these two cases.

Anterior cranial fossa glioblastoma with sleep apnea as the initial manifestation.

Sleep apnea is well known as a primary medical condition at this time. However, life-threatening diseases in which sleep apnea is the presenting symptom are less well described. The case of a 71-year-old man with a frontal lobe glioblastoma whose primary presenting symptom was sleep apnea is discussed. The relationship of intracranial tumors to sleep apnea symptoms is reviewed.

Mononuclear phagocytes migrate into the murine cochlea after acoustic trauma.

Acoustic injury results in destruction of hair cells and numerous nonsensory cells of the cochlea. How these injured structures undergo repair is not well understood. This study was designed to examine the cochlea for the presence of mononuclear phagocytes after tissue injury caused by noise damage. We used octave band noise (8--16 kHz) at three levels (106, 112, and 120 dB) for 2 hours and studied the mice at 1, 3, 7, and 14 days after noise exposure to determine how noise affected hearing thresholds, hair cell number, and tissue injury in the cochlea. Furthermore, we assessed the cochlea for presence of inflammation by performing immunohistochemistry for CD45, common leukocyte antigen. We counted the number of CD45(+) cells that were present in the cochlea at the above-mentioned time points after noise. CD45 is present on all bone marrow-derived white blood cells and is not otherwise expressed in the inner ear. We found that, after noise exposure, there is a large increase in CD45(+) cells. These marrow-derived cells are concentrated in the spiral ligament and spiral limbus, areas that are known to be susceptible to acoustic injury. It is possible that this inflammatory response plays a role in propagating cellular damage in these areas. Immunohistochemistry demonstrates that these cochlear cells are derived from the monocyte/macrophage lineage and serve a phagocytic function in the inner ear.

Ultrasonic detection of middle ear effusion: a preliminary study.

OBJECTIVE: To assess the ability to detect and characterize middle ear effusion in children using A-mode ultrasonography. DESIGN: Prospective nonblinded comparison study. SETTING: Tertiary children's hospital. PATIENTS: Forty children (74 ears) scheduled to undergo bilateral myringotomy with pressure equalization tube placement. INTERVENTIONS: Before myringotomy, ultrasound examination of the tympanic membrane and middle ear space was performed on each ear. Afterward, myringotomy was performed and the type of effusion (serous, mucoid, or purulent) was recorded. Pressure equalization tubes were then placed. MAIN OUTCOME MEASURE: Comparison of ultrasound findings with the visual assessment of the type of middle ear effusion present. RESULTS: Of the 74 ears tested, 45 (61%) had effusion on direct inspection. The effusion was purulent in 8 ears (18%), serous in 9 ears (20%), and mucoid in 28 ears (62%). Ultrasound identified the presence or absence of effusion in 71 cases (96%) (P = .04). Ultrasound distinguished between serous and mucoid effusion with 100% accuracy (P = .04). The probe did not distinguish between mucoid and purulent effusion. CONCLUSIONS: Ultrasonography is an accurate method of diagnosing middle ear effusion in children. Moreover, it can distinguish thin from mucoid fluid. Further refinements in probe design may further improve the sensitivity of fluid detection and allow differentiation of sterile vs infectious effusion.