Development of a pediatric obstructive sleep apnea triage algorithm.

INTRODUCTION: Diagnosis and treatment of obstructive sleep apnea (OSA) in children is often delayed due to the high prevalence and limited physician and sleep testing resources. As a result, children may be referred to multiple specialties, such as pediatric sleep medicine and pediatric otolaryngology, resulting in long waitlists. METHOD: We used data from our pediatric OSA clinic to identify predictors of tonsillectomy and/or adenoidectomy (AT). Before being seen in the clinic, parents completed the Pediatric Sleep Questionnaire (PSQ) and screening questionnaires for restless leg syndrome (RLS), nasal rhinitis, and gastroesophageal reflux disease (GERD). Tonsil size data were obtained from patient charts and graded using the Brodsky-five grade scale. Children completed an overnight oximetry study before being seen in the clinic, and a McGill oximetry score (MOS) was assigned based on the number and depth of oxygen desaturations. Logistic regression, controlling for otolaryngology physician, was used to identify significant predictors of AT. Three triage algorithms were subsequently generated based on the univariate and multivariate results to predict AT. RESULTS: From the OSA cohort, there were 469 eligible children (47% female, mean age = 8.19 years, SD = 3.59), with 89% of children reported snoring. Significant predictors of AT in univariate analysis included tonsil size and four PSQ questions, (1) struggles to breathe at night, (2) apneas, (3) daytime mouth breathing, and (4) AM dry mouth. The first triage algorithm, only using the four PSQ questions, had an odds ratio (OR) of 4.02 for predicting AT (sensitivity = 0.28, specificity = 0.91). Using only tonsil size, the second algorithm had an OR to predict AT of 9.11 (sensitivity = 0.72, specificity = 0.78). The third algorithm, where MOS was used to stratify risk for AT among those children with 2+ tonsils, had the same OR, sensitivity, and specificity as the tonsil-only algorithm. CONCLUSION: Tonsil size was the strongest predictor of AT, while oximetry helped stratify individual risk for AT. We recommend that referral letters for snoring children include graded tonsil size to aid in the triage based on our findings. Children with 2+ tonsil sizes should be triaged to otolaryngology, while the remainder should be referred to a pediatric sleep specialist.

Side effects and complications of injection laryngoplasty for treatment of congenital type 1 laryngeal clefts.

INTRODUCTION: Injection laryngoplasty (IL) is a brief, minimally invasive procedure involving injection of agents to augment the interarytenoid space. It was initially described as a diagnostic and temporizing measure for management of type one laryngeal clefts (LC1) and associated swallowing dysfunction (SwD), but more gradually it is being proposed as a definitive treatment modality. However, the morbidity of this treatment for LC1 remains under-investigated. This study sought to determine the morbidities associated with IL as a treatment modality for LC1 and associated SwD. METHOD: Single centre retrospective review of a prospective surgical database of one Pediatric Otolaryngologist at a tertiary care center. Participants included pediatric patients with an endoscopic diagnosis of LC1, treated with IL between 2000 and 2018-excluding those with concurrent upper airway anomalies. Patient charts were reviewed for demographic information, immediate post-op complications (within the first 14 days following IL), and subsequent management. RESULTS: Out of 85 consecutive, eligible patients, 12 were excluded (5 subglottic stenosis, 6 laryngomalacia, and one tracheomalacia). Of the 73 included patients, 42 were male and 31 females. The median age at IL was 29 months (range 1-132, interquartile range of 38 months). All IL procedures in this study utilized hyaluronic acid derivatives. From this series, 13 patients experienced post-operative complications. The complications encountered were respiratory distress (N = 5), croup-like cough (N = 6), and stridor (N = 6). These complications were either self-limiting (N=9), managed by systemic or inhaled steroids (N = 4), or admitted to hospital for monitoring (N=3). One case (augmented with dextranomer and hyaluronic acid) required intubation, repeat endoscopy, and drainage of seroma. CONCLUSION: IL was followed by respiratory morbidity in nearly two in ten of this series of consecutive patients. All the morbidities occurred in association with one injection product. Parents should be counselled appropriately about potential morbidities associated with this procedure.

Comparison of inhaled versus intravenous anesthesia for laryngoscopy and laryngeal electromyography in a rat model.

BACKGROUND: Propofol and remifentanil intravenous combination is one popular form of total intravenous anesthesia (TIVA) in mainstream clinical practice, but it has rarely been applied to a rat model for laryngoscopy and laryngeal electromyography (LEMG). Our objective was to establish a safe and reproducible general anesthetic protocol for laryngoscopy and endoscopic LEMG in a rat model. Our hypothesis is that TIVA allows a minimally morbid, and feasible laryngoscopy and LEMG. METHODS: Sprague Dawley rats were subjected to either inhalational anesthesia (IA) (isoflurane) or TIVA (propofol and remifentanil) and underwent laryngoscopy and LEMG. The primary outcome was a complete minimally interrupted rigid laryngoscopy and obtaining reproducible motor unit potentials from the posterior cricoarytenoid muscles. The secondary outcome was morbidity and mortality. RESULTS: Seventeen out of twenty-two rats underwent both TIVA and IA. Only two underwent IA only. All nineteen rats that underwent IA had a successful experiment. Seventeen rats underwent TIVA, however, only nine completed a successful experiment due to difficulty achieving a surgical plane, and respiratory events. Upon comparing the success of the two anaesthetic regimens, IA was superior to TIVA (P = 0.0008). There was no statistical difference between the amplitudes (p = 0.1985) or motor units burst duration (p = 0.82605) of both methods. Three mortalities were encountered, one of which was due to lidocaine toxicity and two were during anesthetic induction. Respiratory related morbidity was encountered in two rats, all seen with TIVA. CONCLUSIONS: TIVA is not an ideal anesthetic regimen for laryngeal endoscopy and LEMG in rat models. Contrary to our hypothesis, IA did not affect the quality of the LEMG and allowed a seamless rigid endoscopy.

Correlation between gonial angle and dynamic tongue collapse in children with snoring/sleep disordered breathing - an exploratory pilot study.

BACKGROUND: Drug induced sleep endoscopy (DISE) is hoped to identify reasons of failure of adenotonsillectomy (AT) in treating pediatric sleep disordered breathing (SDB). Maxillomandibular disproportion has been studied as another association which may explain alternative pathogenesis of SDB. We aimed to explore the relation between the size of the gonial angle and inclination of the epiglottis measured from cone beam CT (CBCT) and tongue base collapse based on DISE in children with SDB. METHOD: A retrospective chart review was conducted at a tertiary pediatric center. Children (6-17 years old) assessed at a multi-disciplinary Upper Airway Clinic, diagnosed with SDB and maxillo-mandibular disproportion (MMD), and who underwent DISE were eligible. Variables obtained from the electronic medical records of the clinic and prospective database included demographics, comorbidities, surgeries performed, investigations, DISE findings and CBCT findings. The gonial angle of subjects with and without tongue base collapse (TBC) on SNP were compared. RESULTS: In total 29 patients (13 male, 8 female) age 6-17 (median= 9) were eligible for the study from January 2009 - July 2016. We included 11 subjects, and 10 comparators. The mean gonial angle of the TBC group was 139.3°± 7.6°, while that of the comparison group was 129.4°±3.5 (mean difference -9.937, 95% CI of -15.454 to - 4.421, P = 0.001, power of test 0.95). Additionally, the mean inclination of the epiglottis had a mild positive correlation (r=0.32, p<0.05) with the gonial angle, in the whole cohort. CONCLUSIONS: This pilot study suggests that TBC may be mediated by a wider gonial angle in children with SDB patients. The posterior tilt of the epiglottis on CBCT may be a surrogate sign of TBC.

Unilateral Möbius syndrome: two cases and a review of the literature.

IMPORTANCE: The Möbius sequence is a rare condition defined by the combination of congenital non-progressive facial and abducens nerve palsies. The etiology of the sequence is still unknown, but likely encompasses a group of heterogeneous disorders involving genetic maldevelopment of the brainstem, a fetal vascular insult and/or teratogen exposure. The clinical phenotype reported has expanded over the years, and may be associated with more extensive cranial nerve and oropharyngeal involvement, as well as limb defects. OBSERVATIONS: We describe two cases of children presenting with unilateral Möbius syndrome associated with ipsilateral unilateral palatal weakness. Investigations failed to identified a clear underlying etiology, but both cases shared phenotypic features of other more common cranial facial disorders such as craniofacial microsomia and the velocardiofacial syndrome. CONCLUSION AND RELEVANCE: These two cases highlight the clinical heterogeneity of the Möbius sequence. Although asymmetries are not uncommon, cases with strictly unilateral features are extremely rare, and as such these may represent a distinct subgroup that may pertain to a specific etiology. Although in many cases, evidence of an intrauterine vascular insult may be identified, a contributing genetic etiology should be considered, even in cases with strictly unilateral features. As such genes expressed in the developing rhombencephalon and its vasculature represent good candidates for future investigation.

Unilateral opacification of paranasal sinus CT scans.

OBJECTIVES: The aim of study was to describe the histopathology in patients with unilateral sinus opacification and to identify variables that may predict neoplastic pathology. STUDY DESIGN: A retrospective review of paranasal sinus CT scans performed between 2000 and 2003 was conducted to identify patients with unilateral sinus opacification. RESULTS: Twenty-eight of 1118 CT scans showed unilateral sinus opacification. Twelve patients had neoplastic disease, 13 had inflammatory disease. Nasal discharge was more common in inflammatory than neoplastic disease (P = 0.009). A polyp or mass lesion was more common on nasendoscopy in neoplastic than inflammatory disease (P = 0.01). Bony erosion was only identified in malignant disease. CONCLUSION: A wide variety of pathologies present with unilateral sinus opacification on CT scanning. In our series, neoplastic disease was more associated with a visible polyp or mass lesion and less with nasal discharge. Bony erosion on CT scan was only seen in malignant disease. Histologic confirmation remains obligatory for diagnosis.

A case of the otogenic variant of Lemierre's syndrome with atypical sequelae and a review of pediatric literature.

We report a case of an 8-year-old girl who presented with the clinical picture of Lemierre's syndrome (LS) secondary to bilateral mastoiditis. She developed unilateral sensorineural hearing loss (SNHL) along with internal jugular vein (IJV) thrombosis, septic arthritis of her ankle and cervical fasciitis. Combined antimicrobial, anticoagulant and surgical treatment helped reverse all the effects of the sequelae, including nearly all the hearing loss. This is a unique case of this uncommon variant of the syndrome and with an uncommonly reported complication. The literature indicates that pediatric cases are a minority and enforces that successful management rests on awareness of the condition, vigil and promptness of communication of a multidisciplinary pediatric team.

Does synchronous nasal surgery increase the risk of post-operative haemorrhage in adult patients undergoing tonsillectomy?

Otolaryngologists occasionally perform simultaneous procedures on their patients, the indication being co-existent pathology. This is not a universally accepted practice as some feel that the post-operative morbidity is increased in such patients. Tonsillectomy is a common otolaryngological procedure and the main life-threatening complication, haemorrhage is easily identifiable. This study compares the incidence of post-operative haemorrhage requiring admission in patients undergoing tonsillectomy alone with that in patients undergoing tonsillectomy and nasal surgery. A retrospective study was undertaken of all adult patients undergoing tonsillectomy alone or tonsillectomy and synchronous nasal surgery in Aberdeen Royal Infirmary. Seventy-one patients (34 male) with a mean age of 23 years underwent tonsillectomy and synchronous nasal surgery over a nine-year period 1991-1999. The commonest nasal procedure was reduction of the inferior turbinates (in 48 cases). Three hundred and ninety-eight patients (131 male) with a mean age of 23 years underwent tonsillectomy alone over a nine-month period, July 1998 to April 1999. The incidence of post-tonsillectomy haemorrhage in the synchronous nasal surgery group was 12.7 per cent (9 out of 71) compared with four per cent (16 out of 398) in the tonsillectomy alone group (p <0.01, Chi-squared test). There was no difference in hospital stay between the two groups (mean two days). Synchronous nasal surgery increases the incidence of post-tonsillectomy haemorrhage.

A randomized control trial of post-operative care following endoscopic sinus surgery: debridement versus no debridement.

Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It is now accepted as a safe and effective means of treating sinonasal disease. The purpose of this study was to determine whether post-operative debridement is necessary after ESS. Seventeen patients undergoing bilateral primary ESS were randomized to receive debridement of either the left or right ethmoid cavity. All patients included in the study had symmetrical disease. Saline douches and all other concomitant treatments were delivered bilaterally. Outcome measures were based on regular symptom scores and surgeons' semi-quantitative assessment of the debrided and non-debrided cavities, over a three-month period. Analysis of adhesion rates, healing and symptom scores showed no statistically significant difference between the two groups. In conclusion, this study did not demonstrate significant benefit from post-operative ESS cavity debridement, at least with regard to cavity healing. This should be considered a pilot study and therefore limited conclusions can be drawn. Further work is needed to determine the optimum post-operative care for ESS.

Observations on the early results of treatment of recurrent respiratory papillomatosis using cidofovir.

OBJECTIVE: To document the response of two patients with severe recurrent laryngeal papillomatosis following treatment with intralesional cidofovir in conjunction with carbon-dioxide laser evaporation. SETTING: Tertiary referral centre. METHODS: Retrospective review of treatment of two patients followed up over a 12-month period. INTERVENTION: Microlaryngoscopy and carbon-dioxide laser evaporation of lesions followed by intralesional injection of cidofovir. OUTCOME MEASURES: Photodocumentation and descriptive statistical representation of intervals between endoscopic treatment. The disease was staged according to severity on endoscopy. RESULTS: Initially, both patients showed a marked improvement of disease. However, the disease relapsed to a significant extent. Overall, there was no demonstrable change in the frequency of required endoscopies despite subjective improvement of the airway. CONCLUSION: Cidofovir may be of some benefit in the management of recurrent respiratory papillomatosis, but further studies are still required.

A study of anthropometric measures before and after external septoplasty in children: a preliminary study.

OBJECTIVE: To test the hypothesis that surgery on the growing nasal septum does not adversely affect nasal and midfacial dimensions. DESIGN: Paired study. SETTING: Tertiary care center. PARTICIPANTS: Children treated consecutively during a 4-year period; all had significant nasal obstruction and cosmetic disfigurement secondary to skeletal septal deformities. INTERVENTION: Nasal septal surgery (using an external approach), in which the quadrilateral cartilage was removed, remodeled, and reinserted as a free graft. OUTCOME MEASURES: Anthropometric linear measurements and indexes of the face and nose preoperatively and postoperatively; nasal dorsum length, nasal height, nasal dorsum index, nasal tip protrusion, columellar length, facial height, face width, upper face height, facial index, nose-upper face height index, and columellar length-nasal tip protrusion index. Continuous measurements were transformed into ordered categories with reference to normative data. Data were analyzed using Wilcoxon signed rank sum test (alpha level of.05) and by applying the Bonferroni adjustment for multiple testing. RESULTS: Twenty-six children were studied (12 females and 14 males); age at surgery ranged from 4.5 to 15.5 years (mean age, 9.5 years); average age at postoperative measurement, 12.5 years; mean follow-up, 3.1 years. Only nasal dorsum length (P =.007) and nasal tip protrusion (P =.04) were decreased by a statistically significant level before the Bonferroni adjustment. The change was not considered clinically significant. Thus, relative to age-appropriate norms, the dimensions of the nose and midface and their proportionality did not change after surgery. CONCLUSIONS: Appropriate nasal septal surgery involving excision and subsequent reinsertion of a remodeled segment of the quadrilateral cartilage has no deleterious effects on development of the nose and midface. We question the absolute dogma that nasal surgery in children must always be avoided.

Assessment of vocabulary development in children after cochlear implantation.

OBJECTIVES: To assess vocabulary development in children following cochlear implantation and to evaluate the effect of age at implantation on performance. DESIGN: Retrospective study (mean follow-up, 3(1/2) years). SETTING: Tertiary center. PATIENTS: Children with prelingual deafness provided with a cochlear implant between 1988 and 1999, who serially performed the Peabody Picture Vocabulary Test-Revised (60 patients) and the Expressive One-Word Picture Vocabulary Test-Revised (52 patients). The children were subgrouped into those receiving implants at younger than 5 years and at 5 years or older. OUTCOME MEASURES: Age-equivalent vocabulary test score and gap index (chronological age minus the age-equivalent score, divided by the chronological age at the time of testing) were calculated. For each test, the following were performed: calculation of rate of change for age-equivalent score; comparison of earliest and latest gap indices means (the cohort and intergroup and intragroup comparison); and multiple regression analysis demonstrating the effect of age at implantation, sex, communication mode, etiology of deafness, and residual hearing on the rate of vocabulary development. RESULTS: Expressive and receptive vocabulary development rates were 0.93 and 0.71 (age-equivalent scores per year), respectively. Subgrouped by age at implantation, the children's rates (for both vocabularies) were not statistically different (Peabody Picture Vocabulary Test-Revised, P =.90; Expressive One-Word Picture Vocabulary Test-Revised, P =.23). The global latest gap indices were significantly less than the earliest (Peabody Picture Vocabulary Test-Revised, P =.048; Expressive One-Word Picture Vocabulary Test-Revised, P<.001), indicating an improvement in age-appropriate vocabulary development over time. The age subgroups demonstrated similar results, except for the younger group's receptive gap index. On multiple regression analysis, the significant predictive variables were residual hearing (Expressive One-Word Picture Vocabulary Test-Revised) and male sex and oral communication mode (Peabody Picture Vocabulary Test-Revised). CONCLUSIONS: Children with cochlear implants developed their vocabularies at rates that were sufficient to prevent an increase in their gap indices as related to ideal scores at testing. A late age at implantation does not singularly preclude beneficial development of vocabulary.

The effects of age of cochlear implantation on speech perception outcomes in prelingually deaf children.

We have made a retrospective analysis on 70 prelingually deaf children (78% congenital; age range 2-15 years) followed for up to 5 years post-implant during which both closed set speech perception tests (TAC, WIPI) and open set tasks (PBK, GASP) were administered. We used a binary partitioning algorithm to optimally divide our dataset on the basis of age at implantation This technique achieves an optimal split when the heterogeneity of the data is most reduced (maximal drop in deviance). For the closed set speech perception tests (TAC and WIPI) partitioning best divided-out data at age 4.4 years. For the open set tests optimal division was at a higher age of implantation (GASP word, 5.6 years; PBK word, 8.4 years). Using these partitioning values, we have found statistically significant differences between rate of improvement of scores in the younger implanted children compared with those implanted later.

Vocabulary acquisition rate after pediatric cochlear implantation and the impact of age at implantation.

OBJECTIVE: studies of early vocabulary development after pediatric cochlear implantation show growth rates that approach normality. Do these growth rates continue to rise over time and, therefore, allow a 'catch up' with ideal scores for age, or do they decline after an initial peak. Could age at implantation be a decisive factor in that process? DESIGN: retrospective study (mean follow-up 4 years). PATIENTS: pre-lingually deaf children implanted between 1988 and1999, who serially performed Peabody Picture Vocabulary Test-Revised (PPVT), (37 patients) and Expressive One-word Picture Vocabulary Test-Revised (EOWPVT), (35 patients). OUTCOME MEASURES: the mean rates of age equivalent scores were determined for the whole follow-up period and analyzed further for two post-implant periods (the two halves of follow-up duration of individual patients). After sub-grouping by age at implantation (younger or older than 5 years old), the same analysis was executed for each subgroup. RESULTS: the mean EOWPVT rate of the earlier period was higher than that of the later period (1.33 vs. 0.67, P<0.01) and the mean PPVT rate of the earlier period was higher than that of the later period (0.72 vs. 0.5). The latter difference was not statistically significant (P>0.05). Within subgroups by age at implantation, the PPVT mean rates were stable for younger implanted patients (0.56 for both periods) and dropped for the older implanted sub-group (0.87-0.43, P>0.05). The EOWPVT mean rates declined significantly for the older patients group (1.72-0.55, P<0.01) but insignificantly for the younger patients (0.99-0.77, P>0.05). CONCLUSIONS: vocabulary acquisition rates decline in the post-implantation period. This is more pronounced with older implanted children and the EOWPVT rates. This information on the time course development of vocabulary after implantation would be valuable in counseling and planning habilitation in addition to candidate selection.

A randomised controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients.

Post-operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre-incisional oropharyngeal injection of 0.5% bupivicaine, a 'dummy' injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. ANOVA, chi2 and Fisher's exact test were used for intergroup comparisons. Ninety-two patients (72 women and 20 men), mean age 22 years were studied. Twenty-nine patients received 0.5% bupivicaine, 30 saline and 33 no pre-incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post-tonsillectomy pain.

Primary non-Hodgkin's lymphoma of the frontal sinus: how we diagnosed it.

Isolated primary non-Hodgkin's lymphoma of the frontal sinus is rare. We describe the case of a middle-aged man who came to us with signs of orbital cellulitis complicating an acute infected frontal mucocele. His condition was initially controlled with medical therapy and subsequent endoscopic sinus surgery, but his symptoms eventually returned. We were able to diagnose the lymphoma only by approaching the sinus externally to obtain a biopsy. This case highlights the importance of making a full visual inspection of the involved sinus in order to avoid missing an unexpected, albeit a rarely encountered, pathology.

Target oriented computed tomography-scanning of the paranasal sinuses.

A limited computed tomography (CT) scanning protocol for the paranasal sinuses is proposed consisting of only seven cuts in the coronal plane. A retrospective observational study has shown the ability of these cuts to demonstrate the regions of interest to the FESS surgeon. The regions are detected at a rate ranging from 85% to 96% in this sample of 100 patients. The novelty of the protocol is the principle of targeting those regions. We believe that the targeted protocol is practically feasible and provides the necessary information concerning benign sinus disease, along with the expected reduction of exposure to radiation and reduction of cost.

Non-Hodgkin's lymphoma of the lacrimal sac and concomitant pansinusitis.

Paranasal sinus disease has an established propensity to breach anatomical barriers and present with orbital clinical features. Lacrimal sac lymphomas on the other hand are rare, usually present in males in the sixth decade and 50 per cent of cases have systemic lymphoma/leukaemia. Atypical presentations of lymphomas at this and other sites are reported in patients with acquired immunodeficiency syndrome (AIDS). The clinical features, investigations and treatment of a young human immunodeficiency virus (HIV) sero-negative woman with a non-Hodgkin's lymphoma localized to the lacrimal sac and presenting with a concomitant ipsilateral pansinusitis is described. The importance of submitting surgical material for pathological investigation is stressed.

Bipolar diathermy tonsillectomy.

Tonsillectomy is an operation performed by various techniques. We have developed a bipolar diathermy dissection technique that allows a low intra-operative blood loss without an increase in complications. The average blood loss was less than 4 ml in 100 patients. Most were able to drink and eat by 4 and 10 hours respectively. There was no increase in analgesic requirements. No primary haemorrhage was recorded; three patients had a secondary haemorrhage. The technique allows accurate coagulation of blood vessel and is an easy procedure to learn.