Pott's Puffy Tumor: A Rare, Life-Threatening Presentation of Periorbital Edema.

Pott's puffy tumor (PPT) describes forehead swelling with associated frontal bone osteomyelitis and a subperiosteal abscess (SPA) requiring a high suspicion index for optimal outcomes. PPT is a life-threatening complication of frontal sinusitis typically found in adolescents. Our case is one of the youngest in the literature. This report describes a 3-year-old patient who developed multifocal abscesses in the epidural space with frontal and orbital SPA, requiring surgical intervention. Additionally, her course was complicated by a superior sagittal venous thrombosis, a complication commonly associated with PPT. We present an unusual case of orbital SPA and aim to highlight a life-threatening pediatric condition that is often underrecognized.

Low-Cost Ear Procedure Simulator With Syringe and Tuning Fork: Training Course and Results.

INTRODUCTION: Medical simulation is a continuously expanding field. In surgical specialties, in particular, simulation can provide an alternative avenue for learning. The objective of this process improvement project was to evaluate the effectiveness and practicality of adding simulation-based training to our educational curriculum regarding common otologic procedures. MATERIALS AND METHODS: A low-cost, novel ear procedure simulator was designed and constructed from readily available clinic supplies. Participants were asked to fill out a pre-simulator survey to assess their own comfort and skill level before undergoing the simulation course. A pre-simulation PowerPoint training course was then administered to participants. The participants then underwent the simulation training course and were again asked to fill out a post-simulator training exercise survey to reassess their own comfort and skill level. Institutional review board approval was not required by Tripler Army Medical Center. RESULTS: A total of 15 participants consisting of junior residents in otolaryngology, third- and fourth-year medical students rotating on an otolaryngology clinical clerkship, and one physician assistant in otolaryngology were included in the study. There was a significant improvement in both provider comfort with the procedure and clinical performance of the procedure among participants after training on the simulation-based model. CONCLUSIONS: Simulation-based training provides a safe, effective, and cost-friendly alternative to clinical medical education. Future studies are needed to address the wide-scale applicability of these results to other forms of surgical training.

Aerodigestive clinic reduces emergency department and primary care utilization and increases access to ancillary and specialty care.

OBJECTIVE: The study aimed to evaluate the effect of the aerodigestive clinic (ADC) on healthcare utilization. STUDY DESIGN: Retrospective quality improvement project; before and after. SETTING: The ADC at Tripler Army Medical Center (TAMC) in Honolulu, HI. METHODS: We retrospectively analyzed the electronic medical records of children ≤17 years old seen in the ADC at TAMC between April 2015 and June 2019. The number of emergency department (ED), primary care (PC), specialty care (SC), ancillary care (AC), and teleconsult (TC) encounters were tallied before and after one year of the initial intake visit. RESULTS: A total of 261 children were included during the study period. Comparing visits before aerodigestive evaluation to after aerodigestive evaluation, the total number of visits before and after were similar with significant changes in the distribution of encounters. The total number of ED (-38%) and PC (-40%) visits decreased significantly (p < 0.001 for both). The total number of other visits were found to have non-significant increases. PC visits accounted for nearly one-third (31%) of all visits prior to the initial ADC visit, but only 19% of visits after. PC visits decreased for all age groups. ED visits decreased by nearly half (-48.1%) for ages 1-17, but there was no change for <1-year olds. CONCLUSION: There is a statistically significant reduction in the number of emergency department and primary care visits for patients seen in a multidisciplinary ADC. The distribution of visits differed strongly among age groups. These findings emphasize the positive impact that the multidisciplinary clinic has on healthcare utilization for pediatric aerodigestive patients.

Direct laryngoscopy assisted fiberoptic intubation: A novel technique for the pediatric airway.

OBJECTIVE: To introduce a novel intubation technique for difficult pediatric airways. METHODS: This two-provider technique requires a direct laryngoscope and a flexible fiberoptic laryngoscope. One provider performs direct laryngoscopy which allows for introduction of the flexible laryngoscope. The second provider inserts the flexible laryngoscope with the endotracheal tube loaded, through the oropharynx in to the subglottis. RESULTS: We report three pediatric patients that were initially unable to be intubated by conventional methods. We were ultimately able to successfully intubate these patients with difficult airways using our novel technique. CONCLUSIONS: We found that this technique of direct laryngoscopy assisted flexible fiberoptic intubation is a useful adjunct in select pediatric difficult airway patients.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis.

OBJECTIVE: To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia. DATA SOURCES: PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase. REVIEW METHODS: Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed. RESULTS: A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% (P = .011). CONCLUSION: Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.

First branchial cleft fistula (Work Type 2) with an internal opening to the Eustachian tube: Case report and review of literature.

First branchial cleft anomalies are rare congenital defects of the head and neck. This case report presents a 12-year-old patient with a draining cutaneous pit approximately 1-cm anterior and 5-mm inferior to the right angle of the mandible. Imaging revealed a fistula between the cutaneous pit and Eustachian tube. Further characterization with methylene blue injection into the cutaneous pit resulted in spillage through the right Eustachian tube. Surgical excision of the fistula revealed a cylindrical structure comprised of ectodermal and mesodermal features that most likely represented a Work Type 2 first branchial cleft fistula.

Pediatric Tracheostomy Decannulation: 11-Year Experience.

OBJECTIVE: To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol. STUDY DESIGN: Case series with chart review. SETTING: A single tertiary care institution. SUBJECTS AND METHODS: A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year). RESULTS: Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%. CONCLUSION: Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.

Montelukast and Nasal Corticosteroids to Treat Pediatric Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on anti-inflammatory medications for treating pediatric obstructive sleep apnea and perform meta-analysis of the available data. DATA SOURCES: PubMed/MEDLINE and 4 additional databases. REVIEW METHODS: Three authors independently and systematically searched through June 28, 2018, for studies that assessed anti-inflammatory therapy for treatment of pediatric obstructive sleep apnea (OSA). Data were compiled and analyzed using Review Manager 5.3 (Nordic Cochrane Centre). RESULTS: After screening 135 studies, 32 were selected for review with 6 meeting inclusion criteria. In total, 668 patients aged 2 to 5 years met inclusion criteria for meta-analysis. Of these, 5 studies (166 children) that evaluated montelukast alone as treatment for pediatric OSA found a 55% improvement in the apnea-hypopnea index (AHI) (mean [SD] 6.2 [3.1] events/h pretreatment and 2.8 [2.7] events/h posttreatment; mean difference [MD] of -2.7 events/h; 95% confidence interval [CI], -5.6 to 0.3) with improvement in lowest oxygen saturation (LSAT) from 89.5 (6.9) to 92.1 (3.6) (MD, 2.2; 95% CI, 0.5-4.0). Two studies (502 children) observing the effects of montelukast with intranasal corticosteroids on pediatric OSA found a 70% improvement in AHI (4.7 [2.1] events/h pretreatment and 1.4 [1.0] events/h posttreatment; MD of -4.2 events/h; 95% CI, -6.3 to -2.0), with an improvement in LSAT from 87.8 (3.1) to 92.6 (2.2) (MD, 4.8; 95% CI, 4.5-5.1). CONCLUSIONS: Treatment with montelukast and intranasal steroids or montelukast alone is potentially beneficial for short-term management of mild pediatric OSA.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery.

OBJECTIVE: The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system. METHODS: Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system. RESULTS: 231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery. CONCLUSION: This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

Ectopic Thymic Cyst of the Subglottis: Considerations for Diagnosis and Management.

OBJECTIVES: To share the diagnostic and management challenges created by an extremely rare airway lesion-the subglottic ectopic thymic cyst. STUDY DESIGN: Case report and literature review. METHODS: We review the presentation, management, and clinical course of an infant who presented with a subglottic mass that was histologically confirmed as a thymic cyst. A brief literature review supplements the case presentation Results: We present the third described case of an ectopic thymic cyst presenting as a subglottic mass. The differential diagnosis of subglottic masses in neonates consists primarily of subglottic hemangioma and mucous retention cysts. Otolaryngologists must be prepared for unexpected findings when dealing with critical airways. We compare the presentation and management of our patient with the 2 previously described cases. We propose an embryologic theory for the origin of these rare lesions. CONCLUSIONS: An ectopic thymic cyst is a rare and unexpected cause of neonatal stridor. Management of pediatric airway lesions must allow for unexpected findings at the time of diagnostic and therapeutic endoscopy. The appropriate management of subglottic thymic cysts is poorly defined, but close surveillance for recurrence is mandatory.

International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of type I laryngeal clefts.

INTRODUCTION: The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition. OBJECTIVE: To provide recommendations for the diagnosis and management of type I laryngeal clefts. METHODS: Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method. SETTING: Multinational, multi-institutional, tertiary pediatric hospitals. RESULTS: Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts. CONCLUSIONS: This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Hearing loss in the pediatric patient.

OBJECTIVE: To provide recommendations for the workup of hearing loss in the pediatric patient. METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group. RESULTS: Consensus recommendations include initial screening and diagnosis as well as the workup of sensorineural, conductive and mixed hearing loss in children. The consensus statement discusses the role of genetic testing and imaging and provides algorithms to guide the workup of children with hearing loss. CONCLUSION: The workup of children with hearing loss can be guided by the recommendations provided herein.

Bronchial Compression and Tracheosophageal Fistula Secondary to Prolonged Esophageal Foreign Body.

INTRODUCTION: Foreign body ingestion is a common pediatric problem that can have a delayed presentation, as presented herein. CASE REPORT: We present the case of a 15-year-old female who developed bronchial compression and an acquired tracheoesophageal fistula secondary to a longstanding esophageal foreign body. DISCUSSION: There are several challenges in diagnosis and management of this unusual situation. We review the literature regarding prolonged retention of foreign bodies and the challenges in diagnosis in the developmentally disabled child. CONCLUSION: Providers must have a high suspicion for foreign bodies in the case of unusual symptoms present in children with neurodevelopmental delays.

International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations.

OBJECTIVE: To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia. METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS: Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy. CONCLUSION: Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

Cadaveric Study of an Endoscopic Keyhole Middle Fossa Craniotomy Approach to the Superior Semicircular Canal.

OBJECTIVE: Demonstrate that an endoscopic keyhole approach to the middle cranial fossa is technically feasible for repair of semicircular canal dehiscence. STUDY DESIGN: Cadaveric technical feasibility/methods development study. SETTING: Tertiary care military medical center. PATIENTS: Three fresh cadaveric heads (six sides). INTERVENTION(S): Endoscopic minimally invasive approach to the middle cranial fossa using the Medtronic Fusion Guidance system. MAIN OUTCOME MEASURE(S): Ability to identify the surgical landmarks of the middle cranial fossa and successfully identify and instrument the superior semicircular canal. RESULTS: In every attempt, the arcuate eminence was successfully identified under endoscopic visualization and with the assistance of surgical navigation. The superior semicircular canal was unroofed, and its location confirmed visually and with the navigation system. The opened canal was then plugged with bone wax, bone pate, and covered with fascia. The 15-mm burr hole craniotomy provided ample room for one working instrument and a 4-mm 0-degree endoscope. CONCLUSION: The endoscopic keyhole approach to superior semicircular canal dehiscence is technically feasible in a human cadaveric model. Further studies will determine 1) if this approach is possible and safe in vivo, 2) is associated with improved surgical outcomes, and 3) if surgical navigation aids in this approach.

Dystrophic calcification: A rare pediatric parotid mass.

Dystrophic calcification, the ectopic deposition of calcium in previously damaged or inflamed tissues, is an uncommon finding in the head and neck. Only a few cases have been reported in the parotidomasseteric region, and all of them have been located within and adjacent to the masseter. We present a case of dystrophic calcification occurring entirely within the parotid gland in a 7-year-old girl without apparent inciting inflammation, infection, or trauma. Our patient's presentation highlights the diagnostic challenge associated with parotid masses in the pediatric population. To our knowledge, this is the first reported case of dystrophic calcification occurring entirely within the parotid gland in a child.

Trends in orbital complications of pediatric rhinosinusitis in the United States.

IMPORTANCE: Several studies have documented the prevalence and treatment of orbital complications secondary to pediatric rhinosinusitis, but to our knowledge, none have investigated the national health care burden of this disease since the introduction of the heptavalent pneumococcal vaccine (PCV-7). OBJECTIVE: To identify the current public health burden of orbital complications of pediatric rhinosinusitis, and to determine if the introduction of the PCV-7 has resulted in a change in national practice patterns. DESIGN, SETTING, AND PARTICIPANTS: Population-based study using the 2000 and 2009 Kids' Inpatient Databases to gather data on a sample of all pediatric discharges in the United States during the years 2000 and 2009. Children diagnosed as having orbital complications of sinusitis were identified by corresponding International Classification of Diseases, Ninth Revision (ICD-9) codes. Database analyses generated national estimates of summary statistics and comparison of trends over the 9-year period. INTERVENTIONS: Database analysis. MAIN OUTCOMES AND MEASURES: National health care trends according to year. End points assessed included prevalence, age, sex, length of hospital stay, and treatment of disease. RESULTS: The estimated prevalence of orbital complications of sinusitis requiring hospitalization in the United States has slightly decreased from 5338 (95% CI, 4956-5720) admissions in 2000 to 4511 (95% CI, 4165-4858) in 2009. However, the mean age has increased from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-6.26) years. The proportion of children undergoing surgical treatment increased from 0.108 (95% CI, 0.093-0.123) to 0.195 (95% CI, 0.176-0.213). Total charges increased from $4,140,000 (95% CI, $3,440,000-$4,830,000) to $10,000,000 (95% CI, $8,480,000-$11,600,000) with a mean charge per admission increasing from $8390 (95% CI, $7096-$9685) in 2000 to $22,656 (95% CI, $19,997-$25,314) in 2009. The mean length of stay remained stable at 3.67 (95% CI, 3.37-3.97) to 4.05 (95% CI, 3.81-4.29) hospital days. CONCLUSIONS AND RELEVANCE: The public health impact of orbital complications of pediatric rhinosinusitis continues to be substantial. Since the institution of the PCV-7 vaccine, national trends demonstrate a slightly decreased prevalence of hospital admissions. However, there is a shifting trend toward an older age at admission and a higher proportion of children undergoing surgical treatment.

A new scoring system for upper airway pediatric sleep endoscopy.

IMPORTANCE: Sleep-associated upper-airway obstruction in children is a significant cause of morbidity. Development of a simple, standardized, quantitative technique to assess anatomic causes of sleep-related breathing disorder is important for surgical planning, clinical communication, and research. OBJECTIVE: To design, implement, and evaluate a scoring system to quantify airway obstruction in pediatric drug-induced sleep endoscopy. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective case series conducted at a tertiary pediatric hospital. The patients were children with sleep-related breathing disorder who underwent polysomnography and drug-induced sleep endoscopy. INTERVENTIONS: Flexible fiber-optic laryngoscopy was performed. Endoscopic examinations were recorded on video and assessed by 4 independent raters based on a scoring template. MAIN OUTCOMES AND MEASURES: Five locations in the upper aerodigestive tract (adenoid, velum, lateral pharyngeal wall, tongue base, and supraglottis) were evaluated on a 4-point scale for minimum and maximum obstruction. Internal reliability was assessed by calculating interrater and intrarater intraclass correlation coefficients (ICCs). For external validation, aggregate and site-specific scores were correlated with preoperative polysomnographic indices. RESULTS: Videos recorded of sleep endoscopies from 23 children (mean age, 2.2 years) were reviewed and rated. Children had an average apnea-hypopnea index of 24.8. Seventy percent of interrater and intrarater ICC values (7 of 10 for each set) were above 0.6, demonstrating substantial agreement. Higher total obstructive scores were associated with lower oxygen saturation nadir (P = .04). The scoring system was also used to quantitatively identify children with multilevel airway obstruction, who were found to have significantly worse polysomnographic indices compared with children with single-level obstruction (P = .02). CONCLUSIONS AND RELEVANCE: The proposed scoring system, which is designed to be easy to use and allow for subjectivity in evaluating obstruction at multiple levels, nonetheless achieves good internal reliability and external validity. Implementing this system will allow for standardization of reporting for sleep endoscopy outcomes, as well as aid the practicing clinician in the interpretation of sleep endoscopy findings to inform site-directed surgical intervention in cases of complicated obstructive sleep apnea.