Injection laryngoplasty in infants with unilateral vocal cord paralysis: A survey of ASPO members.

INTRODUCTION: Unilateral vocal cord paralysis (UVCP) in infants may be managed medically or surgically, with the latter including injection laryngoplasty (IL). However, there is limited information regarding injection laryngoplasty in infants. We therefore proposed a survey of American Society of Pediatric Otolaryngology (ASPO) members to elucidate current practices, outcomes, and complications. METHODS: An online survey was distributed to all 548 ASPO members via email. The survey was closed for data analysis 2 months after initial distribution. Statistical analysis was deferred due to the primarily descriptive nature of the data and lack of comparative studies. RESULTS: We received 113 responses for a response rate of 20.6%. Only 31% of the respondents (n = 36) reported performing IL in infants 12 months old or younger. The most commonly cited reasons for not injecting in this age group were preference for non-surgical management and concern for increased risk of airway obstruction. IL was most commonly performed to treat persistent aspiration despite attempts at medical management. The majority (66%) reported no complications, while the remainder noted stridor requiring intensive care unit observation. Re-intubation due to airway obstruction occurred in 6% (n = 2 of 33). Carboxymethylcellulose gel (Prolaryn Gel) was the most commonly used injectable material, but a variety of other materials were used as well. Two respondents noted they perform reinnervation procedures in children, but not in infants, as they require at least a 12 month period of observation for possible spontaneous recovery before considering the option. DISCUSSION: There is limited data regarding management of UVCP in infants with IL, and considerable variation among those who do perform the procedure. While adverse events are rare, multi-institutional studies should be considered to help determine best practices.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Attenuation of Helper T Cell Capacity for TH1 and TH17 Differentiation in Children With Nontuberculous Mycobacterial Infection.

Nontuberculous mycobacteria (NTM) infect children with increasing frequency worldwide. Using blood and lymph node tissue from children with NTM lymphadenitis, and uninfected lymph node tissue from community controls, we evaluated helper T (TH) cells in functional assays of TH1/TH17 differentiation and measured the concentration of their associated cytokines at the site of infection. Circulating TH cells from infected children were attenuated in their TH1/TH17 differentiation capacity and expressed less interferon γ and interleukin 17 after polyclonal stimulation. Similar differences were observed at the site of infection, where most cytokine concentrations were unchanged relative to controls. Our data are consistent with a model wherein TH1/TH17 differentiation is attenuated in NTM-infected children.

Subcutaneous emphysema and vocal fold paresis as a complication of a dental procedure.

Third molar extraction is a common oral surgery performed in the pediatric population. Here we report a case of extensive subcutaneous emphysema of the orbital, masticator, parapharyngeal, retropharyngeal spaces, bilateral carotid and visceral spaces, and pneumomediastinum after third molar extraction with turbine drill. This was treated with intubation for airway protection, transoral drainage, and intravenous antibiotics. After discharge the patient reported persistent dysphonia and was found to have left vocal fold paresis. This was likely related to extensive pneumomediastum causing injury to the recurrent laryngeal nerve. This is the first report of cervicofacial emphysema leading to vocal cord paresis after third molar extraction, demonstrating the importance of serial clinical monitoring in these cases.

Use of text messaging to improve patient experience and communication with pediatric tonsillectomy patients.

OBJECTIVES: The aims of this quality improvement project were to develop a text messaging service to deliver messages to pediatric tonsillectomy patients to improve communication and overall experience. METHOD: Text messages were developed to deliver important information and reminders both preoperatively and postoperatively to pediatric tonsillectomy patients. After success with a small pilot program of five patients, a sample of 85 patients who underwent tonsillectomy participated in the program. RESULTS: Similar to the pilot program, the larger sample size had no canceled procedures and no visits to the emergency department. Approximately 25% of the participants called the ENT clinic nurse line for a question or concern postoperatively. The majority of phone calls were for concerns with pain or pain medications. Parental survey results were positive with respect to the value and overall helpfulness of the text messages. Respondents found the information useful, easy to understand, and it also helped reduce anxiety or level of worry during and after the surgery. Respondents all felt that the number of messages was just right. CONCLUSION: With the explosion of technology and smartphone use, text messaging is an innovative way to provide patient/family education for surgical procedures such as tonsillectomy.

Endoscopic esophageal and tracheal cauterization for closure of recurrent tracheoesophageal fistula: A case report and review of the literature.

OBJECTIVE: Recurrent tracheoesophageal fistula (TEF) can be a diagnostic and therapeutic challenge. Traditional treatment is thoracotomy, which carries significant morbidity and technical difficulty especially in a previously operated field. Recently, endoscopic techniques have been advocated as a primary approach for treatment of recurrent TEF prior to open repair. This case report describes the endoscopic technique used to address a recurrent TEF. The existing literature of all reported endoscopic cauterization methods is reviewed. METHODS: An 8 month old with proximal esophageal atresia and distal TEF underwent endoscopic closure of a recurrent TEF. The fistula was approached endotracheally utilizing Bugbee electrocautery (EC) and endoluminally through the esophagus using argon plasma coagulator and placement of porcine submucosa graft into the tract. Current literature review is presented with a synthesis of data on cases utilizing endoscopically applied EC and the combined results of this closure technique. RESULTS: Our patient has maintained successful closure after a single treatment confirmed on follow up endoscopy 6 months post repair. Including this patient, there have been 30 patients with recurrent TEF treated utilizing endoscopic EC reported in the literature. The overall success rate is 78.8% with a mean of 1.88 procedures per successful closure. Comparing EC alone to EC combined with tissue glues or laser, success rates are 67% and 86% respectively. CONCLUSION: Endoscopic repair of recurrent TEF has proven to be safe and effective in the literature as an alternative to a second thoracotomy/open surgical repair. EC combined with tissue glues or laser is more effective than EC alone based on available data.

Pepsin as a biomarker for laryngopharyngeal reflux in children with laryngomalacia.

OBJECTIVES/HYPOTHESIS: Laryngomalacia is a common cause of newborn stridor. Laryngopharyngeal reflux (LPR) has been associated with laryngomalacia. Although pepsin, a component of LPR, has been associated with inflammatory diseases of the aerodigestive tract, its presence in the airways of laryngomalacia patients is unknown. STUDY DESIGN: Prospective case-control study comparing patients under age 3 years with laryngomalacia to children without laryngomalacia. METHODS: Children less than 3 years old undergoing supraglottoplasty for laryngomalacia or surgery unrelated to the airway, without a history of laryngomalacia, reflux, or respiratory disease, were offered enrollment. Supraglottic lavage samples (3 mL) were obtained from all subjects. Two-millimeter arytenoid biopsies were collected from laryngomalacia patients. Pepsin Western blot and enzyme-linked immunosorbent assay were performed. RESULTS: Ten laryngomalacia and five control subjects were enrolled. Pepsin was detected in lavages of laryngomalacia patients (8/10) but absent in controls (0/5; P = .007). Pepsin was observed more frequently in lavages (8/10) than biopsies (4/10; P = .046) of laryngomalacia subjects. Higher median pepsin concentration was observed in laryngomalacia than control lavages (P = .025). CONCLUSIONS: Pepsin in supraglottic specimens demonstrated an association with laryngomalacia, supporting a role for refluxed pepsin in laryngomalacia. These data corroborate previous work implicating pepsin in inflammatory diseases of the upper airways. Further studies are warranted to investigate the contribution of pepsin to the pathophysiology of laryngomalacia. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:2413-2417, 2017.

A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients.

Approximately 1,500 tonsillectomies are performed annually at a large pediatric academic medical center each year. Families need to be educated on how to care for their child after this surgery. Most tonsillectomy patients are discharged home either the same day as surgery or after one night of observation, resulting in post-operative tonsillectomy recovery and care falling upon the patient's family. Multiple quality improvement efforts to improve family education post tonsillectomy surgery have been performed over the last several years at a large pediatric academic medical center. None of these efforts, however, have focused on the use of technology to provide innovative patient education. The purpose of this project is to provide information to parents via text messages and videos to improve patient experience and outcomes following tonsillectomy. Families provided positive feedback, including that the texts were helpful, easy to understand, and reduced pre-operative and recovery anxiety. Also, none of these families needed to call the ENT clinic for any other questions or concerns. The recovery from tonsillectomy is not easy and this pediatric otolaryngology practice is always searching for new ways to improve care and education. Use of technology is an innovative approach and likely one that will be used more often in the future.

Safety of Ultrasound-Guided Botulinum Toxin Injections for Sialorrhea as Performed by Pediatric Otolaryngologists.

OBJECTIVE: To evaluate incidence of complications and hospital readmission as a result of ultrasound-guided botulinum toxin injections to manage sialorrhea. STUDY DESIGN: Case series with chart review. SETTING: Children's Hospital of Wisconsin. SUBJECTS AND METHODS: A case series with chart review was performed of all cases of ultrasound-guided injection of botulinum toxin by pediatric otolaryngologists from March 5, 2010, to September 26, 2014,. Primary outcomes included complications such as dysphagia, aspiration pneumonia, and motor paralysis. Secondary outcomes included hospitalization, intubation, and nasogastric tube placement. RESULTS: There were 48 patients, 111 interventions, and 306 intraglandular injections identified. Botulinum toxin type A and type B were utilized in 4 and 107 operative interventions, respectively. Type A was injected into 4 parotid and 4 submandibular glands, utilizing doses of 20 U per parotid and 30 U per submandibular gland. Type B was injected into 98 parotid and 200 submandibular glands, with average dosing of 923 U per parotid and 1170 U per submandibular gland, respectively. There were 2 instances of subjectively worsening of baseline dysphagia that self-resolved. No cases were complicated by aspiration pneumonia or motor paralysis. No patients required hospital readmission, intubation, or nasogastric tube placement. CONCLUSION: Prior published data indicated 16% complication incidence with ultrasound-guided injection of botulinum toxin. Our study found a low complication rate (0.6%) with ultrasound-guided injections of botulinum toxin to manage sialorrhea, without cases of aspiration pneumonia or motor paralysis. Of 306 intraglandular injections, there were 2 cases of worsening baseline subjective dysphagia that self-resolved.

Recurrence patterns of cervical infections in children.

OBJECTIVES: (1) Elucidate the recurrence rate of pediatric cervical cellulitis and abscess (2) Evaluate the impact of pre-procedural imaging, length of stay, culture results, age and gender on readmission rate. METHODS: A retrospective review of all admissions to a tertiary pediatric hospital for cellulitis and abscess of the neck (ICD-9 682.1) from 2007 to 2013 including all readmissions within 91 days. RESULTS: There were a total of 178 admissions (171 patients) with the diagnosis of cellulitis and abscess of the neck between 2007 and 2013. The rate of surgical intervention was 74% (n=128). The overall readmission rate within 91 days was 3.5% (n=6). All patients requiring readmission had undergone a procedure during the initial admission and a second procedure during readmission. The readmission rate for patient who initially required a procedural intervention was 4.6%. There was no statistically significant effect of pre-procedural imaging, length of stay, culture results, age or gender on readmission rate. Patients with abscess >20mm in diameter had a significantly longer LOS than patient with smaller abscesses (4.265 days vs 3.667 days, p<0.001). Furthermore, in patients 3 years old or greater, the patients with a larger diameter (>20mm) and larger total size were more likely to need surgical drainage. CONCLUSIONS: This retrospective review of patients admitted with neck cellulitis and abscess at a tertiary care pediatric hospital shows an overall readmission rate of 3.5%. All readmissions required a surgical procedure. Older children with larger abscess are more likely to require surgical drainage.

The use of botulinum toxin B in the treatment of a post-traumatic sialocele in a 4-year-old child: A case report.

Parotid sialoceles are bothersome complications of parotidectomy and penetrating injury to the parotid gland. Though typically self-limited and responsive to conservative management, they can be particularly difficult to manage in the pediatric population where even conservative interventions are less well tolerated. We present the case of a 4-year-old child with a post-traumatic parotid sialocele that was successfully managed with a single injection of botulinum toxin B. To our knowledge, this is the first reported case of the use of botulinum toxin for this purpose in the pediatric population.

Factors influencing successful peer-reviewed publication of original research presentations from the American Society of Pediatric Otolaryngology (ASPO).

OBJECTIVE: To analyze factors associated with progression of an original scientific presentation at the American Society of Pediatric Otolaryngology (ASPO) Annual Meeting to publication in a peer-reviewed journal. A dataset of presenters was created to enable prospective follow-up to assess early impressions regarding publication success with longer-term publication outcomes. METHODS: Prior to the Annual ASPO meeting in 2013, a survey consisting of 10 questions was e-mailed to all 59 presenters. Questions were designed to assess presenter expectations on publication, barriers to publishing, and experience in presenting, publishing and clinical practice. A second survey was sent 12 months later to those respondents of the first survey who were amenable to follow-up. RESULTS: Overall, 46 of 59 (78%) presenters responded to the initial survey prior to their ASPO 2013 presentation. Of these, 34 agreed to participate in a longer-term follow-up of their presentation to publication experience. Of these 34, there were 17 who participated in the follow-up survey 1 year later. Just under half of the original respondents were residents (46%). All presenters (100%) planned to re-submit a revised manuscript if initially rejected. However, 35% of follow-up respondents did not make initial submission to a peer-reviewed journal. Results of a descriptive analysis suggest that more experienced researchers expect their submitted manuscript to be accepted for publication within a shorter time frame than those that have published fewer papers. Time was ranked as the greatest barrier to publication (60%) of those surveyed both in the initial prospective survey and for those who did not publish a paper in the follow-up survey (83%). CONCLUSION: This study suggests a strong desire and expectation of publishing ASPO presentations. Despite this expectation, past research and this data set suggest this expectation often does not materialize. "Time constraints" were the most commonly identified barrier to publication. To enhance dissemination of new findings from ASPO meetings, institutions and individuals should examine methods that facilitate and incentivize publication of findings in peer-reviewed publications.

Transient swallowing dysfunction in typically developing children following supraglottoplasty for laryngomalacia.

OBJECTIVE: To evaluate early postoperative swallowing function in otherwise typically-developing children following supraglottoplasty. METHODS: Retrospective chart review case series. RESULTS: Of 37 children identified as having undergone supraglottoplasty for severe laryngomalacia at our institution between January 2007 and October 2011, 24 were identified as otherwise typically developing with no indications/signs of swallowing problems pre-operatively and eligible for inclusion in this study. Twenty-two children underwent bilateral supraglottoplasty and 2 children underwent unilateral supraglottoplasty using the CO2 laser or the laryngeal skimmer microdebrider in combination with cold steel technique, based on the discretion of four Pediatric Otolaryngologists. Seventeen children were seen post-operatively for a clinical swallow evaluation. Six children were found to have swallowing dysfunction. Four of the six children showed variable symptoms, signs, or findings concerning for aspiration with oral feeding. Three of six underwent video fluoroscopic swallow study (VFSS). All 6 children responded to dietary modifications, positioning alterations, and anti-reflux medications. All showed improvement by their 4-week post-operative follow-up visit. The median age of the 24 patients at the time of surgery was 3 months, with a range from 2 weeks to 4 years. The median age of the patients found to have transient post-operative swallowing dysfunction was 1.5 months, with a range of 2 weeks to 4 months. There was no association between post-operative swallowing dysfunction and the surgical technique employed. CONCLUSIONS: Supraglottoplasty in otherwise typically developing children carries a risk of transient swallowing dysfunction with a low risk of persistent dysfunction. Most patients can be assessed post-operatively via clinical swallow evaluation without requiring an instrumental swallow study.

Pediatric sleep surgery.

Adenotonsillectomy is the most common surgery performed for sleep disordered breathing with good outcomes. Children with obesity, craniofacial disorders, and neurologic impairment are at risk for persistent sleep apnea after adenotonsillectomy. Techniques exist to address obstructive lesions of the palate, tongue base, or craniofacial skeleton in children with persistent sleep apnea. Children with obstructive sleep apnea have a higher rate of peri-operative complications.

Choosing a fellow or fellowship: a survey of pediatric otolaryngologists.

IMPORTANCE: The numbers of pediatric otolaryngology fellowship programs and applicants have increased over the past 5 years. However, the qualities desired in programs and applicants have not been explored. OBJECTIVE: To determine the factors that fellowship program directors and applicants believe to be most important in choosing a fellow and the factors most important to fellowship applicants in choosing a program. DESIGN, SETTING, AND PARTICIPANTS: Cohort study using an anonymous online survey of 2012 pediatric otolaryngology fellowship program directors and applicants. Respondents were asked to rank a list of 10 qualities from most to least important for judging the strength of a fellowship applicant. Applicants also assessed the importance of factors in choosing a fellowship. MAIN OUTCOMES AND MEASURES: Rank of each factor by members of each group. RESULTS: Thirty-two of 47 applicants (68%) and 15 of 31 fellowship directors (48%) completed the survey. For applicants, the most important factors when choosing a fellowship program were gaining strong experience in airway management and otology, faculty reputation, and location, whereas Accreditation Council for Graduate Medical Education (ACGME) accreditation, fellowship longevity, and salary were less important. For choosing an applicant, applicants indicated that the interview, prior applicant knowledge (trusted recommendation), and letters of recommendation, sequentially, should be given the greatest weight. Directors reported that they used the same top 3 factors to rank applicants, but knowledge or trusted recommendation of the applicant ranked first. Applicants who successfully matched interviewed at (mean, 9.5 vs 3.0; P = .003), applied at (mean, 11.6 vs 4.3; P = .02), and ranked (mean, 8.3 vs 2.3; P < .001) more fellowship programs than those who did not. United States Medical Licensing Examination scores higher than 230 and AΩA membership status did not significantly affect fellowship match. CONCLUSIONS AND RELEVANCE: Personal knowledge or a trusted colleague's recommendation may be the most important determinant when pediatric otolaryngology fellowship programs choose an applicant. When fellows choose a program, the opportunity to gain surgical experience in both otology and airway management is crucial, but ACGME accreditation status seems less important. Successful applicants ranked and interviewed at more fellowship programs than nonmatching applicants.

Sympathetic neuropathy and dysphagia following doxycycline sclerotherapy.

This case report demonstrates neurologic sequela following treatment with doxycycline sclerotherapy. A six-week-old child presented with respiratory distress from a macrocystic lymphatic malformation, extending from the skull base to the anterior mediastinum. Following doxycycline sclerotherapy, the airway symptoms resolved; however, the child developed silent aspiration and Horner's syndrome. Two months following treatment the patient resumed oral diet and at one year post-intervention there has been no recurrence of symptoms, with only mild ptosis remaining. While neuropathies following doxycycline sclerotherapy have been described, aspiration has never been documented. This case demonstrates a single patient's clinical course and resolution of their neuropathies.

Pediatric cervicofacial necrotizing fasciitis: a case report and review of a 10-year national pediatric database.

OBJECTIVE: To present a case of a pediatric cervicofacial necrotizing fasciitis (NF), a rapidly progressive infection, and a review of a 10-year pediatric inpatient database. DESIGN: Case report and review. SETTING: Pediatric intensive care unit. PATIENTS: A healthy 5-year-old male who developed NF of the lower lip 36 hours following minor trauma. International Classification of Diseases, Ninth Revision, code 728.86 (NF), was the inclusion criteria for the Kids' Inpatient Database (KID) in 1997 and 2006. RESULTS: A pediatric case is presented with a thorough photographic record demonstrating the need for rapid diagnosis and treatment. In a review of the KID from 1997 and 2006, the relative risk of being discharged with NF in 2006 vs 1997 was 1.4 (95% CI, 9.95-2.28). Age at diagnosis of NF was older in 2006 compared with 1997 (11.5 years vs 8.05 years; P < .001). Deaths with a diagnosis of NF increased from 1997 compared with 2006: from 3.9% to 5.4%. In 2006, the odds of death were 15.1 times higher in pediatric discharges with a diagnosis of NF compared with discharges without a diagnosis of NF (P < .001; 95% CI, 9.3-23.1). CONCLUSIONS: Even with the advent of new treatments and antibiotics, the incidence and death rates of NF have changed little over the past 10 years. While it is still a rare diagnosis, knowledge and awareness of necrotizing fasciitis with aggressive medical and surgical treatment are still the foundation in disease survival.