Minimally Invasive Management of Neonatal Piriform Fossa Sinus Tract: A Scoping Review.

OBJECTIVE: In rare situations, neonates may present with respiratory distress and neck swelling from a piriform fossa sinus tract (PFST) lesion. Open surgical excision of PFST may be associated with higher complication rates, especially in neonates. Endoscopic treatment has been shown to have high success rates in older children, but neonatal outcomes appear to be less promising. The objective of this study was to review the existing literature on endoscopic treatment of PFST in neonates. REVIEW METHODS: PRISMA-ScR guidelines for scoping reviews were employed. Medline and Embase databases were searched in accordance with a detailed search strategy. Nine studies met criteria for inclusion. RESULTS: A total of 21 neonates with PFST treated endoscopically were reviewed. Mean age at onset of symptoms was 11.6 days. Neck swelling was the most common presenting symptom (20/21, 95%), followed by respiratory distress (6/9, 66.6%). Success rate after initial endoscopic treatment was 57% (12/21); among those, seven patients required additional concurrent treatments such as neck/pharyngeal swelling decompression or sclerotherapy. Nine patients underwent a second intervention (43%) and three patients (14%) required three interventions. Notably, 90% of patients (19/21) achieved success with only minimally invasive approaches. Two patients underwent open salvage surgical excision after recurrence following initial endoscopic treatment. CONCLUSION: Neonates with PFST and cystic neck masses are prone to recurrence after initial minimally invasive endoscopic treatment; however, high success rate may be achieved after repeat interventions. Adjunctive measures to optimize outcome may include swelling decompression w/wo sclerotherapy to cause fibrosis and postoperative nasogastric tube feeding. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2585-2591, 2024.

Endoscopic treatment in pediatric patients with recurrent and H-type tracheoesophageal fistulas - A systematic review and meta-analysis.

OBJECTIVES: Endoscopic treatments for managing recurrent tracheoesophageal fistula (rTEF) and H-type TEF are being utilized lately; however, the preferred technique is yet to be determined. We aimed to systematically review existing publications on endoscopic treatment of rTEF and H-type TEF to analyze their success and complication rates. METHODS: PRISMA guidelines were followed. MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were comprehensively searched in accordance to a priori developed protocol, from 1975 until 2020. English, Spanish and German papers were included. Studies were independently screened and analyzed by two reviewers. RESULTS: 84 full texts were assessed for eligibility out of 581 screened studies, of these, 39 studies with 127 patients were eligible for inclusion (115 rTEF and 12 H-type TEF). All included studies were cases reports or case series. Overall success rate was 45% with sealant injection, 87% with de-epithelialization and 80% with sealant injection and de-epithelialization combined. The mean number of required treatments for success was 1.9 (range 1-6). Mixed effect model meta-analysis of case series with n > 1 showed that sealant injection had a significantly lower success rate of 50% (95% CI 1-99%, I2 72%) compared to de-epithelialization 90% (95% CI 72-99%, I2 27%), p = 0.007 and the combination of both techniques 87% (95% CI 68-99%, I2 11%), p = 0.02. Nine patients (7%) had transient respiratory distress. No mortalities reported. CONCLUSION: Endoscopic treatment for rTEF and H-type fistula is a minimally invasive technique with favorable outcome and considerably less morbidity compared to open surgery, suggesting it as a safe and effective first line treatment option. Repeated endoscopic treatment attempts can be expected to obtain complete closure. De-epithelization techniques with or without combined tissue adhesive injection had significantly better results than sealant injection techniques alone.

Tracheal inflammatory myofibroblastic tumor presenting as an obstructive pediatric foreign body.

We describe an unusual presentation of a suspected pediatric foreign body (FB) aspiration which was found to be an occlusive inflammatory myofibroblastic tumor (IMT) of the distal trachea. These are rarely reported entities, with the potential for significant airway bleeds. Multidisciplinary discussion and involvement allowed for a safe patient outcome.

Hearing Outcomes with Percutaneous and Transcutaneous BAHA® Technology in Conductive and Mixed Hearing Loss.

OBJECTIVES: To evaluate outcomes of BAHA Connect® and BAHA Attract® implantations, and to examine the prognostic utility of a preimplantation Softband®-attached processor trial. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Patients who underwent Connect® (19 ears) and Attract® (25 ears) implantation between 2007 and 2017. INTERVENTION: BAHA® implantation. MAIN OUTCOME MEASURES: Unaided air conduction (AC), bone conduction (BC), and speech reception thresholds (SRTs), as well as free field (FF) aided with Softband®-attached processor and with implant-attached processor thresholds. RESULTS: Serviceable implant-attached processor PTA0.5,1,2 kHz (≤35 dB HL) was achieved in 89 and 88% of the Connect® and the Attract® ears, respectively, while at 4 kHz this was achieved in 68 and 32% of the Connect® and the Attract® ears, respectively (p  =  0.032). Significantly more Connect® ears showed alignment between FF aided with implant-attached processors thresholds and BC thresholds. The alignment between the Softband®-attached processors thresholds and implant-attached processors thresholds was similar in the two groups. Both groups exhibited similar positive improvement in the quality of life questionnaires. CONCLUSIONS: Accessibility to sound with the implant-attached processor is well predicted by the pre-implantation Softband® trial, both in the BAHA Connect® and in the BAHA Attract® ears. Hearing rehabilitation targets at 0.5, 1, and 2 kHz are met by most Connect® and Attract® ears, while at 4 kHz the outcome with Attract® is poorer. This information should be presented to the patient during consultation prior to a decision as to the type of BAHA® device to be implanted.

Acute mastoiditis: 20 years of experience with a uniform management protocol.

OBJECTIVES: To characterize the clinical presentation of pediatric patients who, upon AM diagnosis, also had imaging-diagnosed ICCs (ID-ICCs); to define the group of AM patients at risk of developing ID-ICCs; and to update knowledge about organisms causing AM. STUDY DESIGN: Analysis of all AM patients admitted between 1997 and 2018 and treated according to an obligatory protocol including both brain imaging and sampling for bacterial culture upon clinical diagnosis of AM. RESULTS: Of 166 admitted patients (0.5-19 years old) 22 (13%) already had ID-ICCs. In patients who, on admission, had already received antibiotics for acute otitis media (AOM) and also had CRP (C-reactive protein) levels above 93.5 mg/L, the risk of ID-CC was increased by 22.5-fold (P < 0.0001). Bacterial culture results were available for all patients and were positive in 115 (69%). Organisms most commonly found in patients without prior antibiotic treatment were group A Streptococcus pyogenes (53%), Streptococcus pneumoniae (23%), and Haemophylus influenzae (11%), while with prior antibiotic treatment they were Fusobacterium necrophorum (21%), Streptococcus pyogenes (18%) and Pseudomonas aeruginosa (18%). CONCLUSIONS: Since the risk of ID-ICC in patients with the abovementioned CRP and prior antibiotic treatment was significantly higher than in the others, these high-risk patients should undergo diagnostic imaging on admission. Antibiotic treatment prior to AM development may promote growth of non-AOM pathogen.

Idiopathic Intracranial Hypertension Presenting as Auditory Neuropathy Hearing Disorder in a Child.

Otologic manifestations are known to occur in patients with idiopathic intracranial hypertension (IIH), but the occurrence of sensorineural hearing loss, especially in pediatric populations, has been addressed in only a few reports. Here, we describe a pediatric patient who presented with IIH and severe bilateral hearing loss. The patient's hearing loss was diagnosed as a form of auditory neuropathy (AN) and resolved after prompt treatment of the increased intracranial pressure. This case points to a possible association between IIH and AN and suggests that IIH may potentially be a reversible cause of AN spectrum disorder. Laryngoscope, 129:E407-E411, 2019.

Procalcitonin and interleukin 6 for predicting blood culture positivity in sepsis.

BACKGROUND: Procalcitonin and interleukin 6 (IL-6) are well-known predictors of blood culture positivity in patients with sepsis. However, the association of procalcitonin and IL-6 with blood culture positivity was assessed separately in previous studies. This study aims to examine and compare the performance of procalcitonin and IL-6, measured concomitantly, in predicting blood culture positivity in patients with sepsis. METHODS: Forty adult patients with sepsis were enrolled in the study. Blood cultures were drawn before the institution of antibiotic therapy. The area under the curve (AUC) of the receiver operating characteristic curve was estimated to assess the performance of procalcitonin and IL-6 in predicting blood culture positivity. RESULTS: Positive blood cultures were detected in 10 patients (25%). The AUC of procalcitonin and IL-6 was 0.85 and 0.61, respectively. The combined performance of procalcitonin and IL-6 was similar to that of procalcitonin alone, AUC of 0.85. On univariate analysis, only procalcitonin and IL-6 were associated with blood culture positivity. Multivariate logistic regression analysis showed that only procalcitonin was associated with blood culture positivity (odds ratio, 12.15 [1.29-114.0] for levels above the median compared with levels below the median). Using procalcitonin cut points of 1.35 and 2.14 (nanogram per milliliter) enabled 100% and 90% identification of positive blood cultures and reduced the need of blood cultures by 47.5% and 57.5%, respectively. CONCLUSIONS: Compared with IL-6, procalcitonin better predicts blood culture positivity in patients with sepsis. Using a predefined procalcitonin cut points will predict most positive blood cultures and reduce the need of blood cultures in almost half of patients with sepsis.

Brain natriuretic peptide at discharge as a predictor of 6-month mortality in acute decompensated heart failure.

BACKGROUND: Brain natriuretic peptide (BNP) is well established in detecting acute decompensation of heart failure (ADHF). The role of BNP at discharge in predicting mortality is less established. Accumulating evidence suggests that inflammatory cytokines play an important role in the development of heart failure. We aimed to examine the contribution of BNP, interleukin 6, and procalcitonin to mortality in ADHF. METHODS: A cohort of 33 patients with ADHF was identified between March 2009 and June 2010 at Rambam Health Care Campus, Haifa, Israel. The cohort was followed up for all-cause mortality during 6 months after hospital discharge. Cox proportional hazard model was used to assess the association between BNP, interleukin-6 and procalcitonin and all-cause mortality. RESULTS: As compared to BNP at admission, BNP at discharge was more predictive for all-cause mortality. The area under the curve for BNP at admission and discharge was 0.810 (P=.004) and 0.864 (P=.001) respectively. Eleven patients (33.3%) patients who died during the follow-up period had higher BNP levels, median 2031.4 (IQR, 1173.4-2707.2), than those who survived; median 692.5 (IQR, 309.9-1159.9), (P = .001). On multivariate analysis, BNP remained an independent predictor for 6 month all-cause mortality HR 9.58 (95% CI, 2.0-45.89) for levels above the median compared to lower levels, (P=.005). Albumin, procalcitonin and interleukin 6 were not associated with all-cause mortality. CONCLUSIONS: BNP at discharge is an independent predictor for all-cause mortality in patients with ADHF. Compared with BNP at admission, BNP at discharge has slightly higher predictive accuracy with regard to 6-month all-cause mortality.

Interleukin-6 at discharge predicts all-cause mortality in patients with sepsis.

PURPOSE: Interleukin-6 (IL-6) is a proinflammatory cytokine that plays a central role in the pathogenesis of sepsis. We aim to investigate the association between IL-6 and all-cause mortality in patients with sepsis. METHODS: A cohort of 40 elderly patients with sepsis was identified between March 2009 and June 2010 at Rambam Health Medical Campus, Haifa, Israel. The cohort was followed up for all-cause mortality occurring during the 6 months after hospital discharge. Cox proportional hazard model was used to assess the association between IL-6 and all-cause mortality. RESULTS: Iinterleukin-6 at discharge had a higher predictive accuracy for all-cause mortality when compared with IL-6 at admission. The area under the curve was 0.752 (P = .015) and 0.545 (P = .661), respectively. Eleven (27.5%) patients died during follow-up; the subjects who died have higher IL-6 levels at discharge (median, 50.6 pg/mL [interquartile range, 39.6-105.9]) compared with survivors at the end of follow-up (median, 35.4 [interquartile range, 15.8-49]; P = .014). The risk of all-cause mortality was higher in subjects with IL-6 levels above the median compared with subjects with lower IL-6 levels (log-rank P = .017). On multivariate Cox proportional analysis, adjusting for the potential confounders, IL-6 at discharge remained an independent predictor for 6 month all-cause mortality (hazard ratio, 6.05 [1.24-24.20]) for levels above the median compared with lower levels. CONCLUSIONS: Iinterleukin-6 at discharge is an independent predictor of all-cause mortality in patients with sepsis. Compared with IL-6 at admission, IL-6 at discharge better predicts all-cause mortality.