Urinary Leukotriene E4 Levels in Children with Sleep-Disordered Breathing.

Objective Due to limitations of polysomnography (PSG), novel ways to evaluate pediatric obstructive sleep apnea (OSA) are needed. Urinary leukotriene E4 (LTE4), an inflammatory marker, has been identified as a potential biomarker for pediatric OSA. The objective of the study was to assess whether urinary LTE4 levels correlate with OSA severity, as determined by obstructive apnea-hypopnea index (AHI) and nadir oxygen saturation. Study Design Prospective trial. Setting Tertiary care children's hospital. Subjects and Methods Children (age, 3-16 years) with sleep-disordered breathing (SDB) who were referred for PSG were included. Urine samples were obtained the morning following PSG, and urinary LTE4 levels were quantified with enzyme-linked immunoassay kits. Results A total of 113 children were enrolled, and the mean age was 7.3 years. Thirty-nine percent (n = 44) were obese, and the majority were white (53%, n = 58). Seventy-eight percent (n = 88) were diagnosed with OSA (AHI >1), with 27% (n = 30) having severe disease (AHI >10). The mean urinary LTE4 level was 91.3 ng/mM. Urinary LTE4 levels did not correlate with AHI ( P = .77) or nadir oxygen saturation ( P = .64). There was a significant difference in urinary LTE4 levels between patients with mild SDB and those with moderate to severe OSA ( P = .03). Conclusion Urinary LTE4 levels do not correlate with AHI in children with SDB. Compared with children with severe OSA, children with mild SDB have higher urinary LTE4 levels. Further research is needed determine whether urinary LTE4 is a satisfactory biomarker for pediatric OSA.

Adenotonsillectomy outcomes in children with sleep apnea and narcolepsy.

OBJECTIVE: To identify improvements in daytime sleepiness following adenotonsillectomy in children with non-severe obstructive sleep apnea and narcolepsy. STUDY DESIGN: Case series with chart review over 15 years. SETTING: Tertiary Children's Hospital. SUBJECTS AND METHODS: Children between 6 and 17 years of age with narcolepsy that underwent adenotonsillectomy for non-severe obstructive sleep apnea (OSA) were included. Narcolepsy was diagnosed based on clinical assessment and the Multiple Sleep Latency Test (MSLT) results. A standardized instrument, the pediatric Epworth Sleepiness Scale (ESS), was used to assess daytime sleepiness before and after adenotonsillectomy. RESULTS: Nine children with a mean age of 12.1 years were included. The majority of the subjects (78%, n = 7) were African American and six children (66.7%) were obese. Four children (44%) were treated with wake promoting agents during the study. The mean preoperative apnea hypopnea index on polysomnography was 4.89 (SD 1.86), while the mean sleep latency on MSLT was 6.32 min (SD 3.14). The mean preoperative ESS was 16.10 and the postoperative ESS was 10.80 (SD 3.96). There was significant improvement (p = 0.02) in the ESS following adenotonsillectomy with seven children (78%) reporting diminished daytime sleepiness. CONCLUSIONS: Children with non-severe OSA and narcolepsy experience significant improvement in daytime sleepiness following adenotonsillectomy. Future studies are needed to determine the incidence and clinical significance of non-severe OSA in children with narcolepsy.

E-cigarettes: An update on considerations for the otolaryngologist.

PURPOSE: We provide an update in the literature and national regulations regarding electronic cigarettes with special attention to the pediatric population. BACKGROUND: Electronic nicotine delivery systems (ENDS) are handheld battery operated devices that vaporize nicotine-containing liquids for inhalation. Use of these products has dramatically increased over the last several years, particularly among the youth. ENDS are being marketed with advertising techniques and flavors which appeal to the adolescent and young adult population. More reports of accidental pediatric exposures are being documented, as are suicides from abuse of liquid nicotine. Federal regulation has only now become required of these devices. CONCLUSION: Use of e cigarettes among adolescents increases each year. Government oversight is needed to protect our children from the re-normalization of tobacco. Otolaryngologists should be prepared to counsel their patients and families regarding the latest in ENDS use.

E-cigarettes: Considerations for the otolaryngologist.

PURPOSE: To review the literature regarding electronic cigarettes and discuss potential implications and need for advocacy for the pediatric otolaryngologist. BACKGROUND: Electronic cigarettes (e-cigarettes) are battery-operated devices that deliver nicotine-containing vapors via inhalation. Research on the health related consequences of e-cigarettes is ongoing and safety has yet to be established. E-cigarettes are not presently under the regulation of any national governing body with wide accessibility to minors. Use of these products has substantially increased since arrival to the market, particularly within the adolescent population. These products are marketed via various platforms including television, Internet and social media. Hundreds of flavors are offered and e-cigarettes are packaged in various colors. Not only are the ill health effects and addictive quality of nicotine concerning, these products have the potential to serve as a gateway for minors to tobacco use. APPLICATIONS: The relationship between tobacco use, secondhand smoke exposure and otolaryngology specific diseases has well been defined. As use of electronic cigarettes increases, pediatric otolaryngologists should be aware of the ongoing literature regarding these products and to be prepared to counsel families accordingly. CONCLUSIONS: The use of e-cigarettes among teenagers, potential implications of secondhand vapor exposure from parents and friends, and concerns this may encourage adolescents to utilize conventional tobacco products needs to be considered.

Autism spectrum disorder 101: A primer for pediatric otolaryngologists.

Based on a comprehensive review of the literature as well as personal experiences at a tertiary children's hospital, we present an encompassing guide of the management of children with autism spectrum disorder (ASD) in the otolaryngology practice. ASD is a disorder involving persistent deficits in social communication and interaction across multiple contexts with restricted and repetitive patterns of behavior, which presents early in age and causes significant impairment in function. With the increasing prevalence of autism, the otolaryngologist's understanding of the disease and how it affects the management of patients is of paramount importance in order to provide a safe medical and surgical environment. Special considerations in the outpatient visit and peri-operative setting in the management of ASD patients can enhance the patient-provider relationship and improve the quality of care delivered. We discuss several strategies, such as utilization of communication devices and use of pre-medication prior to surgery, to facilitate the clinical experience.

Anatomical basis of the vascular risk related to the circumflex scapular artery during posterior approach to the scapula.

PURPOSE: The vasculature and anastomosis around the scapula is extremely intricate making surgical treatment complicated. We aimed to determine the "at risk area" for the circumflex scapular artery and its anastomosis with the suprascapular artery during posterior approach to the scapula. METHODS: Sixteen shoulders from eight embalmed adult cadavers were dissected through posterior approach to the scapula to study the relationship of the circumflex scapular artery and its anastomosis with the suprascapular artery to bony landmarks of the posterior scapula. Three measurements were obtained: from inferior glenoid rim to the point of the bony groove of the circumflex scapular artery; from the posterior glenoid rim to the spinoglenoid notch; and from the spinoglenoid notch to the circumflex scapular artery. RESULTS: The circumflex scapular was identified at a distance of 2.9 cm from the inferior glenoid rim and at a distance of 4.6 cm from the spinoglenoid notch, as it winds around the lateral border of the scapula to enter the infraspinous fossa. The suprascapular neurovascular bundle was identified at the spinoglenoid notch 1.8 cm from the posterior glenoid rim. CONCLUSIONS: We were able to identify the relationship of the circumflex scapular artery to the anatomic landmarks of the scapula and to define the "at risk area" for the ascending branch of the circumflex scapular artery and its anastomosis with the suprascapular artery. We believe our anatomical study may aid in the avoidance of vascular complications during internal fixation of scapular fractures.

Buck's direct repair of lumbar spondylolysis restores disc stresses at the involved and adjacent levels.

BACKGROUND: Lumbar spondylolysis was reported to cause disc degeneration at both caudal and cranial adjacent level. However, basic disc biomechanics in the spondylolytic spine is not fully understood. Purpose of this study was to analyze the disc stresses at cranial and caudal adjacent level of lumbar spondylolysis. Also, the biomechanical effects of Buck's technique on disc stresses at these two segments were evaluated. METHODS: An experimentally validated three-dimensional non-linear finite element model of the intact ligamentous L3-S1 segment was used. Bilateral lumbar spondylolysis was simulated by creating bilateral pars defects with 1.0 mm gap at L5. Buck's direct repair model was simulated with 4.0 mm cannulated Titanium screws, placed bilaterally across the defect. Von Mises stresses in the annulus fibrosus and nucleus pulposus at L4/5 (cranial adjacent) and L5/S (caudal adjacent) disc levels were analyzed in flexion, extension, lateral bending and axial rotation in response to 400 N of axial compression and 10.6 Nm moment. The highest values were compared among the three models, intact, spondylolysis and Buck's technique. FINDINGS: After spondylolysis occurred at L5, annulus fibrosus and nucleus pulposus stresses at L4/5 increased to 111% and 120%, respectively. After the Buck's technique it recovered to 102% and 105%, correspondingly. On the other hand, at L5/S, annulus fibrosus stress increased to 168%, and nucleus pulposus, 155%, which was much higher when compared to the stresses at L4/5. After the Buck's technique the stresses were decreased to 125% and 120%, correspondingly. During rotation motion, especially, the operation normalized the disc stress completely. INTERPRETATION: Spondylolysis increases disc stresses at the affected as well as cranial adjacent level, and it may lead to disc degeneration at both levels. However, the increase in stresses is higher at the affected caudal level, when compared to the cranial level. Buck's technique may restore the disc stresses back to normal at both disc levels. Thus, this technique may be beneficial from a biomechanical perspective as well.