Drug-induced sleep endoscopy findings in surgically-naïve obese vs non-obese children.

OBJECTIVE: To determine if drug-induced sleep endoscopy (DISE) findings are different in obese versus non-obese pediatric patients with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB). METHODS: Prospective, observational cohort study from June 2017 to June 2018 at a tertiary academic pediatric medical center that included surgically-naïve children ages 2-12 with diagnoses of OSA or sleep-disordered breathing. Subjects with a known diagnosis of craniofacial syndromes, genetic disorders, prior adenoidectomy or tonsillectomy, or chronic tonsillitis as the indication for surgery were excluded. Two groups were assessed for patterns of obstruction based on DISE videos at each anatomic airway level using a previously published DISE scoring system. The groups included obese subjects (BMI ≥ 95th percentile) and non-obese controls (BMI <85th percentile). Each video was graded by two blinded, fellowship-trained Pediatric Otolaryngologists. RESULTS: Fifty-one patients were included, 26 non-obese and 25 obese. Based on anatomic airway level, there was no statistically significant difference in airway obstruction at the velum (p = 0.134), adenoid (p = 0.592), lateral pharyngeal walls (p = 0.867), tongue base (p = 0.977), or supraglottis (p = 0.428) between obese and non-obese children. CONCLUSION: Our prospective study did not associate severity of obstruction with obesity status based on anatomic airway levels. Further studies are needed to elucidate the etiology of the high rate of persistent obstructive sleep apnea in obese children.

Teratoma of the neonatal head and neck: A 41-year experience.

OBJECTIVE: To review our institution's experience with the presentation, evaluation, and management of teratoma of the head and neck in the neonatal population. DESIGN: Retrospective case series (November 1970 through September 2011). SETTING: Tertiary care children's hospital. PATIENTS: 14 patients (12 boys and 2 girls). INTERVENTION: Detailed review of presentation, diagnostic approaches, surgical management, and outcomes. MAIN OUTCOME MEASURES: Anatomic sites, use of pre and post-natal imaging, use of EXIT (ex utero intrapartum treatment) procedure, presenting symptoms, surgical approaches, additional therapeutic modalities, and outcomes are reviewed. RESULTS: Seven patients were diagnosed prenatally, while the remaining 7 patients were diagnosed at birth or shortly thereafter. The tumor emanated from the neck in 9 patients, the nasopharynx/oropharynx in 3 patients, the external nose in 1 patient and the face in 1 patient. Nine patients had associated upper airway obstruction. Four underwent an EXIT procedure, with 3 requiring intubation and 1 requiring tracheostomy. All patients underwent surgical resection. One patient demonstrated recurrence at follow-up. CONCLUSIONS: Teratoma of the head and neck, though rare, is an important part of the differential diagnosis of neck masses in children, particularly in the perinatal period. The ability to make this diagnosis prenatally with high-resolution fetal ultrasound and MRI (magnetic resonance imaging) permits planning for airway and tumor management prior to delivery. An EXIT procedure should be considered when airway compromise by tumor compression is suspected. Early surgical excision is the treatment of choice and recurrence is rare when a complete resection is achieved.

The presentation and management of mandibular tumors in the pediatric population.

OBJECTIVES/HYPOTHESIS: To review the presentation and management of malignant tumors of the mandible in children. STUDY DESIGN: Case series. METHODS: Children 0 to 21 years old presenting to a tertiary pediatric hospital with a diagnosis of a malignant tumor involving the mandible were included. Comparison groups included children from the Surveillance, Epidemiology, and End Results database with malignant mandible tumors as well as a group of children with benign mandibular lesions from the same institution. Main outcome measures for the institutional malignant group included presentation, tumor characteristics, treatment modalities, and clinical outcome. RESULTS: Sixteen patients with malignant and 183 patients with benign lesions were identified at the primary institution. The most common presentation in both groups was mandibular swelling or mass. Malignant tumors included sarcoma (n = 11), leukemia/lymphoma (n = 2), squamous cell carcinoma (n = 1), malignant spindle cell tumor (n = 1), and yolk sac tumor (n = 1). The national database identified 56 malignant cases, of which 71% were sarcomas. Thirteen patients at our institution (81%) underwent mandibulectomy and 12 were reconstructed using free tissue transfer. Eleven of the 13 (85%) were treated with adjuvant therapy. After an average follow-up of 32.8 months, seven (44%) had no evidence of disease, three (19%) were deceased, three (19%) were alive with disease, and three (19%) were lost to follow-up. CONCLUSIONS: Malignant mandibular tumors in children are most often sarcomas but can include other rare lesions. Free flap reconstruction is a reasonable option for even very young children requiring extensive mandibular surgery.

Utilization of lipid-laden macrophage index in evaluation of aerodigestive disorders.

OBJECTIVES/HYPOTHESIS: The utility of the lipid-laden macrophage index (LLMI) in the evaluation of airway inflammatory processes remains controversial. There is a paucity of normative data in both pediatric and adult populations, and there is wide variability in the reported cases. The goal of this project was to review the LLMI levels in a large series of patients with a wide range of well-documented pulmonary and airway diseases (cystic fibrosis, aspiration, tracheo/bronchomalacia, recurrent pneumonia, asthma, immunosuppressed conditions, and laryngeal clefts) to develop a better understanding of the clinical utility of the LLMI. STUDY DESIGN: This study is a retrospective analysis of patients who underwent initial bronchoscopy with broncheoalveolar lavage (BAL) and had specimens sent for determination of LLMI. This study was performed at a major pediatric tertiary care medical center from April 12, 2006 to July 13, 2009. METHODS: Medical charts were reviewed for major diagnoses, indications for bronchoscopy, the side of lung (right versus left), documented aspiration, suspected aspiration, neutrophil counts, and patient age. These qualitative and quantitative variables were considered in relation to the LLMI. RESULTS: The cohort of patients examined were 4.9 ± 4.3 years (4 days to 18 years of age). Forty-two percent were female and 58% were male. The highest median LLMI was in immunocompromised patients with a median of 78. Recurrent pneumonia, aspiration, tracheo/bronchomalacia, and cystic fibrosis had median LLMI levels of 55, 49, 40, and 50, respectively. There was a wide range of LLMI within each primary diagnosis. There was no significant correlation between neutrophils percentage in the BAL and LLMI. There were no significant differences between BAL specimens obtained from the right or left side. CONCLUSIONS: To our knowledge, this is the largest series of patients reported in the literature to have an LLMI compared with underlying diagnoses. Based on our data and analyses, there is wide variability between the range of LLMI and the primary diagnosis. As such, the diagnostic utility of the LLMI is limited and should be interpreted with caution.