Mitigating Infectious Complications of Injection Pharyngoplasty with Calcium Hydroxyapatite for Velopharyngeal Insufficiency: Retropharyngeal Abscess and Osteomyelitis.

Velopharyngeal insufficiency is a complex condition with various treatment options. In this case, a patient with a cleft palate who was treated for velopharyngeal insufficiency with calcium hydroxyapatite injection pharyngoplasty developed persistent cervical pain on postoperative day 6. CT imaging showed a hypodense structure in the right retropharyngeal tissue, and cultures tested positive for Streptococcus intermedius and Staphylococcus aureus. An MRI later revealed skull base osteomyelitis. The infection was controlled via surgical intervention and antibiotics. This case highlights potential severe complications from injection pharyngoplasty and it underscores the importance of early recognition and management of infectious complications.

Conscious Perception of Facial Asymmetry in a Unilateral Cleft Lip Model.

OBJECTIVE: Lip asymmetry after a unilateral cleft lip repair can be perceived as an unsatisfactory result. The objective of this study is to determine the degree of upper lip asymmetry and/or nasal alar hooding required for recognition of asymmetry in a simulated model of unilateral cleft lip. DESIGN: A model of unilateral cleft lip was created using digital morphing software to simulate asymmetries in vermilion height and nasal hooding in photographs of children. Volunteers were shown photographs for different time intervals and with varying degrees of asymmetry. Ability to detect facial asymmetry was recorded and analyzed. SETTING: This study was conducted by surveying layperson volunteers in public community settings. PARTICIPANTS: 108 layperson volunteers were randomly surveyed. MAIN OUTCOME MEASURES: The primary outcome measure was a reported lip or nose asymmetry by the volunteers. Proportions and corresponding 95% confidence intervals were obtained to estimate the probability of reporting an asymmetry at 3- and 10-second intervals. RESULTS: After 3- and 10-second exposure, labial asymmetry was perceived by ≥50% of subjects at 2 mm (62%, P = .001) and 1 mm (89%, P < .0001), respectively. Nasal asymmetry was detected by <50% of subjects at 3 seconds, but ≥50% perceived a 3-mm alteration at 10 seconds (64%, P < .0001). Photographs with combined nasal and labial modification did not lower the threshold for asymmetry perception compared to either deformity alone. CONCLUSIONS: This study is the first to determine a predictable millimeter threshold for perceived asymmetry in cleft lip deformity using a digital model.

Evaluation and management of cytomegalovirus-associated congenital hearing loss.

PURPOSE OF REVIEW: The current article reviews the current literature related to congenital cytomegalovirus (CMV)-related hearing loss. The discussion will focus on the epidemiology, pathogenesis, and clinical presentation of human CMV infection as it pertains to hearing loss. Current methods of CMV diagnosis with a focus on the evolving trend toward broader neonatal screening protocols will also be explored. Discussion of medical, surgical, and audiologic management of the condition will also be addressed. RECENT FINDINGS: Much of the current research on this topic is focused on improving detection of CMV through screening programs. Some advances in understanding cochlear pathogenesis have also been made. SUMMARY: Congenital CMV infection remains an important cause of hearing loss in infants and children. Early detection of CMV infection can broaden treatment options and allow for improved hearing and language outcome for patients with CMV-associated sensorineural hearing loss.

The impact of adenoid size on rate of revision sphincter pharyngoplasty.

OBJECTIVES/HYPOTHESIS: Determine the impact of adenoid size and prior adenoidectomy on outcomes of sphincter pharyngoplasty. STUDY DESIGN: Retrospective review. METHODS: Retrospective review of patients 18 years of age or younger, who underwent sphincter pharyngoplasty for velopharyngeal insufficiency (VPI) from 2007 to 2012. Nasal endoscopy and nasometry testing were administered pre- and postoperatively. Preoperative adenoid size was scored by two blinded otolaryngologists. Primary outcome measures were sphincter pharyngoplasty revision rate, achievement of normal resonance, and degree of improvement in nasometry scores. RESULTS: Eighty-six patients were included in this study. The overall rate of revision sphincter pharyngoplasty was 28%. Patients with mild adenoid hypertrophy underwent less revision surgery (14%) than patients with moderate to severe adenoid hypertrophy (38%, P = .046). Subgroup analysis was performed based on prior repair of cleft or submucous cleft palate and history of 22q11 microdeletion. Smaller adenoids were associated with lower surgical revision rates in patients who did not have a history of cleft palate or 22q11 microdeletion (P = .014 and .018, respectively). Adenoid size did not impact revision rates in patients with repaired cleft palates or those with 22q11 microdeletions. CONCLUSIONS: Smaller or absent adenoids are associated with lower rates of revision surgery after sphincter pharyngoplasty in children with VPI. Patients with VPI and bulky adenoids, who do not have a history of cleft palate or 22q11 microdeletion, should be considered for adenoidectomy prior to sphincter pharyngoplasty.

Balloon laryngoplasty for pediatric laryngeal stenosis: case series and systematic review.

OBJECTIVES/HYPOTHESIS: The aim of this study was to systematically review available literature on the outcomes of children treated with balloon laryngoplasty (BLP) as a primary or adjuvant treatment for subglottic or laryngeal stenosis, as well as briefly report on a new series of 60 children treated at the Medical University of South Carolina from 2007 to 2013. STUDY DESIGN: Review of published case series and retrospective chart review. METHODS: A literature search was performed in PubMed and MEDLINE to identify trials that reported clinical outcomes of BLP in human patients under the age of 18 with subglottic or laryngeal stenosis. Single case reports and series studying the dilation of tracheal or bronchial stenosis alone were excluded. Hospital billing codes were used to identify appropriate patients for retrospective chart review. A successful outcome for chart review was determined to be decannulation of previous tracheostomy or avoidance of open laryngotracheoplasty or tracheostomy. RESULTS: Seven studies published between 1991 and 2012 met inclusion criteria and reported outcomes with success defined through improvement of symptoms, decrease in Myer-Cotton level of stenosis, decannulation, or avoidance of reconstructive procedures. Including 60 children from our institution, 202 patients between 1 day and 22 years of age (average 35 months) underwent 457 dilations, with an average of 2.26 dilations per patient (2.25 in our population). The overall success rate was 64% (77% in our population). No complications were reported with subglottic or laryngeal dilations. CONCLUSIONS: BLP is a highly effective, low-risk alternative or adjunct to traditional reconstructive procedures in children with subglottic or laryngeal stenosis. LEVEL OF EVIDENCE: 4.

Laryngomalacia.

Laryngomalacia is the most common cause of stridor in infants. Stridor results from upper airway obstruction caused by collapse of supraglottic tissue into the airway. Most cases of laryngomalacia are mild and self-resolve, but severe symptoms require investigation and intervention. There is a strong association with gastroesophageal reflux disease in patients with laryngomalacia, and thus medical treatment with antireflux medications may be indicated. Supraglottoplasty is the preferred surgical treatment of laryngomalacia, reserved only for severe cases. Proper identification of those patients who require medical and surgical intervention is key to providing treatment with successful outcomes.