Surgery for Obstructive Sleep Apnea in Obese Children: Literature Review and Meta-analysis.

OBJECTIVES: Surgical intervention for obstructive sleep apnea (OSA) in overweight and obese children may not be as effective as it is in normal-weight children. The purpose of this study was to systematically review the effects of various surgical interventions for OSA in obese children and to meta-analyze the current data. DATA SOURCES: PubMed, OVID, and Cochrane databases. REVIEW METHODS: Databases were searched for studies examining adenotonsillectomy, uvulopalatopharyngoplasty, supraglottoplasty, or tongue base surgeries and combinations in obese children with OSA. Adenotonsillectomy was the only procedure with enough data for meta-analysis; polysomnographic data were extracted and analyzed using a random-effects model. RESULTS: For adenotonsillectomy, 11 studies were included in the meta-analysis. Despite significant improvement in the apnea-hypopnea index (22.9 to 8.1 events/h, P < .001), respiratory disturbance index (24.8 to 10.4 events/h, P < .001), and oxygen saturation nadir (78.4% to 87.0%, P < .001), rates of persistent OSA ranged from 51% to 66%, depending on the outcome criterion used. There was evidence of limited effectiveness for surgical interventions to treat OSA in obese children using uvulopalatoplasty (12.5%) and tongue base surgery (74%-88%). CONCLUSIONS: Surgical interventions for OSA in overweight and obese children are effective at reducing OSA but with higher rates of persistent OSA than reported for normal-weight children. However, the amount of reduction appears to vary by surgical procedure. More attention should be paid toward preoperative weight loss and patient selection, and parents should be provided with realistic postoperative expectations in this difficult-to-treat population.

A tyrosine sulfation-dependent HLA-I modification identifies memory B cells and plasma cells.

Memory B cells and plasma cells are antigen-experienced cells tasked with the maintenance of humoral protection. Despite these prominent functions, definitive cell surface markers have not been identified for these cells. We report here the isolation and characterization of the monoclonal variable lymphocyte receptor B (VLRB) N8 antibody from the evolutionarily distant sea lamprey that specifically recognizes memory B cells and plasma cells in humans. Unexpectedly, we determined that VLRB N8 recognizes the human leukocyte antigen-I (HLA-I) antigen in a tyrosine sulfation-dependent manner. Furthermore, we observed increased binding of VLRB N8 to memory B cells in individuals with autoimmune disorders multiple sclerosis and systemic lupus erythematosus. Our study indicates that lamprey VLR antibodies uniquely recognize a memory B cell- and plasma cell-specific posttranslational modification of HLA-I, the expression of which is up-regulated during B cell activation.

Tracheostomy care: Clinical practice patterns of pediatric otolaryngologists-head and neck surgeons in a publicly funded (Canadian) health care system.

OBJECTIVES: To investigate variability in pediatric tracheostomy tube care practice patterns and access to resources across Canada. METHODS: Canadian pediatric otolaryngologists-head & neck surgeons reported their own practice patterns for children with chronic tracheostomy tubes using a web-based, 29-item multiple choice and short answer questionnaire. Domains investigated included tracheostomy team membership, inpatient care practices, caregiver education, homecare resources, speech and communication, and completeness of emergency tracheostomy kits. RESULTS: The response rate was 86.4% (38/44). Most respondents care for children with tracheostomy tubes as part of an inter-professional team (25/36; 69.4%) and arrange routine follow-up with a speech and language pathologist (22/36; 61.1%). However, the majority (23/34; 67.6%) of respondents do not formally reassess caregiver competencies (i.e. cardiopulmonary resuscitation, emergency tracheostomy care). Notably, respondents were also unsure 36.1% (13/36) of how frequently Shiley tracheostomy tubes should be washed and reused with the majority (15/36; 41.7%) reporting never. Most (15/36; 41.7%) respondents were also unsure of reuse recommendations for Bivona tracheostomy tubes. One third (12/36; 33.3%) of respondents were unsure about government-funded homecare services being provided in their community to children with tracheostomy tubes. CONCLUSION: There is much variability in pediatric tracheostomy tube care practice patterns across Canada. Results suggest that an evidence-based Canadian clinical practice guideline may help to streamline care provided to Canadian children with tracheostomy tubes.

Antibodies Encoded by FCRL4-Bearing Memory B Cells Preferentially Recognize Commensal Microbial Antigens.

FCRL4, a low-affinity IgA Ab receptor with strong immunoregulatory potential, is an identifying feature of a tissue-based population of memory B cells (Bmem). We used two independent approaches to perform a comparative analysis of the Ag receptor repertoires of FCRL4+ and FCRL4- Bmem in human tonsils. We determined that FCRL4+ Bmem displayed lower levels of somatic mutations in their Ag receptors compared with FCRL4- Bmem but had similar frequencies of variable gene family usage. Importantly, Abs with reactivity to commensal microbiota were enriched in FCRL4+ cells, a phenotype not due to polyreactive binding characteristics. Our study links expression of the immunoregulatory FCRL4 molecule with increased recognition of commensal microbial Ags.

Adenotonsillectomy for Obstructive Sleep Apnea in Children with Complex Chronic Conditions.

Objective To estimate the prevalence of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Study Design A retrospective cohort study. Setting The Hospital for Sick Children Sleep laboratory. Subjects Children ≤18 years of age who had moderate to severe obstructive sleep apnea and had polysomnography pre- and postadenotonsillectomy. Methods Medical and polysomnographic data were reviewed. The prevalence of persistent obstructive sleep apnea postadenotonsillectomy was determined for the following groups: no complex chronic conditions, single-system complex chronic conditions, and multisystem complex chronic conditions. Results We reviewed data of 133 (84 male) children. Their mean (standard deviation) age was 5.5 (3.8) years. The persistent obstructive sleep apnea rate postadenotonsillectomy was highest in children with multisystem complex chronic conditions (57%), intermediate in children with single-system complex chronic conditions (29%), and lowest in children without complex chronic conditions (15%), P = .0004. The odds (confidence interval) of having persistent obstructive sleep apnea postadenotonsillectomy was 7.42 (2.16-25.51) times higher in children with multisystem complex chronic conditions vs no complex chronic conditions and 3.35 (1.16-9.64) times higher in children with multisystem complex chronic conditions vs single-system complex chronic conditions. Conclusions Although adenotonsillectomy is considered first-line therapy in healthy children older than 2 years for the treatment of obstructive sleep apnea, there is a significantly greater risk of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Therefore, other surgical procedures or nonsurgical management may need to be considered as first-line treatment for this cohort.

The Use of Speaking Valves in Children With Tracheostomy Tubes.

One-way speaking valves have been successfully used to restore audible meaningful speech in adult patients after tracheostomy tube placement. One-way speaking valves have also been used in pediatric patients after tracheostomy tube placement with promising results. We conducted a scoping review to synthesize and summarize the current evidence on the use of one-way tracheostomy tube speaking valves in the pediatric population to identify knowledge gaps that could inform future research programs and facilitate evidence-based clinical decision making. The Arksey and O'Malley 5-step methodological framework was used for this scoping review. We searched OVID MEDLINE, EMBASE, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar to locate articles published between January 1, 1946 and May 26, 2016. Our search resulted in a total of 524 articles. After removing 270 duplicates, we screened 254 abstracts, and 50 articles were identified for full text review. We excluded 38 references. A total of 12 articles met our inclusion criteria. Details of all studies were charted. Application of the Sackett levels of evidence to evaluate the qualitative strength of the evidence provided by the 12 articles selected for study found that 6 studies were level 5, 4 were level 4, and 2 studies were categorized as level 3 evidence. Eligibility criteria for trials of speaking valves were inconsistent across all studies and included a combination of clinical assessment coupled with published indications. Much of the literature has focused on tolerance/successful use of speaking valves in children with a tracheostomy with limited evidence on its impact on verbal communication. Current evidence on the use of speaking valves in children with a tracheostomy, its indication, and its impact on verbal communication is inadequate, mandating further research in this area.

What families have in the emergency tracheostomy kits: Identifying gaps to improve patient safety.

OBJECTIVE: To evaluate the contents of parent-created emergency tracheostomy kits and identify deficiencies. METHODS: This was an observational study. Data on emergency tracheostomy kits were abstracted for 30 consecutive children who had a tracheostomy tube in situ during an outpatient clinic visit with the Division of Respiratory Medicine and/or the Department of Otolaryngology-Head and Neck Surgery at the Hospital for Sick Children between February 1 and October 30, 2016. A checklist of 12 essential items based on expert consensus was used to evaluate each tracheostomy kit. RESULTS: Emergency tracheostomy kits from all children were missing at least one item from the 12-item checklist. Nineteen (63%) kits had three or more critical items missing. All kits had the same size tracheotomy tube. Twenty-two (73%) kits did not have a half size smaller tracheostomy tube. Fifteen (50%) were missing a manual resuscitation bag and four (13.3%) were missing a suction machine. Children who had tracheostomy tube in situ for ≥4 years were more likely to have ≥3 missing items in their kit (43.4%) compared to those who had tracheostomy tube for <4 years (20%), (χ2 (1) = 9.85, P = 0.0017). CONCLUSION: Maintenance of a fully stocked emergency tracheostomy kit can save a child's life. It is incumbent upon healthcare providers to ensure ongoing reassessment of knowledge and skills required to care for a child with a tracheostomy tube and to regularly review the components of a child's emergency tracheostomy kit.

Pediatric ossiculoplasty with titanium total ossicular replacement prosthesis.

OBJECTIVES/HYPOTHESIS: To assess the medium-term efficacy of total ossicular reconstruction with a titanium total ossicular replacement prosthesis (TORP) in children. STUDY DESIGN: Case series. METHODS: A consecutive series of children receiving an adjustable-length titanium TORP was identified from a prospective surgical and audiological database. Audiometric testing was obtained preoperatively, 2 months postoperatively, and subsequently at 6- to 12-month intervals. Four-frequency pure-tone averages (PTA) were determined for air conduction (AC) and bone conduction thresholds, as well as air-bone gap (ABG). Pre- and postoperative measures were compared to determine degree of improvement. The proportion with successful outcome (defined as ≤ 30 dB hearing level [HL] AC) was determined over time with Kaplan-Meier analysis. RESULTS: Seventy-five TORPs were inserted in 71 children aged 7 to 18 years, with a median follow-up of 2.7 years (0.6-5.5 years). The mean postoperative PTA AC threshold and ABG at 1 year were 35 dB HL and 29 dB, respectively, with ABG closure of 14 dB. The maximum gain in AC was 40 dB, achieved in eight (11%) cases. Successful outcome was seen in 50% of children at first follow-up. Over the following 1 to 3 years, hearing levels deteriorated to AC > 30 dB HL in an additional 10% of patients. Four patients had revision surgery, one for prosthesis extrusion and three for a lack of improvement in hearing. CONCLUSIONS: Titanium TORPs offer children an effective method of ossicular reconstruction, with infrequent extrusion at least in the short term. The hearing improvement achieved in the early postoperative period appears to be maintained over the first year but may not be sustained over longer time periods.

Prevalence of voice & swallowing complaints in Pre-operative thyroidectomy patients: a prospective cohort study.

BACKGROUND: Compressive symptoms are common in patients with thyroid disease and are an accepted indication for thyroidectomy. The objective of this study was to evaluate the prevalence and severity of voice and swallowing complaints in pre-operative thyroidectomy patients and to compare these with thyroid volume, thyroid pathology and laryngopharyngeal reflux. METHODS: A consecutive case series design was performed. All patients undergoing a thyroidectomy (partial or total) at a tertiary care centre during a 2 year period were invited to participate. Fifty nine (10 male, 49 female) aged 19-73 were enrolled (59.3% total thyroidectomy, 40.7% partial thyroidectomy). Voice and swallowing complaints were subjectively evaluated using the Voice Handicap Index (VHI) and the Modified Swallowing Impairment Score (MSIS), respectively. All patients completed the Reflux Symptom Index (RSI) and underwent videostroboscopy. Vocal function was objectively evaluated using perceptual ratings (GRBAS) and acoustic voice analysis (jitter, shimmer, maximum phonation time, maximum fundamental frequency range). The relationship between voice and swallowing symptoms was compared with thyroid volume and surgical pathology. RESULTS AND DISCUSSION: The average VHI score was 8.39, representing normal voice scores. Of the objective voice measures, only jitter and a subset of GRBAS measures were slightly elevated. Swallowing complaints were reported at least "some of the time" by 25 patients (41.7%), and "often or always" by 16 patients (26.7%). Of the patients with voice and swallowing complaints, 68.4% and 56%, respectively, had elevated RSI scores consistent with laryngopharyngeal reflux. No correlation was found with thyroid volume or thyroid pathology. CONCLUSIONS: Swallowing complaints appear to be common in pre-operative thyroidectomy patients. A large percentage, however, have associated laryngopharyngeal reflux which may in part account for these symptoms. Patients presenting with compressive thyroid symptoms should be evaluated for laryngopharyngeal reflux, and treated where appropriate.

Delayed facial nerve paresis after using the KTP laser in the treatment of cholesteatoma despite inter-operative facial nerve monitoring.

To describe an unforeseen complication that occurred in three patients following the use of the KTP laser. We present a case series including three consecutive patients (two boys and one girl, mean age 11.7 years) who underwent tympanomastoidectomy using a KTP laser and standard intra-operative facial nerve monitoring, and in whom a post-operative facial nerve injury was identified. Intra-operatively, the facial nerve was not encountered or exposed, and the KTP laser was not used directly on the nerve. The facial nerve monitor did not alarm. The three patients began experiencing a paresis from POD #7-9, with House-Brackmann facial nerve score of II-III at maximum severity. This resolved fully between 4 and 7 weeks after the onset of the paralysis. The KTP laser during cholesteatoma surgery has been shown to decrease residual disease but may however also cause a temporary, delayed, mild facial nerve paresis. We discuss the mechanisms for injury and the role of intra-operative facial nerve monitoring in the context of this uncommon and unforeseen complication.

Abnormal voicing in children using cochlear implants.

OBJECTIVES: To measure acoustic voice outcomes in children with bilateral cochlear implants and to compare these with established norms, as well as to determine whether these acoustic measures were influenced by duration of cochlear implant use, age at implantation, and overall "time in sound." DESIGN: Cross-sectional study. SETTING: Pediatric tertiary care cochlear implant center. PATIENTS: All children using bilateral cochlear implants who were followed up during a 4-month period at our implant center were invited to participate. Twenty-seven children (17 males and 10 females) aged 3 to 15 years were enrolled. Causes of deafness included congenital (n = 8), genetic (n = 8), meningitis (n = 3), cytomegalovirus (n = 2), and unknown (n = 6). The interval between first and second implantations ranged from simultaneous to 7.8 years (mean, 4.2 years). MAIN OUTCOME MEASURES: Children completed acoustic voice testing using a Computerized Speech Lab and a Multi-Dimensional Voice Program. Acoustic results were compared with those of children receiving unilateral implants and with normative data. RESULTS: Compared with established pediatric normative data, children with bilateral implants demonstrated poor control of long-term frequency perturbation and long-term amplitude perturbation when vocalizing sustained phonations (P < .001 for both). This finding was consistent with data previously reported in children using unilateral cochlear implants. Long-term control of frequency perturbation improved as children used their bilateral cochlear implants over time and was significantly influenced by overall time in sound (P = .02). CONCLUSIONS: Similar to unilateral cochlear implant users, children using bilateral implants have difficulty controlling long-term frequency perturbation and long-term amplitude perturbation during sustained phonations. These measures improved as the duration of usable hearing increases.

Prognostic factors in patients with multiple recurrences of well-differentiated thyroid carcinoma.

Introduction. Patients with multiple recurrences of well-differentiated thyroid carcinoma (WDTC) have markedly reduced overall survival when compared with those who have 45, stage III/IV disease, distant metastasis, vascular invasion, MACIS score >6, and time to recurrence of <12 months were found to be significant predictors for mortality in this subgroup. Conclusions. Patients with multiple recurrences of WDTC follow a distinct clinical course, marked with multiple treatment failures and a substantial risk of mortality.

Voice outcomes following repeated surgical resection of laryngeal papillomata in children.

OBJECTIVES: 1) To apply perceptual and acoustic voice assessments to children treated for juvenile-onset recurrent respiratory papillomatosis (JORRP); 2) to compare voice outcomes following treatment for JORRP using microdebrider versus carbon dioxide (CO(2)) laser. STUDY DESIGN: Prospective cohort study. SETTING: This study was conducted at a tertiary pediatric academic center (March 2008-March 2009). SUBJECTS AND METHODS: Children with active JORRP were assessed using perceptual and acoustic voice analysis following treatment with either CO(2) laser or microdebrider. Outcome measures included overall severity rating, jitter, shimmer, and noise-to-harmonic ratio (NHR). The unpaired Student t test and Pearson correlation tests were used to explore the statistical significance of hypothesis tests. RESULTS: Eleven patients (8 male, 3 female) aged three to 17 years were enrolled. There were six children in the CO(2) laser cohort and five children in the microdebrider cohort. The immediate postoperative scores were significantly lower in the microdebrider cohort (vs the CO(2) cohort) for jitter, shimmer, NHR, and perceptual scores (P < 0.05), indicating a better voice quality in the microdebrider group. Jitter, shimmer, and NHR showed a significant positive correlation with the proportion of CO(2) laser procedures (P < 0.05). CONCLUSION: This is the first study to use perceptual and objective acoustic evaluations to compare voice outcomes following microdebrider or CO(2) laser treatment of JORRP. The results of this study suggest that treatment with the microdebrider results in a better immediate and early postoperative voice outcome. Moreover, the data demonstrate a correlation of worsening voice quality with increased exposure to the CO(2) laser.