Polysomnogram outcomes in patients with laryngomalacia and obstructive sleep apnoea treated surgically versus non-surgically.

OBJECTIVE: To compare supraglottoplasty versus non-surgical treatment in children with laryngomalacia and mild, moderate and severe obstructive sleep apnoea. METHODS: Patients were classified based on their obstructive apnoea hypopnoea index on initial polysomnogram, which was compared to their post-treatment polysomnogram. RESULTS: Eighteen patients underwent supraglottoplasty, and 12 patients had non-surgical treatment. The average obstructive apnoea hypopnoea index after supraglottoplasty fell by 12.68 events per hour (p = 0.0039) in the supraglottoplasty group and 3.3 events per hour (p = 0.3) in the non-surgical treatment group. Comparison of the change in obstructive apnoea hypopnoea index in the surgical versus non-surgical groups did not meet statistical significance (p = 0.09). CONCLUSION: All patients with laryngomalacia and obstructive sleep apnoea had a statistically significant improvement in obstructive apnoea hypopnoea index after supraglottoplasty irrespective of obstructive sleep apnoea severity, whereas patients who received non-surgical treatment had more variable and unpredictable results. Direct comparison of the change between the two groups did not find supraglottoplasty to be superior to non-surgical treatment. Larger prospective studies are recommended.

Tone in Noise Detection in Children with a History of Temporary Conductive Hearing Loss.

Children with a history of temporary conductive hearing loss (CHL) during early development may show long-term impairments in auditory processes that persist after restoration of normal audiometric hearing thresholds. Tones in noise provide a simplified paradigm for studying hearing in noise. Prior research has shown that adults with sensorineural hearing loss may alter their listening strategy to use single-channel energy cues for tone-in-noise (TIN) detection rather than rove-resistant envelope or spectral profile cues. Our objective was to determine the effect of early CHL on TIN detection in healthy children compared to controls. Children ages 4-7 years, with and without a history of CHL due to otitis media with effusion (OME) before age 3 years, participated in a two-alternative forced choice TIN detection task. Audiometric thresholds were normal at the time of testing. Thresholds for detection of a 1000 Hz tone were measured in fixed-level noise and in roving-level noise that made single-channel energy cues unreliable. Participants included 23 controls and 23 with a history of OME-related CHL. TIN thresholds decreased with increasing age across participants. Children in both groups showed similar TIN sensitivity and little or no threshold elevation in the roving-level condition compared to fixed-level tracks, consistent with use of rove-resistant cues. In contrast to older listeners with sensorineural hearing loss, there was no detectable change in TIN sensitivity with roving level for children with a history of OME-related CHL.

Upper lip tie: A novel classification scale with improved inter-rater reliability.

Objectives: Upper lip tie (ULT) is a clinical condition with restrictive attachment of the superior labial frenulum (SLF), which may inhibit flanging of the lips. Objective outcome studies are lacking in part due to unreliable classification systems that rely solely upon a single attachment parameter of the SLF. This study's objectives are to describe a novel 3-point classification system for ULT and compare its inter-rater reliability to the Kotlow and Stanford systems. Methods: Five raters used the Kotlow and Stanford systems, as well as our novel 3-point scale to score images of the SLF from 20 newborns seen at our institution between September 1, 2017 and April 1, 2018. Newborn birth weight, gestational age, and demographic data were collected from the infant's medical record. Fleiss's kappa was used to calculate inter-rater reliability for all classification systems. Results: The parameters for our novel 3-point classification system for ULT were as follows: length from alveolar edge to frenulum gingival attachment, length of frenulum on stretch, and free-lip to total-lip length ratio. Our novel scale yielded the highest inter-rater reliability of 0.41, compared to 0.24 and 0.25 under the Kotlow and Stanford systems. Conclusion: While the Kotlow and Stanford systems are based upon a single anatomical parameter, our novel 3-point classification scale uses three oral parameters that encompass anatomical points of attachment as well as the maximal length of the ULT on stretch. Our classification scheme is the first to incorporate a functional parameter of the SLF, and thereby more fully characterizes ULT.Level of Evidence: Level 4.

Adenoidectomy may decrease the need for a third set of tympanostomy tubes in children.

OBJECTIVE: To determine whether removing or retaining adenoids at the time of placement of a second set of ear tubes impacts the need for a third set of ear tubes later in childhood. STUDY DESIGN: Single-institution retrospective case series. SETTING: Tertiary academic university hospital. METHODS: We identified pediatric subjects who had undergone a second ear tube placement between 1/1/17 and 9/1/19. Subjects were stratified into two groups: 1) adenoids removed at time of second tympanostomy tube insertion (TT+A) and 2) adenoids retained at time of second tympanostomy tube insertion (TT-A). A subset of children less than age 4 was also studied independently. The primary outcome was number of patients requiring a third set of tympanostomy tubes. RESULTS: A total of 136 subjects met inclusion and exclusion criteria. Among children less than 4 years of age (n = 99), the incidence of requiring a third set of tubes was significantly lower in the TT+A group <4 (12.8%; 6/47) compared to the TT-A group <4 (44.2%; 23/52) (p = 0.0008) with an odds ratio of 0.18 (95%CI 0.067-0.51) and number needed to treat of 3.2. CONCLUSION: Performing adenoidectomy in children less than 4 years of age at the second tympanostomy procedure was associated with a reduced incidence of requiring a third set of ear tubes.

Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia.

OBJECTIVES: There is debate among otolaryngologists and other practitioners about whether upper lip tie contributes to difficulty with breastfeeding and whether upper lip tie and ankyloglossia are linked. Our objectives were to evaluate the anatomy of the upper lip (maxillary) frenulum, to determine if the visual anatomy of the upper lip has an effect on breastfeeding, and to determine whether the occurrence of lip tie and tongue tie are correlated. METHODS: A prospective cohort study of 100 healthy newborns was examined between day of life 3-7. Surveys were completed by the mother at the time of the initial exam and 2 weeks later. The maxillary frenulum was graded based on the Stanford and Kotlow classifications by two independent reviewers. Inter-rater reliability and relationships between tongue tie, lip tie, and the infant breastfeeding assessment tool (IBFAT) were calculated. RESULTS: Inter-rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458). There was no correlation between the upper lip tie classification and breastfeeding success score. Lastly, there was a modest inverse correlation in the degree of tethering for the tongue and lip. CONCLUSIONS: There was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch. There was also no relationship between tip to frenulum length (tongue tie) and visualized lip anatomy, suggesting that tongue tie and lip tie may not cluster together in infants. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:E1701-E1706, 2021.

Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort.

OBJECTIVE: Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation. METHODS: Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings. RESULTS: Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) (P = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement. CONCLUSION: Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration. LEVEL OF EVIDENCE: 2b.

Ankyloglossia and Other Oral Ties.

Ankyloglossia and other oral ties have been recognized for centuries, but interest in and literature on these topics has recently increased. This article presents the latest evidence on the diagnosis and management of tongue-tie and outlines some of the controversies and gaps in the existing evidence. Anterior tongue-tie is accepted in most clinical practices as a potential risk for breastfeeding difficulty, and good evidence exists that division of an anterior tongue-tie leads to improved breastfeeding outcomes. Posterior tongue ties and upper lip-ties are being studied more intensively to provide sound, evidence-based recommendations on their diagnosis and treatment.

Amplitude Modulation Detection in Children with a History of Temporary Conductive Hearing Loss Remains Impaired for Years After Restoration of Normal Hearing.

Otitis media with effusion (OME) is considered a form of relative sensory deprivation that often occurs during a critical period of language acquisition in children. Animal studies have demonstrated that hearing loss during early development can impair behavioral sensitivity to amplitude modulation (AM), critical for speech understanding, even after restoration of normal hearing thresholds. AM detection in humans with a history of OME-associated conductive hearing loss (CHL) has not been previously investigated. Our objective was to determine whether OME-associated CHL in children ages 6 months to 3 years results in deficits in AM detection in later childhood, after restoration of normal audiometric thresholds. Children ages 4 to 7 years with and without a history of OME-associated CHL participated in an AM detection two-alternative forced-choice task at 8 and 64 Hz modulation frequencies using a noise carrier signal and an interactive touch screen interface. Thirty-four subjects were studied (17 with a history of OME-related CHL and 17 without). Modulation detection thresholds improved with age and were slightly lower (more sensitive) for the 64 Hz modulation frequency for both groups. Modulation detection thresholds of children with a history of OME-associated CHL were higher than control thresholds at 5 years, but corrected to expected levels between ages 6-7. OME-associated CHL results in impaired AM detection, even when measured years after restoration of normal audiometric thresholds. Future studies may shed light on implications for speech and language development and academic success for children affected by OME and associated conductive hearing loss.

Defining Tip-Frenulum Length for Ankyloglossia and Its Impact on Breastfeeding: A Prospective Cohort Study.

OBJECTIVE: The purpose of this study was to investigate the normal lingual frenulum anatomy in newborns and to evaluate tip-frenulum distance as an objective diagnostic tool for identifying newborns at risk for anterior and posterior tongue tie and breastfeeding difficulty. MATERIALS AND METHODS: The distance from the tongue tip to the insertion of the lingual frenulum was measured in a group of 100 healthy newborns to establish normative data. The presence of a visible or palpable cord was noted. Inter-rater reliability was assessed. Breastfeeding surveys including a maternal pain scale and Infant Breastfeeding Assessment Tool (IBFAT) were administered on days of life 2 and 14 to determine whether these findings predict breastfeeding difficulty. RESULTS: Mean tip-frenulum length was 9.07 mm. Intraclass correlation coefficient between observers for tip-frenulum length was 0.82. A visible cord was identified in 21 subjects (21%). A palpable cord was identified in 59 subjects (59%). Unweighted κ coefficients for inter-rater reliability of visible and palpable cords were 0.91 and 0.47, respectively. Visible cord and shorter tip-frenulum distance were independently predictive of higher maternal pain scores. A positive correlation was identified between tip-frenulum length and IBFAT scores for mothers with two or more previous breastfed children. CONCLUSIONS: Tongue tip-frenulum length correlated with maternal nipple pain, and was useful as an objective tool for identifying newborns at risk for ankyloglossia. Maternal breastfeeding experience appears to be an important factor in the link between tongue anatomy and breastfeeding difficulty. The presence of a palpable cord was variable across examiners, and should be interpreted with caution when evaluating newborns for posterior tongue tie.