Myringotomy tube placement: understanding the impact of the coronavirus disease 2019 pandemic.

OBJECTIVE: Otolaryngologists perform bilateral myringotomy and tube placement for surgical management for otitis media with effusion. This retrospective study aimed to address the extent to which the coronavirus disease 2019 pandemic and season impact the number of bilateral myringotomy and tube placement procedures performed at a tertiary care centre. METHODS: A total of 1248 charts of children who underwent bilateral myringotomy and tube placement from January 2018 through February 2021 were reviewed. RESULTS: The cohort included 41.6 per cent females and 58.4 per cent males, with 63.7 per cent having private insurance. The median age at surgery was 2.6 years. The spring season had the most bilateral myringotomy and tube placement procedures per week. The number of bilateral myringotomy and tube placement procedures performed per week after the onset of the coronavirus disease 2019 pandemic was significantly lower compared to the years prior. There was no difference in number of intra-operative effusions pre-pandemic versus after the pandemic onset. CONCLUSION: This study sheds light on the impact of the coronavirus disease 2019 pandemic and seasonality on the rates of tympanostomy tube procedures, vital for understanding the temporality of ear infections.

First bite syndrome following transcervical arterial ligation after transoral robotic surgery.

OBJECTIVE: To assess the incidence of first bite syndrome (FBS) in transoral robotic surgical (TORS) patients undergoing transcervical arterial ligation. METHODS: Retrospective case series of all patients diagnosed with FBS following prophylactic transcervical arterial ligation of branches of the external carotid system between March 2010 and December 2016 at a single academic center. RESULTS: Six patients with FBS after TORS with transcervical arterial ligation were evaluated, representing 7% of all patients who underwent neck dissection with concomitant transcervical arterial ligation (6 of 83). Median presentation of FBS was 63 days, with an average duration of 66 days. Treatment ranged from observation to botulinum toxin injection. CONCLUSION: Patients who undergo transcervical arterial ligation to minimize bleeding complications following TORS are at risk of developing first bite syndrome. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1589-1593, 2018.

Routine airway surveillance in pediatric tracheostomy patients.

OBJECTIVES: The aim of this study is to review airway findings in children with tracheostomies who underwent surveillance direct laryngoscopy and bronchoscopy (DLB) to determine the yield of routine airway evaluation in these patients. STUDY DESIGN: Retrospective chart review at tertiary referral children's hospital. METHODS: A retrospective chart review was conducted of all of the children with tracheostomies who underwent DLB after tracheostomy between 1984 and 2015. RESULTS: A total of 303 patients met inclusion criteria. The median time interval between tracheostomy and first follow-up DLB was 12.0 months (IQR 4.8-28.9 months). There was no significant difference in the incidence of airway lesions between patients who underwent endoscopy <6 months post tracheostomy versus those who had a longer time interval between tracheostomy and DLB (p = 0.16). One hundred sixty seven patients (55.1%) were diagnosed with lesions, with suprastomal granulation (39.9%) being the most common. Symptomatic patients were significantly more likely to have an airway lesion identified (69.9% versus 42.0%; p < 0.001). Ventilator dependent patients and those with either cardiopulmonary disease or traumatic injury as indications for tracheostomy were significantly more likely to have an airway lesion (p = 0.01). CONCLUSIONS: The high incidence of airway lesions noted during surveillance DLB support the utility of routine airway endoscopy in pediatric tracheostomy patients. Symptomatic patients, those with ventilator dependence, or cardiopulmonary or trauma indications for tracheostomy are more likely to have airway lesions and should be monitored closely. The ideal time interval between surveillance endoscopies needs to be examined further.

Indications of pediatric tracheostomy over the last 30 years: Has anything changed?

IMPORTANCE: Recent reports have shown that the indications for pediatric tracheostomy have evolved over time. OBJECTIVE: To review the indications for pediatric tracheostomy over the last 30 years. DESIGN: Retrospective chart review. SETTING: Tertiary referral children's hospital. PARTICIPANTS: Patients who underwent tracheostomy. INTERVENTION: Surgical tracheostomy placement. MAIN OUTCOMES AND MEASURES: Medical records for patients who underwent surgical tracheostomy over the 30-year study period (1984-2014) were reviewed. Patient characteristics including age, gender, birth-weight, gestational age and death were collected and compared with the primary indication for tracheostomy using bivariable analysis. RESULTS: Five hundred and one patients met inclusion criteria. The most common primary indications for tracheostomy were cardiopulmonary disease (34%) and neurological impairment (32%), followed by airway obstruction (19%), craniofacial (11%), and traumatic injury (4%). Over the last five years (2010-14) cardiopulmonary disease became the most common indication for tracheostomy. CONCLUSIONS: and RELEVANCE: The indications for pediatric tracheostomy have evolved over the past 30 years. Infectious causes of airway obstruction and tracheostomy have almost disappeared. Tracheostomy is now most commonly performed in very premature patients with cardiopulmonary or neurological impairment who require prolonged ventilator support.

Sinus Computed Tomography Imaging in Pediatric Cystic Fibrosis: Added Value?

STUDY OBJECTIVE: To evaluate the prevalence of computed tomography (CT) sinus imaging in a pediatric cystic fibrosis (CF) population, determine changes in Lund Mackay (LM) scores over time, and estimate radiation exposure. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: In total, 202 pediatric patients with CF who underwent endoscopic sinus surgery (ESS) were included. The total number of CT scans was calculated for each patient, with specific focus on the indications for and subsequent outcomes of the sinus CT scan subgroup. RESULTS: Patients underwent a total of 1718 CT scans, 832 of which were sinus CT scans (mean of 4.2 sinus scans per patient). Disease evaluation (54%) and preoperative planning (35%) were the most common indications. Otolaryngologists were more likely to order imaging for preoperative evaluation, and those scans were more likely to result in surgery compared with those requested by other physicians (P < .001). Ninety CT scans (10.8%) led to no change in management. There was no significant difference in LM scores between patients admitted to the hospital or prescribed antibiotics and those who were not. There was also no significant change in LM score following ESS after adjusting for age and sex (P = .23). CONCLUSION: Based on LM scores, all sinus CT scans in patients with CF reveal moderate to severe sinus disease. Effort should be made to minimize radiation exposure in patients with CF by limiting sinus CT scans to the preoperative context or for evaluation of potential sinusitis complications.

Swallowing dysfunction among patients with laryngeal cleft: More than just aspiration?

BACKGROUND: The Modified Barium Swallow (MBS) is the most widely utilized instrumental assessment of swallowing disorders in children; however, the exact role in the evaluation of laryngeal clefts remains controversial. METHODS: This study was an IRB-approved retrospective review on patients diagnosed with laryngeal cleft from 2002 to 2014. The objective was to describe the range of swallowing dysfunction that may be present in patients with laryngeal clefts both pre- and post-intervention (conservative management versus surgery). A speech-language pathologist reviewed MBS studies and medical records to determine Penetration-Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS) scores. RESULTS: One hundred seventy-five patients who underwent laryngeal cleft repair during the study period (type 1, n=111; type 2, n=54; type 3, n=9; type 4, n=1) were included. Fifty patients who were managed conservatively (type 1) were also included. Swallowing impairment was demonstrated in all phases of swallowing for all cleft types. Oral phase impairment ranged from 27-67% pre-intervention to 19-75% post-intervention, triggering impairment from 24-42% pre-intervention to 24-75% post-intervention, and pharyngeal phase impairment (laryngeal penetration and aspiration) from 57-100% pre-intervention to 40-100% post-intervention. Laryngeal penetration and aspiration on thin and thick liquids, silent aspiration, PAS, and FOIS scores are reported. Significant improvements in swallowing function (p<0.05) were documented in all of the conservatively and surgically managed sub-groups. CONCLUSIONS: The MBS study is a useful tool for evaluating swallowing function in patients with laryngeal cleft and provides information beyond the lack or presence of aspiration. Understanding impairments in all phases of swallowing may be beneficial for perioperative management.

Update on current evaluation and management of pediatric nasal dermoid.

OBJECTIVES/HYPOTHESIS: To review the presentation of congenital pediatric nasal dermoid and present guidelines for its evaluation and management. STUDY DESIGN: Retrospective chart review from 1970 to 2014 at a tertiary referral children's hospital. METHODS: The medical records of all patients diagnosed with a nasal dermoid during the study period were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes. RESULTS: Ninety-six patients underwent excision of a congenital nasal dermoid during the study period. The mean age at presentation was 3.1 years (range, 0.1-19.3 years). Thirty-four (35%) females and 62 (65%) males were included. The most common presentation was a nasal dorsal mass in 66 (69%) patients. Ninety-two (96%) of the patients underwent preoperative imaging. Seventy-eight (82%) of the patients did not show any clinical or radiographic evidence of intracranial extension preoperatively. Eighty-five (89%) of the patients underwent extracranial excision, and 11 (11%) underwent combined intracranial and extracranial excision. Eight patients (8%) presented with recurrence, on average 3.3 years (range, 1-6 years) after initial excision. Mean follow-up time was 8 years (range, 1-18 years). CONCLUSION: Preoperative imaging of nasal dermoid is crucial to evaluate for intracranial extension, thus facilitating complete removal. Thin section, high-resolution magnetic resonance with contrast provides excellent detail of the extent of the nasal dermoid including intracranial extension. Thin-section high-resolution computed tomography with multiplanar reformatted images provides complimentary information regarding the bone anatomy of the frontonasal region. Surgical strategy is dictated by preoperative imaging and is dependent on the extent of the lesion, but limited facial incisions are preferred. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2151-2160, 2016.

Congenital nasal neuroglial heterotopia and encephaloceles: An update on current evaluation and management.

OBJECTIVES/HYPOTHESIS: To describe our experience and current management approach for congenital nasal neuroglial heterotopia (NGH) and encephaloceles. STUDY DESIGN: Retrospective chart review at a tertiary pediatric hospital from 1970 to 2013. METHODS: Thirty patients met inclusion criteria: 21 NGH and nine encephaloceles. Data including demographics, pathology, imaging modality, surgical approach, resection extent, outcomes, and complications were analyzed. RESULTS: Fourteen NGH patients (67%) presented with an internal nasal mass and nasal obstruction. Three patients (14%) presented with an external nasal mass and four (19%) had a mixed lesion. Median age at surgery was 0.51 years (interquartile range 1.32 years). Thirteen (62%) had an intranasal endoscopic approach. Median operative time was 1.6 hours (interquartile range 1.2 hours), and there were no major complications. Nine patients with encephalocele were identified: six (67%) presented with transethmoidal encephaloceles, two (22%) presented with nasoethmoidal encephaloceles, and one (11%) presented with a nasofrontal lesion. The median age at surgery was 1.25 years (interquartile range 1.4 years). All patients required a craniotomy for intracranial extension. Median operative time was 5 hours (interquartile range 1.9 hours), and eight patients (88%) had a total resection. Length of stay ranged from 3 to 14 days. CONCLUSION: Nasal neuroglial heterotopia and encephaloceles are very rare lesions that require multidisciplinary evaluation and management. At our institution, there has been a shift to magnetic resonance imaging alone for the evaluation of NGH to avoid radiation exposure. Endoscopic extracranial resection is feasible for most intranasal and mixed NGH without an increase in operative time, residual disease, or complications. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2161-2167, 2016.

To stent or not to stent? A meta-analysis of endonasal congenital bilateral choanal atresia repair.

OBJECTIVES: The use of nasal stents as a postoperative adjunct following repair of choanal atresia remains controversial. The study objective was to systematically review the literature regarding the efficacy and safety of stenting following transnasal endoscopic repair of bilateral choanal atresia. STUDY DESIGN: Systematic review with meta-analysis. METHODS: A comprehensive search in PubMed, EMBASE, CINAHL, and the Cochrane Library was conducted. Inclusion criteria included articles written in the English language with five or more subjects and clear intervention data and outcomes. Two independent reviewers screened studies for eligibility, appraised the level of evidence, extracted data, and resolved discrepancies by consensus. Successful surgery was defined as the absence of restenosis. RESULTS: Of 154 identified studies, 15 met inclusion criteria. Levels of evidence varied from level 3 to 4. Mean age at surgery ranged from 5 days to 25 months. Thirteen studies (n = 167 patients) included patients who were stented; the weighted pooled proportion of successful surgery was 65% (95% confidence interval [CI], 49-76%). Mean duration of stenting ranged from 48 hours to 16 weeks. Six studies (n = 42) evaluated patients who were not stented; the weighted pooled proportion of successful surgery was 64% (95% CI, 42-84%). Complications associated with stenting included alar injury, vestibular stenosis, columellar tear, and stent dislodgement or blockage. CONCLUSIONS: Success rates for bilateral choanal atresia repair were similar with and without the use of nasal stents. The use of nasal stents may be associated with more complications. There is insufficient data to determine if mitomycin C is a useful therapeutic adjunct.

Total serum glycan analysis is superior to lectin-FLISA for the early detection of hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) is a primary cancer of the liver that is predominantly the result of infection with a hepatotropic virus such as hepatitis B virus or hepatitis C virus. As liver cancer is often asymptomatic, the development of sensitive noninvasive biomarkers is needed for early detection and improved survival. EXPERIMENTAL DESIGN: We have previously identified alterations in the N-linked glycosylation of serum proteins with the development of HCC and identified many of the proteins that contained the altered glycosylation. In the current study, we compared the ability of the identified proteins to diagnose HCC with the total serum glycan analysis. RESULTS: Surprisingly, glycan analysis of total serum had the greatest ability to distinguish HCC from cirrhosis with an AUROC of 0.851, a sensitivity of 73% at a specificity of 88%. When total glycan sequencing was combined with alpha-fetoprotein (AFP), the sensitivity increased to 95% at a specificity of 90%. CONCLUSION AND CLINICAL RELEVANCE: Changes in glycosylation as detected in whole serum could be used to diagnose HCC with greater sensitivity and specificity than that observed through the analysis of specific protein glycoforms or protein levels. Such an assay could have value in the management of those at risk for the development of HCC.