Evaluation of Noise Exposure Levels in Pediatric ENT Operating Rooms.

OBJECTIVE: Operating room (OR) sounds may surpass noise exposure thresholds and induce hearing loss. Noise intensity emitted by various surgical instruments during common pediatric otolaryngologic procedures were compared at the ear-level of the surgeon and patient to evaluate the need for quality improvement measures. STUDY DESIGN: Cross-sectional study. SETTING: Single tertiary care center. METHODS: Noise levels were measured using the RISEPRO Sound Level Meter and SoundMeter X 10.0.4 at the ear level of surgeon and patient every 5 minutes. Operative procedure and instrument type were recorded. Measured noise levels were compared against ambient noise levels and the Apple Watch Noise application. RESULTS: Two hundred forty-two total occasions of noise were recorded across 62 surgical cases. Cochlear implantation surgery produces the loudest case at the ear-level of the patient (91.8 Lq Peak dB; P < .001). The otologic drill was the loudest instrument for the patient (92.1 Lq Peak dB; P < .001), while the powered microdebrider was the loudest instrument for the surgeon (90.7 Lq Peak dB; P = .036). Noise measurements between surgeon and patient were similar (P < .05). Overall agreement between the Noise application and Sound Level Meter was excellent (intraclass correlation coefficient of 0.8, with a 95% confidence interval ranging from 0.32 to 0.92). CONCLUSION: Otolaryngology OR noises can surpass normal safe thresholds. Failure to be aware of this may unwittingly expose providers to noise-related hearing loss. Mitigation strategies should be employed. Quality improvement measures, including attention to surgical instrument volume settings and periodic decibel measurements with sound applications, can promote long-term hearing conservation. DISCUSSION: Otolaryngology OR noises can surpass normal safe thresholds. Failure to be aware of this may unwittingly expose providers to noise-related hearing loss. The duration, frequency of exposure, and volume levels of noise should be studied further. IMPLICATIONS FOR PRACTICE: Mitigation strategies should be employed. Quality improvement measures, including attention to surgical instrument volume settings and periodic decibel measurements with sound applications, can promote long-term hearing conservation.

Evaluation of Cochlear Implantation in Children With Cochlear Nerve Absence or Deficiency.

OBJECTIVE: To identify associations between cochleovestibular anatomy findings and hearing outcomes found in children with imaging evidence of an absent or hypoplastic cochlear nerve treated with cochlear implantation (CI). STUDY DESIGN: retrospective review. SETTING: Cochlear implant program at tertiary care center. METHODS: A retrospective review was performed to identify children with imaging evidence of cochlear nerve absence or deficiency who underwent CI evaluation. High-resolution 3-dimensional T2-weighted magnetic resonance imaging in the oblique sagittal and axial planes were reviewed by a neuroradiologist to identify cochleovestibular anatomy. Hearing was assessed pre and postoperatively with Speech Perception Category scores. RESULTS: Seven CI recipients were identified (n = 10 ears) who had bilateral severe to profound sensorineural hearing loss with lack of auditory development with binaural hearing aid trial and imaging evidence of cochlear nerve aplasia/hypoplasia. All ears had 2 nerves in the cerebellopontine angle (100%, n = 10), half of the ears had evidence of 2 or less nerves in the internal auditory canal (IAC). All children showed large improvement in speech perception after CI. CONCLUSION: Our experience with CIs for children with absent or hypoplastic cochlear nerves demonstrates that CI can be a viable option in select patients who satisfy preoperative audiological criteria. Radiological identification of a hypoplastic or aplastic cochlear nerve does not preclude auditory innervation of the cochlea. CI recipients in this subgroup must be counseled on difficulty in predicting postimplantation language and speech outcomes, and cautioned about facial nerve stimulation.

Predicting failure of detection of peritonsillar abscess with ultrasound in pediatric populations.

PURPOSE: Some patients require additional imaging following ultrasound (US) to definitively diagnose a peritonsillar abscess (PTA), delaying intervention and disease resolution. We seek to evaluate patient characteristics which may predispose to a secondary imaging requirement to diagnose PTA, in order to better understand ultrasound limitations and predict who will require additional studies. MATERIALS AND METHODS: Retrospective chart review of patients with an US for suspected PTA between July 2017 and July 2020. Patient age, weight, and clinical characteristics, such as pain, trismus, and reduced neck range of motion (ROM) were collected. The need for additional imaging, subsequent surgical intervention, and hospital length of stay (LOS) were also recorded. RESULTS: Of 411 qualifying patients, 73 underwent additional imaging. Patients who required additional imaging were younger (9.8 vs 11.3 years, p = 0.026) and more likely to have decreased neck ROM (17.8 vs 5.3 %, p = 0.001). Surgical intervention was performed more commonly (27.4 vs 14.8 %, p = 0.015) and hospital LOS was longer (24.0 vs 5.0 h, p < 0.001) in those with secondary imaging. CONCLUSIONS: Specific patient characteristics, such as younger age and decreased neck range of motion, are associated with a higher need for additional imaging. Additionally, the need for additional imaging is associated with a longer hospital LOS and increased likelihood of surgical intervention. Nearly 18 % of patients who underwent US evaluation of PTA required secondary imaging. Although transcervical US remains an excellent tool for diagnosing PTA, this data supports the utility of secondary imaging in certain instances.

A Nearly Obstructive Intratracheal Mass in a Pediatric Patient.

A 12-year-old girl presented to the clinic with a 3-month history of intermittent stridor; her symptoms were initially most prominent while playing sports and were suspected to be due to asthma or seasonal allergies. What is your diagnosis?

Cholesteatoma: Canalplasty for External Auditory Stenosis in a Pediatric Patient.

External auditory canal (EAC) stenosis is the narrowing of the external auditory meatus to less than 4 mm. Severe stenosis of the EAC may inhibit the ability to conduct sound and may lead to the formation of a cholesteatoma. While most cases of EAC stenosis may be managed nonoperatively, the significant impact that the associated symptoms can have on patients may require surgical intervention. Progression of the cholesteatoma can erode the bony ossicles, may encase the facial nerve, and impact infection risk causing chronic otorrhea, and further worsening patient quality of life. We present the case of a pediatric patient who presented due to chronic left-sided hearing loss. Further examination and imaging demonstrated near-total obstruction of the left EAC secondary to a soft tissue mass and evidence of bony hypertrophy. Following a canalplasty, the patient now has returned to baseline hearing and has no associated complications. Canalplasty remains a safe, effective surgical intervention for EAC stenosis complicated by cholesteatoma.

Fourth branchial cleft sinus with foreign material within thyroid gland.

Fourth branchial cleft anomalies are rare lesions that present diagnostic dilemmas to otolaryngologists. The report presented is a case of a 17-year-old female with food matter and abscess within the thyroid gland that were associated with a 4th branchial cleft sinus. A thyroid ultrasound revealed a 3.0 x 1.5 x 2.5-cm lesion with abnormal echogenicity that was concerning for early abscess. The patient subsequently underwent direct laryngoscopy and right thyroid lobectomy. Her symptoms resolved after surgery. This case demonstrates an unusual presentation in which food passed through the tract to the thyroid gland itself.

Efficacy of common reagents for killing ticks in the ear canal.

OBJECTIVE: To determine if widely available solutions can effectively kill ticks that may be found in the human ear canal. METHODS: This study was prospective, controlled and blinded animal study. Lone star ticks (Amblyomma americanum), both nymphal and adult, were submerged in one of four preparations (acetone, isopropyl alcohol 70%, ethanol 95%, or 4% lidocaine) in test tubes (n = 20 per group) for 20 minutes. Ticks were agitated by intermittent probing. Activity of the nymphal ticks was directly observed while those of the adult ticks was video-recorded during the exposure period. Two blinded investigators viewed the videos of adult ticks and during the exposure period to determine the time until death (ie, movement cessation). Mortality was assessed immediately after exposure, and confirmed 24 and 48 hours after exposure. RESULTS: Acetone killed ticks most rapidly (nymph mean time = 185.1 s; adult mean time = 562.9 s). Isopropyl alcohol 70% (nymphs, 328.9 s; adults, 1128.4 s) and ethanol 95% (nymphs, 294 s; adults, 1129.4 s) took longer to kill the ticks. All ticks treated with 4% lidocaine survived. These differences were significant (nymphs, P < .0001; adults, P < .0001). CONCLUSIONS: Acetone was the fastest acting and most effective reagent, followed by ethanol and isopropyl alcohol. These solutions may prove useful in otoacariasis with an intact tympanic membrane. LEVEL OF EVIDENCE: N/A.

Collagen and α-Tubulin of Mouse Tympanic Membrane Fibroblasts Treated with Quinolones and Aminoglycosides.

Objective To assess collagen and α-tubulin levels of mouse tympanic membrane fibroblasts treated with quinolone and aminoglycoside antibiotics at concentrations found in eardrops. Study Design Prospective controlled cell culture study. Setting Academic tertiary medical center. Subjects Mouse tympanic membrane fibroblasts. Methods In experiment 1, fibroblasts were treated with the following for 24 or 48 hours: phosphate-buffered saline (negative control), dilute hydrochloric acid (positive control), 0.5% gatifloxacin, or commercially available 0.3% ciprofloxacin, 0.3% ciprofloxacin + 0.1% dexamethasone, 0.3% ofloxacin, 0.5% moxifloxacin, 0.3% gentamicin, or 3.5 mg/mL of neomycin + polymyxin B sulfate + hydrocortisone. In experiment 2, cells were treated with the pure form of gatifloxacin, gentamicin, ofloxacin, or ciprofloxacin. Cells were observed with phase-contrast microscope until harvested. Proteins were extracted for Western blotting with antibodies against collagen α1 type I (collagen 1A1) and α-tubulin, and for densitometry to quantify levels. Results Collagen and tubulin levels in fibroblasts treated with ofloxacin, moxifloxacin, gatifloxacin, or gentamicin for 24 hours were not different from the saline control. Fibroblasts treated with neomycin + polymyxin B + hydrocortisone, ciprofloxacin + dexamethasone, or ciprofloxacin for 24 hours had lower collagen 1A1 and α-tubulin levels (all P < .001) than the negative control. After 48 hours, fibroblasts treated with neomycin + polymyxin B sulfate + hydrocortisone, ciprofloxacin + dexamethasone, ciprofloxacin, or moxifloxacin had lower collagen 1A1 ( P ≤ .007) and α-tubulin ( P < .0001; except ciprofloxacin, P = .033) as compared with control. In experiment 2, only cells treated with ciprofloxacin had lower collagen 1A1 and α-tubulin levels and cell viability (all P < .0001) than control. Cytotoxicity assay and phase-contrast images mirrored the protein findings. Conclusion The adverse impact of topical antibiotic exposure on tympanic membrane collagen and tubulin protein levels is drug specific. This may be important for selection of ototopical therapy.

Ciprofloxacin Decreases Collagen in Mouse Tympanic Membrane Fibroblasts.

OBJECTIVES: To determine how collagen production by tympanic membrane fibroblasts is affected by ciprofloxacin at levels found in eardrops. STUDY DESIGN: Prospective, controlled, and blinded cell culture study. SETTING: Academic tertiary medical center. SUBJECTS: Cell culture of mouse fibroblasts. METHODS: A primary fibroblast culture was established from mouse tympanic membranes. Fibroblasts were cultured until they were 75% confluent, then treated with dilute hydrochloric acid (control) or ciprofloxacin (0.01% or 0.3%) for 24 or 72 hours for Western blotting and for 24 or 48 hours for cytotoxicity assay. Cells were observed with phase-contrast microscope. Western blotting was performed for collagen type 1 α1 (collagen 1A1) and α-tubulin. RESULTS: Fibroblasts treated with 0.01% and 0.3% ciprofloxacin for 24 hours had lower levels of collagen 1A1 (P = .0005 and P < .0001, respectively) and α-tubulin (both P < .0001) than control fibroblasts. Collagen 1A1 and α-tubulin levels were lower in fibroblasts treated with 0.3% than with 0.01% ciprofloxacin (P = .02 and P = .014). After 72 hours, 0.3% ciprofloxacin completely eliminated collagen 1A1 and α-tubulin (P < .001). Cells treated with 0.01% ciprofloxacin for 72 hours also had lower collagen 1A1 (P < .0001) and α-tubulin (P = .005) as compared with the control. Seventy-two-hour incubation in 0.01% or 0.3% ciprofloxacin resulted in lower levels of collagen 1A1 (P = .009 and P < .0001, respectively) and α-tubulin (P = .007 and P < .0001, respectively) than 24-hour incubation. Cytotoxicity assay and phase-contrast microscopy mirrored these findings. CONCLUSIONS: Treatment of tympanic membrane fibroblasts with 0.3% ciprofloxacin, as found in eardrops, reduces fibroblast viability and collagen and α-tubulin protein levels. These findings could explain tympanic membrane healing problems associated with quinolone eardrops.

Histologic versus pH probe results in pediatric laryngopharyngeal reflux.

OBJECTIVE: A comparison of histologic findings from the post-cricoid region versus nasopharyngeal pH probe results in the diagnosis of laryngopharyngeal reflux (LPR) in the pediatric patient. STUDY DESIGN: Retrospective review. SETTING: Outpatient pediatric otolaryngology private practice. SUBJECT AND METHODS: 63 consecutive patients, age 6-months to 17-years between June 1, 2009 and October 6, 2010, tested by simultaneous post cricoid biopsy and nasopharyngeal pH probe monitoring using the Restech Dx-pH Measurement System (Respiratory Technology Corporation, San Diego, CA). RESULTS: Of the 63 total patients (age 6-months to 17-years), 11 (17%) were excluded due to a pulled probe, one additional patient did not have a biopsy taken and one probe failed after insertion making a total of 50 patients with complete data sets. Thirty-six of those 50 patients had a positive probe with a negative biopsy (72%). Four (8%) had both a positive probe and biopsy and 10 (16%) had a negative probe and negative biopsy. No patients had a negative probe and positive biopsy. Symptoms used to identify patients suspected of reflux included: throat clearing, nasal congestion, cough, history of recurrent sinusitis with negative radiographic findings, halitosis, culture negative sore throat, post nasal drip, otalgia, poor appetite and stomach ache. CONCLUSION: Eighty percent of our patients (40) were either positive for reflux by pH probe or by pH probe and biopsy. The Restech Dx-pH Measurement System appeared to be well tolerated in all age groups. There were no complications. We found this a useful tool in confirming clinical suspicion of LPR.