Vincristine-induced vocal cord paresis and paralysis in children.

OBJECTIVES: To describe three new cases of vincristine-induced vocal cord paresis or paralysis (VIVCPP) in children and to review the diagnosis and management of this neuropathy. METHODS: Retrospective case series. Diagnosis of VIVCPP was confirmed by laryngoscopy in all children. RESULTS: Less than 20 cases of VIVCPP in children have been previously documented in the literature. Of the three children in our case series, one had unilateral vincristine-induced vocal cord paresis and two had bilateral VIVCPP. The first two patients each had two separate episodes of paresis, lasting 4 months and 1 month respectively. In the last patient, whose medical course was complicated by many additional factors, vocal cord paralysis persisted for over three years. CONCLUSIONS: Clinicians must evaluate children with suspected VIVCPP for concomitant symptoms and signs of vincristine neuropathies and examine the vocal cords via laryngoscopy. The effects of vincristine neurotoxicity can be waxing and waning, demonstrate delayed onset and persist well beyond drug cessation. Further studies are needed to identify effective neuroprotectants and delineate appropriate vincristine dosing in patients with vincristine neurotoxicity and cancer.

Surgical Outcomes for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome.

This study aimed to compare outcomes of concomitant palatoplasty and sphincter pharyngoplasty with pharyngeal flap and sphincter pharyngoplasty alone for the treatment of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome. Thirty-one cases were identified for inclusion in the study. Patients were separated into 3 surgical groups: combined palatoplasty and sphincter pharyngoplasty (n = 11), pharyngeal flap (n = 7), and sphincter pharyngoplasty (n = 13). Outcome measures included perceptual speech analyses, surgical complications, and revision rates. There were no differences in preoperative speech analysis scores (P = .31). The combined palatoplasty and sphincter pharyngoplasty procedure had similar speech outcomes compared to pharyngeal flap, and both were significantly better than sphincter pharyngoplasty alone. Complication rates (P = .61) and the need for revision surgery (P = .25) were similar among all 3 groups. Concomitant palatoplasty and sphincter pharyngoplasty may be an alternative treatment for velopharyngeal insufficiency in children with 22q11.2 deletion syndrome.

Upper airway obstruction in neonates: Does sleep exacerbate symptoms?

OBJECTIVE: Describe the factors that exacerbate upper airway obstructions (UAOs) in neonates. STUDY DESIGN: Retrospective chart review. SETTING: Pediatric tertiary care hospital. SUBJECTS AND METHODS: All neonates hospitalized between 1/1/2010 and 12/31/2014 diagnosed with either: 1) laryngomalacia, 2) Pierre Robin sequence, or 3) vocal cord paralysis were included in this study. Patient charts were reviewed to determine factors that exacerbated symptoms of airway obstruction. The independent variable was patient diagnosis, and the outcome measure was exacerbating factors. RESULTS: In patients with laryngomalacia (n = 31), 41.9% worsened with agitation, 38.7% worsened with feeding, 16.1% worsened with positioning, 0.0% worsened during sleep, and 25.8% had no aggravating factors. In Pierre-Robin patients (n = 31), 48.4% worsened with agitation, 16.1% worsened with feeding, 61.3% worsened with positional changes, 0.0% worsened during sleep, and 12.9% had no aggravating factors. In vocal cord paralysis patients (n = 25), 72.0% worsened with agitation, 8.0% worsened with feeding, 20.0% worsened with positional changes, 4.0% worsened during sleep, and 24.0% had no aggravating factors. CONCLUSION: Airway obstruction was not reliably exacerbated during sleep for any of the diagnoses studied in this review. Our findings show that agitation exacerbates airway obstruction in most patients with vocal cord paralysis, and positioning exacerbates airway obstruction in the majority of patients with PRS. Aggravating factors in laryngomalacia are variable. These findings question the utility of polysomnography as a diagnostic tool for hospitalized neonates with these conditions. LEVEL OF EVIDENCE: 4.

Congenital and iatrogenic laryngeal and vocal abnormalities in patients with 22q11.2 deletion.

BACKGROUND: Voice abnormalities often go unrecognized in patients with 22q11.2 deletion because speech abnormalities become the focus of evaluation. OBJECTIVE: To analyze voice and vocal fold abnormalities in patients with 22q11.2 deletion by examining voice, not speech. METHODS: This is a case series with chart review from 2009 to 2016. Records of both a velocardiofacial syndrome (VCF) clinic and pediatric otolaryngology clinic at a tertiary pediatric hospital were reviewed. All patients with confirmed 22q11.2 deletion were identified. Cardiac, otolaryngological, speech, and voice characteristics were recorded along with surgical history. Main outcomes included voice characteristics based on speech therapy assessment, along with vocal fold or laryngeal abnormalities. Co-morbidities and surgical history were also recorded. RESULTS: 109 patients were identified with 22q11.2 deletion by genetic testing. Eighteen percent (n = 20) displayed a vocal fold or laryngeal abnormality, either congenital or iatrogenic. The most common congenital abnormalities were laryngeal web (n = 10) and subglottic stenosis (n = 7). The most common iatrogenic abnormality was paralyzed left vocal fold (n = 4). Perceptual analysis by speech therapy showed 65% (n = 71) with a voice within normal limits while 17% (n = 19) were not within normal limits. Of the 20 patients with a vocal fold abnormality, 15% (n = 3) presented a voice within normal limits, while 65% (n = 13) were not within normal limits. Of the 19 patients with a voice outside normal limits, 68% (n = 13) had a diagnosed vocal fold abnormality. Sixteen percent (n = 3) of these patients had an abnormal voice as a result of other issues. CONCLUSION: Out of 109 patients with 22q11.2 deletion, 18% displayed a laryngeal abnormality and 17% had abnormal vocal quality. This suggests that voice and vocal fold abnormalities are important to consider in this population. Distinguishing between speech and voice abnormalities in patients with 22q11.2 deletion can help ensure appropriate intervention.

Sleep and Speech Outcomes After Superior Adenoidectomy in Children with Cleft Palate.

Objective To describe the sleep and speech outcomes in patients with cleft palate who underwent superior adenoidectomy. Subjectives and methods This is a case series with chart review of patients with diagnoses of cleft palate and sleep disordered breathing (SDB), obstructive sleep apnea (OSA) or nasal obstruction treated with superior adenoidectomy from 1991-2015 at the Children's Hospital of Minnesota. Postoperative clinic notes documented the changes in symptoms following surgery. All speech outcomes were recorded. Results Fifty patients (23 females, 27 males) aged 11 months to 17 years were included. Forty-six patients (92%) had improvement of sleep symptoms including snoring, nighttime restlessness, and witnessed apnea events, following superior adenoidectomy. Forty-two of the 46 patients (91%) had stable speech postoperatively with either no development or no worsening of velopharyngeal insufficiency (VPI). Conclusion Superior adenoidectomy is an effective procedure to alleviate symptoms of sleep disordered breathing in patients with cleft palate without significantly affecting speech.

Assisted Reproduction is Not Associated with Increased Risk of Congenital Head and Neck Defects.

This abstract was presented at the American Academy of Otolaryngology-Head and Neck Surgery Annual Meeting, Orlando, FL, September 2014 with the abstract published (Neumann C, Thompson D, and Sidman J; Assisted reproduction is not associated with increased risk of head and neck defects; Otolaryngology-Head and Neck Surgery; Vol 151, Issue 1, supplement, 2014). Objectives - Compare the rate of head and neck anomalies between children conceived via artificial reproductive technology (ART) versus those conceived via natural methods. - Determine the risk of congenital head and neck abnormalities associated with ART. Study design A retrospective chart review cross-sectional study from 2004-2014 of all patients admitted to the neonatal intensive care unit (NICU) at a tertiary pediatric hospital. Results A total of 14,857 charts were examined; 2,288 patients were conceived via ART, while 12,569 patients were conceived via natural methods. There were 8,022 males and 6,637 females. There were 40 patients born with defects via ART, while there were 681 patients born with defects via natural conception. The total occurrence of congenital malformations was higher for patients conceived naturally versus those conceived with artificial reproduction (5.41% vs. 1.74%). The odds ratio was 0.31 with a 95% CI of 0.23 to 0.43 and a P-value of < 0.0001; the relative risk of having any one of the head and neck defects with ART was 1.04 with a 95% CI of 1.03 to 1.05 and a P-value < 0.0001. Conclusion There appears to be no increased risk of congenital head and neck defects in children conceived via ART versus those conceived naturally.

Neuroradiographic findings in 22q11.2 deletion syndrome.

22q11.2 deletion syndrome (22q11.2DS) is a common genetic disorder with enormous phenotypic heterogeneity. Despite the established prevalence of developmental and neuropsychiatric issues in this syndrome, its neuroanatomical correlates are not as well understood. A retrospective chart review was performed on 111 patients diagnosed with 22q11.2DS. Of the 111 patients, 24 with genetically confirmed 22q11.2 deletion and brain MRI or MRA were included in this study. The most common indications for imaging were unexplained developmental delay (6/24), seizures of unknown etiology (5/24), and unilateral weakness (3/24). More than half (13/24) of the patients had significant radiographic findings, including persistent cavum septi pellucidi and/or cavum vergae (8/24), aberrant cortical veins (6/24), polymicrogyria or cortical dysplasia (4/24), inner ear deformities (3/24), hypoplastic internal carotid artery (2/24), and hypoplastic cerebellum (1/24). These findings reveal the types and frequencies of brain malformations in this case series, and suggest that the prevalence of neuroanatomical abnormalities in 22q11.2DS may be underestimated. Understanding indications for imaging and frequently encountered brain malformations will result in early diagnosis and intervention in an effort to optimize patient outcomes.

Excision of sublingual gland as treatment for ranulas in pediatric patients.

OBJECTIVE: The aim of this case study is to demonstrate that post-operative complication rates of sublingual gland excision for treatment of ranulas are equal to or less than alternative methods with a lower recurrence rate than other surgical methods. METHODS: This was a retrospective review of pediatric patients from 2004 to 2015 at Children's Hospitals and Clinics of Minnesota. Sixteen ranulas and 6 plunging ranulas were treated via sublingual gland excision during this time frame. Data examined included age, gender, scans of the lesion, location and size of lesion, surgical procedures, complications, and recurrence. RESULTS: There were 22 patients who met criteria. Only one patient had recurrence of the lesion (4.5%). One patient reported lateral tongue numbness post-operatively, and one patient had a hypoglossal nerve injury, with tongue deviation upon exam. Both of these complications were temporary and resolved within months of the procedure. CONCLUSION: Although sublingual gland excision is a definitive treatment for ranulas, many surgeons still utilize other methods such as marsupialization, drainage of the cyst, or excision of ranula alone as the primary method of treatment due to concerns about complications. This retrospective study demonstrates that excision of the sublingual gland is both a safe and effective method of treatment for ranulas.

Early Airway Intervention for Craniofacial Anomalies.

This article reviews the presentation of children with craniofacial anomalies by the most common sites of airway obstruction. Major craniofacial anomalies may be categorized into those with midface hypoplasia, mandible hypoplasia, combined midface and mandible hypoplasia, and midline deformities. Algorithms of airway interventions are provided to guide the initial management of these complex patients.

Prevention and Treatment of Pain in Children: Toward a Paradigm Shift.

Rosenfeld et al in their recent article "Office Insertion of Tympanostomy Tubes without Anesthesia in Young Children" describe using a "papoose board for restraint" while performing a procedure resulting in severe pain for a significant number of children: a myringotomy and tube insertion. In 2016, it is inappropriate to perform elective painful procedures in children without treatment to avoid or minimize pain. We strongly disagree with the authors' conclusion "that office insertion of tubes in young children is a feasible alternative to general anesthesia for caregivers and clinicians who are comfortable with this choice."

Clefting of the Alveolus: Emphasizing the Distinction from Cleft Palate.

Oral clefting is one of the most common significant fetal abnormalities. Cleft lip and cleft palate have drastically different clinical ramifications and management from one another. A cleft of the alveolus (with or without cleft lip) can confuse the diagnostic picture and lead to a false assumption of cleft palate. The cleft alveolus should be viewed on the spectrum of cleft lip rather than be associated with cleft palate. This is made evident by understanding the embryological development of the midface and relevant terminology. Cleft alveolus carries significantly different clinical implications and treatment options than that of cleft palate. Accurately distinguishing cleft alveolus from cleft palate is crucial for appropriate discussions regarding the patient's care.

A Pediatric Decannulation Protocol: Outcomes of a 10-Year Experience.

OBJECTIVES: (1) Describe an institutional protocol that focuses on the essential steps for decannulation of pediatric patients with long-term tracheostomies. (2) Discuss the preliminary observations of the safety of this protocol in regard to decannulation failures and successes in a selected patient population. STUDY DESIGN: Case series with chart review. SETTING: A tertiary pediatric hospital. SUBJECTS: Subjects were pediatric patients with chronic tracheostomies undergoing decannulation. Ages ranged from 1 to 17 years old. Indications for initial tracheostomy included chronic lung disease, airway obstruction, and trauma. METHODS: Subjects underwent decannulation attempt following a specific protocol. The protocol consisted of operative laryngoscopy and bronchoscopy. If the airway was deemed adequate for decannulation at that time, the tracheotomy tube was removed, and the child was monitored overnight; the patient was considered for discharge the following day if no complications arose. No routine capping, downsizing, or polysomnography was performed. RESULTS: Thirty-five patients fit the criteria and were decannulated within 24 hours of endoscopy. Successful decannulation served as the primary outcome. Of the 35 decannulated patients, 54% (n = 19) were discharged the day following decannulation and another 37% (n = 13) on postdecannulation day 2. There were no acute failures or readmissions. Average inpatient stay for those decannulated was 1.8 days. CONCLUSION: This study describes the preliminary observations of a decannulation protocol in a small subset of patients. The protocol resulted in no acute failures and offers a conservative approach to resource utilization, making it unique when compared with other published protocols.

Use of External Distractors and the Role of Imaging Prior to Mandibular Distraction in Infants With Isolated Pierre Robin Sequence and Stickler Syndrome.

IMPORTANCE: Computed tomographic (CT) scans are often obtained before mandibular distraction osteogenesis in patients with isolated Pierre Robin sequence. There is concern regarding the risk of radiation exposure from CT in children. OBJECTIVE: To evaluate whether preoperative CT is necessary for adequate airway, feeding, and aesthetic outcomes following mandibular distraction with external distraction devices in infants with isolated Pierre Robin sequence. DESIGN, SETTING, AND PARTICIPANTS: In a retrospective review of medical records, infants who underwent mandibular distraction between January 1, 1998, and September 30, 2014, at 2 tertiary children's hospitals were identified using procedure codes. Data analysis was conducted December 1, 2014, to March 31, 2015. Fifty-two patients fit the inclusion criteria of isolated Pierre Robin sequence or Stickler syndrome, of being younger than 9 months at the time of distraction, and of use of external distractors. Forty-two of these infants did not receive preoperative CT imaging. EXPOSURE: Mandibular distraction osteogenesis for isolated Pierre Robin sequence or Stickler syndrome. MAIN OUTCOME MEASURES: Number of infants who were able to avoid tracheostomy or achieve decannulation, who were able to avoid placement or achieve removal of a gastrostomy tube, and in whom there were no intraoperative complications, no open-bite deformity, no malocclusion, no asymmetry, and no postoperative complications. RESULTS: In comparison with the 10 infants who underwent preoperative CT, all 42 of the infants (100%) who did not receive preoperative CT imaging successfully avoided tracheostomy or achieved decannulation (P = .04) and 40 patients (95%) did not require placement of a gastrostomy tube or were able to undergo gastrostomy tube removal postoperatively (P < .001). There were no significant differences between the CT and non-CT groups in the other 5 outcome measures. Two patients (5%) required postoperative gastrostomy tube placement, 2 patients (5%) had minor intraoperative complications that might have been anticipated with CT, 2 patients (5%) demonstrated malocclusion, and 1 infant (2%) had asymmetry at the end of the distraction phase. CONCLUSIONS AND RELEVANCE: This series suggests that the absence of preoperative CT does not compromise functional or aesthetic outcomes in mandibular distraction with external distraction devices in infants with isolated Pierre Robin sequence or Stickler syndrome. This finding has implications for cost containment and reduction of radiation exposure to a vulnerable population. LEVEL OF EVIDENCE: 4.

Patterns of Pediatric Mandible Fractures in the United States.

IMPORTANCE: The mandible is arguably the most frequently fractured facial bone in children. However, facial fractures are rare in children compared with adults, resulting in few large studies on patterns of pediatric facial fractures. OBJECTIVE: To report the patterns, demographics, and cause of pediatric mandible fractures across the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was conducted of the Healthcare Cost and Utilization Project's National Emergency Department Sample from January 1 to December 31, 2012, using the International Classification of Disease, Ninth Revision, codes for mandible fractures (802.20-802.39) among patients 18 years and younger who presented to emergency departments. Demographics, fracture site, and fracture mechanism were analyzed to identify factors associated with fractures. Analysis was conducted from July 9 to July 28, 2015. RESULTS: There were 1984 records, representing a weighted estimate of 8848 cases of pediatric mandible fracture. The mean patient age was 14.0 years (95% CI, 13.6-14.3). The male to female ratio was 4:1 and females were comparatively younger, with a mean age of 12.5 years (95% CI, 11.8-13.1; P < .001). The most frequently fractured sites were the condyle, in 1288 patients (14.6% [95% CI, 12.6%-16.5%]), and the angle, in 1252 patients (14.1% [12.4%-15.9%]). Associated intracranial injuries occurred in 756 patients (8.5% [7.1%-10.0%]), and cervical spine fractures occurred in 393 (4.4% [3.5%-5.4%]). The fracture site and mechanism of injury varied with age and sex. For patients 12 years and younger, the most frequent fracture site was the condyle, accounting for 636 fractures (27.9% [24.2%-31.6%]), and the most frequent cause was falls, accounting for 692 fractures (30.3% [25.9%-34.8%]). In teenaged patients (13-18 years), the angle was the most frequent fracture site, accounting for 1157 fractures (17.6% [15.6%-19.6%]), and the most frequent cause was assault, accounting for 2619 fractures (39.9% [36.4%-43.3%]). For male patients, the angle was the predominant site, accounting for 1053 fractures (15.0% [13.1%-16.8%]), and the leading cause was assault, accounting for 2360 fractures (33.5% [30.2%-36.9%]). For female patients, the condyle was the most frequent site, accounting for 369 fractures (20.3% [16.0%-24.6%]), and the leading cause was falls, accounting for 422 fractures (23.2% [18.6%-28.0%]). CONCLUSIONS AND RELEVANCE: In this study, age and sex disparities among pediatric mandible fractures were identified. Younger patients and female patients tend to have condyle fractures caused more commonly by falls while older patients and male patients tend to have angle fractures caused by assault. LEVEL OF EVIDENCE: NA.

Tramadol versus codeine/acetaminophen after pediatric tonsillectomy: A prospective, double-blinded, randomized controlled trial.

OBJECTIVE: Tonsillectomy is one of the most common pediatric surgical procedures performed in the United States. The postoperative period can be particularly painful, and there is currently no consensus on an optimal analgesic regimen. The objective of this study was to evaluate efficacy and safety of the single drug tramadol versus codeine/acetaminophen post-tonsillectomy. DESIGN: Prospective, double-blinded, randomized controlled trial. SETTING: Large, Midwestern US pediatric hospital. PATIENTS: Eighty-four children aged 4-15 years who underwent a tonsillectomy (with or without adenoidectomy) procedure were randomized and 74 were included in the analysis. INTERVENTIONS: Group 1 received liquid codeine/acetaminophen for 10 days post-tonsillectomy (5 days scheduled, followed by 5 days as-needed). Group 2 received liquid tramadol for 10 days post-tonsillectomy (5 days scheduled, followed by 5 days as-needed). MAIN OUTCOME MEASURES: Efficacy and side effects were evaluated using a 10-day take-home diary that was completed by parents. RESULTS: Children in both study arms reported adequate post-tonsillectomy pain management without significant differences between groups in pain scores. Oversedation was significantly higher on the day of surgery in the codeine/acetaminophen group, and itching was experienced by significantly more children in the tramadol group during the postoperative period. CONCLUSIONS: As part of multimodal analgesia, scheduled plus as-needed tramadol may be considered for children in the postoperative setting due to its analgesic properties, low potential for side effects, and good safety profile.

Bone conduction noise exposure via ventilators in the neonatal intensive care unit.

OBJECTIVES/HYPOTHESIS: To demonstrate that neonatal ventilators can expose patients to high noise levels through bone conduction (BC) as well as air conduction (AC). STUDY DESIGN: Observational study. METHODS: Three ventilators and various settings on a positive airway pressure machine (continuous, high bilevel, and low bilevel pressure) were tested. A sound level meter was used to measure the noise levels at a set distance from the ventilator to represent AC, on the ventilator circuit to represent BC at the alveolus, and within the ventilator circuit. RESULTS: The BC sound levels (74.1, 81.1, 86, 89.2 dBC) were significantly higher than the AC sound levels (72.8, 72.9, 70, 71.7 dBC) for the jet ventilator, continuous positive airway pressure setting, low bilevel setting, and high bilevel setting, respectively (P < .001). The sound level within the ventilator circuit ranged from 94.9 to 113.2 dBC depending on the machine/setting and was significantly louder than both AC or BC for all machines/settings (P < .001). CONCLUSIONS: There are concerning ventilator dependent noise levels present on and within ventilation circuitry that could be presented to the infant via BC. LEVEL OF EVIDENCE: NA

Dynamic facial reanimation with orthodromic temporalis tendon transfer in children.

IMPORTANCE: To our knowledge, orthodromic temporalis tendon transfer (OTTT) for dynamic facial reanimation has not been described for use in children. OBSERVATIONS: Three pediatric patients with permanent facial paralysis underwent OTTT using our modified technique between August 30, 2010, and January 23, 2012. Outcomes were assessed by the surgeons, patients, and patient families, with the longest follow-up period being 13 months after surgery. Two patients were 4 years old at the time of surgery, and the third patient was 17 years old. All underwent upper eyelid gold weight placement and OTTT. The hospital length of stay was 1 to 2 nights. By the first postoperative visit, all patients exhibited improved symmetry at rest, creation of a melolabial crease, and voluntary movement of the oral commissure and smile production without physical therapy. CONCLUSIONS AND RELEVANCE: The OTTT for dynamic facial reanimation in children seems to be safe and effective. To our knowledge, this is the first report of the use of this procedure in pediatric patients. This procedure has an advantage over free muscle transfer procedures in achieving immediate dynamic reanimation in a single-stage surgical procedure, without significant additional donor site morbidity. This is an important procedure in our armamentarium for treating pediatric facial paralysis.

Hearing outcomes in children with cleft palate and referred newborn hearing screen.

OBJECTIVES/HYPOTHESIS: To determine the prevalence of long-term hearing loss in patients with cleft palate who fail their universal newborn hearing screen. STUDY DESIGN: The study is a retrospective chart review from a tertiary pediatric center and tertiary children's hospital. METHODS: Newborns with cleft palate born between January 2002 and July 2012 were identified from a pediatric otolaryngology practice database. This cohort was then reduced to include only those patients who referred their universal newborn hearing screen. Postpressure equalization tube audiology results, follow-up audiology results, type of cleft, and comorbid conditions were collected for each patient who was both born with a cleft palate and referred their universal newborn hearing screen. RESULTS: A total of 317 newborns presented to the pediatric otolaryngology practice for cleft palate, with 89 (28%) having documented referred universal newborn hearing screen. At the time of data collection, 67 (75%) of 89 had normal hearing results, whereas 22 (25%) of 89 did not yet have normal hearing results. Fourteen patients had permanent hearing loss, and all 14 had a comorbid condition. Type of cleft and presence of a comorbid condition were correlated to hearing outcomes. CONCLUSIONS: Newborns with cleft palate who refer their universal newborn hearing screen could postpone diagnostic hearing testing until after placement of pressure equalization tubes, unless there is a clue to permanent hearing loss such as a comorbid condition.

Prenatal consultation with the pediatric otolaryngologist.

OBJECTIVES: To examine the spectrum of fetal head and neck anomalies that may prompt prenatal referral and to determine the frequency of these consultations. STUDY DESIGN: Case series with chart review. METHODS: The billing databases of two urban pediatric otolaryngology practices were queried for ICD-9 codes corresponding to fetal anomalies between January 2010 and December 2012. The pediatric otolaryngology practices in this study evaluate all fetal head and neck anomalies referred to their respective institutions, including craniofacial disorders. RESULTS: Over a three-year period, 53 women presented for fetal otolaryngology consultation, with each practice seeing approximately one consultation every 6 weeks (every 5 weeks (JDS) and every 7 weeks (ARS)). The average maternal and gestational age at presentation were 28.7 years and 27.2 weeks, respectively. 83% of the cases (n = 44) involved some form of cleft lip with or without cleft palate. Other head and neck anomalies included fetal goiter/other congenital neck mass (9% (n = 5)) and micrognathia (6% (n = 3)). Macroglossia (n = 1) and facial cleft (n = 1) each accounted for 2% of cases. Cleft mothers presented earlier in pregnancy (average 26.8 weeks) than those with a neck mass (average 32.3 weeks) (p < 0.05). Only 3 cases (6%) merited ex utero intrapartum treatment. CONCLUSIONS: Depending on the referral practices at a given medical center, craniofacial surgeons rather than pediatric otolaryngologists may be evaluating the majority of fetal head and neck anomalies, as orofacial clefts account for most prenatal consultations. The wide spectrum of congenital neck masses may or may not demand monitoring of the airway during the peripartum period.