bluuebunny/crossref_metadata_2025 huggingface dataset:
Middle Cranial Fossa Dehiscence as an Incidental Finding on CT
Authors: Valika Taher , Redleaf Miriam
Published: September 2014

Objectives:

Determine the prevalence of middle cranial fossa (MCF) dehiscence on computed tomography (CT) scans and establish its increase with age.

Methods:

All high‐resolution temporal bone CT scans completed at a tertiary care center from 2011 to 2013, ordered by 1 otologist for any reason, were reviewed. Scans showing soft tissue, fluid, trauma, or previous operations were excluded. A total of 183 patients (296 ears) were reviewed blinded for age. The MCF floor was divided into 7 regions and systematically inspected. Ages of the patients were subsequently extracted from the medical record.

Results:

Logistic regression analysis confirmed increasing MCF dehiscence with age (P <. 05, odds ratio [OR] 1.07, R = 0.584). Overall ages (1‐88 years; average 38.5 years), 32% of MCF floors were dehiscent at any one site. For age 60 years and over, 55% were dehiscent. For 226 paired ears, if one ear was dehiscent, there was a 66% chance the other ear was dehiscent as well. Superior canal dehiscence (SCD) was seen in 7% of all patients, and only in combination with MCF dehiscence. SCD occurred in 16% of dehiscent ears. The most common sites were directly above the malleus head and above the additus ad antrum (36% and 28%, respectively).

Conclusions:

The incidence of MCF dehiscence increases with age. Over all ages, approximately 32% of ears show dehiscence. Over 60 years, approximately 55% show dehiscence. The increase of dehiscence with age is statistically significant. The most common sites along the MCF floor are in the epitympanum over the malleus head and additus ad antrum.
Minimally Invasive Surgery for Osteointegrated Auditory Implants: A Comparison of Linear vs Punch Techniques
Authors: Coelho Daniel H. , Gordon Steven A.
Published: September 2014

Objectives:

(1) Describe the benefits of the minimally invasive Punch Method without soft tissue reduction (PM) for the placement of percutaneous osteointegrated auditory implants. (2) Compare and contrast techniques and outcomes from PM with the Linear Method with soft tissue reduction (LM).

Methods:

A retrospective chart review was conducted of all patients who received a percutaneous bone‐anchored auditory implant from 2009 to 2013 at a tertiary otology practice by a single surgeon. LM was used until 2011 when a switch was made for all patients to PM. Preoperative variables recorded included age, sex, body mass index (BMI), smoking status, indication, and device selected. Outcomes measures included surgical time, skin reaction grading by Holgers score at 1 week and at most recent follow‐up, and any other complications. Two‐sample t test was used to compare.

Results:

Fifty‐one patients (34 LM, 17 PM) were identified with an average follow‐up of 16.9 months (22.3 LM, 5.8 PM). Average surgical time was found to be significantly shorter for the PM group (10.2 minutes vs 48.8 minutes, P <. 01). There were no statistically significant differences between LM and PM for mean Holgers score at first (LM 0.24, PM 0.47 P =. 87) or most recent follow‐up (LM 0.62, PM 0.41, P =. 22). Additionally, there were no significant correlations with age, sex, BMI, smoking status, indication, or device selected.

Conclusions:

The Punch Method offers several potential surgical and cosmetic advantages over the Linear Method, without compromising skin‐reactivity outcomes. This study supports a growing trend towards minimally invasive percutaneous auditory implant surgery.
Dismal Economics: Robot‐Assisted Surgeries in Otolaryngology
Authors: McKinnon Brian J. , Cantwell Laureen
Published: September 2014

Objectives:

Determine the current cost impact and financial outcomes of robot‐assisted surgery in otolaryngology.

Methods:

A systematic review of the literature with a defined search strategy. Using keywords robotic or robot, ENT or otolaryngology, cost or economic, transoral robotic surgery or TORS, and thyroidectomy or parathyroidectomy, searches were performed on PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar, and reviewed by the authors for inclusion in the study.

Results:

A total of 4 papers were identified as being appropriate for analysis. Two addressed cost impact and financial outcome of robotic thyroidectomy, 1 the cost impact and financial outcome of transoral robotic surgery, and a fourth included otolaryngology robotic surgeries in the profitability analysis of robotic surgery but did not specify case or procedure types. Analyses found robotic thyroidectomy cost prohibitive, though transoral robotic surgery was financially sustainable, as overall costs of care are decreased from reduced length of stay.

Conclusions:

There are diverging cost impact and economic outcomes being reported in robot‐assisted surgery in otolaryngology. These trends should inform our decisions as to where robotic surgery should be focused to garner greatest cost and economic benefit.
A Novel High‐Throughput Ototoxicity Assay in Zebrafish: Platform for Drug Development Targeting Hearing Loss
Authors: Platto Terry , Hurbon Audriana , Igarashi Suzu , Meister Edward , Dunn Allison , Jacob Abraham
Published: September 2014

Objectives:

Develop a functional assay of zebrafish (Danio rerio) swimming behavior correlated with anatomic studies of hair cells along the lateral line as a platform for high‐throughput drug development against hearing loss.

Methods:

In vivo animal study at university animal care facilities. Five‐day postfertilization (dpf) zebrafish were treated with 0 (control)‐1000 µM concentrations of cisplatin. In darkness, swimming behavior was analyzed using infrared video systems housed within a novel, multilane, high throughput apparatus to calculate the rheotaxis index (RI). The RI, which represents the ability of fish to properly orient relative to water current, allowed direct comparison of various cisplatin doses to controls simultaneously. Hair cells of zebrafish exposed to cisplatin were also stained with Yo‐Pro1 and imaged using confocal microscopy in order to correlate anatomic changes with changes in swimming behavior.

Results:

A dose‐dependent relationship between cisplatin concentration and RI was found. 0 µM (control): RI 39.85%; 250 µM: RI 38.11%; 500 µM: RI 25.12%; 750 µM: RI 22.97%; 1000 µM: RI 17.84%. The decline in rheotaxis performance correlated directly with increasing dosage of cisplatin.

Conclusions:

There are currently no Food and Drug Administration–approved pharmacological treatments for hearing loss. Using a validated behavioral assay to test ototoxic dose of cisplatin against varying concentrations of potentially otoprotective/otoregenerative compounds establishes a first‐ever, high‐throughput biologic platform for drug development against hearing loss.
Ossicular Erosion and Air‐Bone Gap in Attic and Tensa Cholesteatomas
Authors: da Costa Sady S. , Rosito Leticia S. , Canali Inesangela , Selaimen Fábio André , Jung Yuri P. , Pauletti Marcos G. T. , Freitas Luiza A.
Published: September 2014

Objectives:

(1) Compare the air‐bone gap between patients with posterior epitympanic (attic) and posterior mesotympanic (tensa) cholesteatomas. (2) Correlate the air‐bone gap and intraoperative ossicular chain findings.

Methods:

Cross‐sectional study. In total, 262 patients with attic and tensa cholesteatomas treated at a tertiary hospital were included. Audiometry was performed, and the pure tone average air‐bone gap (PTA‐ABG) was compared between the 2 groups. In addition, ossicles were classified as normal, eroded, or absent based on intraoperative evaluation. Data were compared using the Mann‐Whitney and Chi‐square tests, and statistical analysis was performed using SPSS.

Results:

Attic cholesteatoma was diagnosed in 51.1% of patients and tensa cholesteatoma in 48.9%. The mean patient age was 33 ± 18.7 years, and 52.3% were male patients. The PTA‐ABG was higher in tensa cholesteatoma cases than in attic cholesteatoma (30.25 ± 12.82 dB and 26.73 ± 13.08 dB, respectively, P =. 031). There were no differences in the malleus erosion or absence prevalence and the stapes suprastructure prevalence (P =. 09 and P =. 17, respectively). The incus was normal in 17.6% of the attic and 6.3% of tensa cholesteatoma cases; eroded in 79.4% of tensa and 48.6% of attic cases; and absent in 33.8% of attic and 14.3% of tensa cholesteatoma cases (P <. 01).

Conclusions:

The PTA‐ABG was higher in tensa cholesteatoma cases and correlated with a lower normal incus prevalence and a higher eroded incus prevalence compared to attic cholesteatoma cases.
Preoperative Systemic Antimicrobial Prophylaxis in Contaminated Middle Ear Surgery for Cholesteatoma
Authors: Pierce Nathan , Antonelli Patrick J.
Published: September 2014

Objectives:

Evaluate the efficacy of combined anti‐staphylococcal and anti‐pseudomonal preoperative antibiotics for preventing surgical site infections following tympanoplasty and mastoidectomy (TM) with contaminated cholesteatoma.

Methods:

Study Design: Retrospective chart review Method: Medical records of patients who underwent TM for cholesteatoma were reviewed. Only cases considered to have contaminated or dirty/infected surgical fields were included. Patients were excluded if there was preexisting infection or intraoperative finding requiring systemic antibiotic therapy. The primary outcome measure was postoperative perichondritis, pinna abscess, peri‐otic cellulitis, and peri‐otic abscess requiring systemic antibiotics or surgical intervention.

Results:

The charts of 362 patients who underwent TM were reviewed. 195 met inclusion criteria. Preoperative antibiotics included clindamycin and ceftazidime or gentamicin. Patients treated with no perioperative antibiotics had an infection rate of 11% and those treated with perioperative antibiotics had a rate of 1% (P =. 02).

Conclusions:

The use of preoperative antibiotics to cover staphylococcal and pseudomonal species prevented surgical site infections as compared to no perioperative antibiotics.
Protocol for Auditory Brainstem Implants in Children
Authors: Colletti Giacomo , Shannon Robert V. , Mandala Marco , Colletti Liliana , Colletti Vittorio
Published: September 2014

Objectives:

Auditory brainstem implants (ABIs) have been implanted in 64 children with no permanent major complications. We detail the protocol for ABI patient selection, ABI surgery and intra‐operative monitoring, and device fitting and rehabilitation with children.

Methods:

Sixty‐four children received the ABI between 2000 and 2013. The follow‐up ranged from 6 months to 8 years. A protocol is presented for acoustic and electrophysiological assessment of ABI candidacy. A retrosigmoid‐transmeatal approach was used in the Neurofibromatosis type 2 (NF2) and a retrosigmoid approach in the nontumor children. Tests for assessing auditory and cognitive development and rehabilitation are recommended.

Results:

All children, except NF2 subjects, scored 0 before ABI implantation on all tests, even the 31 children previously fitted with a cochlear implant. Perceptual outcomes showed statistically significant improvements over time. At the last follow‐up no significant postoperative complications were observed.

Conclusions:

ABIs have been shown to be beneficial for children who cannot use a cochlear implant. However, implanting an ABI in a child requires special care and expertise and should only be undertaken by an experienced pediatric implant team. This paper presents a comprehensive protocol for application of ABIs in children.
Safety of Topical Mitomycin C after Keloid Excision: A Pilot Study
Authors: Teti Virginia P. , Liu Michelle F. , Lim Alan A. , Cilento Benjamin W. , Gallagher Thomas Q.
Published: September 2014

Objectives:

(1) Ascertain the safety of topical mitomycin C in the prevention of recurrent keloid scars after surgical excision. (2) Determine the efficacy of mitomycin C in keloid prevention.

Methods:

This was a prospective pilot study of 10 patients. Between August 2009 and September 2011, subjects underwent surgical excision of keloids located in the head and neck region with a one‐time, intraoperative, topical application of mitomycin C. Patients were followed for 12 months postoperatively. During this period, laboratory values reflecting complete metabolic profile and coagulation studies were drawn preoperatively and postoperatively (at 2 weeks and the first, second, and third months). Additionally, photo‐documentation was obtained at regular intervals to ascertain the efficacy in prevention of keloid recurrence.

Results:

Twelve patients enrolled in the study. Nine patients completed the protocol. Three patients dis‐enrolled prior to surgical excision. No patients were lost to follow‐up. Analysis of variance performed demonstrating no statistical significance in the variance of the laboratory values. Additionally, no patient demonstrated abnormality of any laboratory value beyond the reference range. Next, clinical examination of the wounds demonstrated no evidence of necrosis or dehiscence. Finally, no wound demonstrated recurrence at the one‐year follow‐up visit.

Conclusions:

Mitomycin C appears safe for topical use after excision of keloids in the head and neck region. This study demonstrates no evidence of recurrence in all patients enrolled and followed for one year.
Radiosurgical Trends for Treatment of Vestibular Schwannomas in the United States
Authors: Maducdoc Marlon M. , Ghavami Yaser , Linskey Mark E. , Djalilian Hamid R.
Published: September 2014

Objectives:

(1) Analyze the recent trends in radiosurgery for vestibular schwannomas (VS). (2) Determine the number of VS treated with radiosurgery since 1990 in the United States.

Methods:

Large databases were obtained by contacting the manufacturers of the 2 main radiosurgical machines used to treat VS in the United States. Analysis of de‐identified data from Leksell Gamma Knife reporting was carried out to investigate the treatment trends for VS. The main variable investigated was the number of VS treated by radiosurgery in the United States. Extrapolations were made to the available data to estimate the trends of radiosurgical treatment.

Results:

The number of VS treated by radiosurgery has been increasing. In the US, radiosurgery for treatment of VS was approximately 150 to 200 per year from 1991 to 1993. However, VS cases treated by radiosurgery were approximately 1520 and 1490 in 2011 and 2012, respectively. This indicates an approximate average annual rate of increase of about 4.7% (SD: 8.6%). Currently, treatment of VS accounts for 8.4% of all head and neck radiosurgical procedures in the United States. Since 1991, the approximate number of patients undergoing radiosurgery for VS is 16,000 in the United States and 70,000 worldwide.

Conclusions:

The current study shows a possible changing trend in the management of VS. Our findings support the conclusion of other studies that suggest a growing number of patients are opting to receive radiosurgical treatment. Additionally, the data highlights the growing population of VS treated with radiosurgery.
Stem Cells within PGAt Observed In Vivo after 6 Weeks Enhance Facial Nerve Regeneration
Authors: Costa Heloisa J. Z. R. , Bento Ricardo F. , Salomone Raquel , Azzi‐Nogueira Deborah , Costa Máarcio P. , Haddad Luciana A.
Published: September 2014

Objectives:

Autografting, the gold‐standard method for facial nerve repair with tissue loss, in association with high quality scaffolds and cell implants, has disclosed distinct experimental outcomes. The aim of the study was to evaluate the functional and histological effects of bone marrow stem cells (BMSC) combined with polyglycolic acid tube (PGAt) in autografted rat facial nerves.

Methods:

After neurotmesis of the mandibular branch of the rat facial nerve, surgical repair consisted of nerve autografting (groups A‐E), contained in PGAt (groups B‐E), filled with basement membrane matrix (groups C‐E), with undifferentiated BMSC (group D) or Schwann‐like cells that had differentiated from BMSC (group E). Axon morphometrics and an objective compound muscle action potentials (CMAP) analysis were conducted. Immunofluorescence assays were carried out with Schwann cell marker S100 and anti‐B‐galactosidase to label exogenous cells.

Results:

Six weeks after surgery, animals from either cell‐containing group had mean CMAP amplitudes significantly higher than control groups. Differently from other groups, facial nerves with Schwann‐like cells implants had mean axonal densities within reference values. This same group had the highest mean axonal diameter in distal segments. We observed expression of the reporter gene LacZ in nerve cells in the graft and distally from it in groups D and E. Group E cells had LacZ coexpressed with S100.

Conclusions:

Regeneration of the facial nerve was improved by BMSC within PGAt in rats, yet Schwann‐like cells were associated with superior effects. Accordingly, groups D and E had BMSC integrated in neural tissue with maintenance of former cell phenotype for 6 weeks.
Subtotal Resection for Management of Large Jugular Paragangliomas with Intact Lower Cranial Nerves
Authors: Wanna George B. , Sweeney Alex D. , Carlson Matthew L. , Latuska Richard F. , Rivas Alejandro , Bennett Marc L. , Haynes David S.
Published: September 2014

Objectives:

(1) Evaluate the use of subtotal resection as the primary treatment modality for large jugular paragangliomas in patients with intact lower cranial nerves. (2) Evaluate functional outcomes and tumor control following subtotal resection. (3) Identify the utility of salvage radiotherapy for residual progressive disease.

Methods:

Retrospective series from a tertiary academic referral center evaluating patients who presented with advanced (Glasscock‐Jackson grade 3 to 4) jugular paragangliomas (JP) and normal lower cranial nerve function. Primary outcome measures included extent of resection, long‐term tumor control, need for additional treatment, and postoperative lower cranial nerve function.

Results:

Fourteen patients seen between 1999 and 2013 (mean age 48.6 years; range, 26‐70) met inclusion criteria. The average maximum preoperative tumor dimension was 3.1 cm. The mean postoperative residual tumor volume was 29.3% (range, 3.5%‐58.4%). When the residual tumor volume was less than 20% of the preoperative volume, no tumor growth occurred through an average of 35.4 months of follow‐up (P <. 01). Four tumors (28.6%) demonstrated serial growth at an average of 22.5 months following resection, 3 of which were treated with salvage stereotactic radiotherapy providing durable control at an average of 12 months of follow‐up. No patient experienced permanent postoperative lower cranial neuropathy.

Conclusions:

Subtotal resection of JP with preservation of the lower cranial nerves is a viable management strategy. If >80% of the preoperative tumor volume is resected, the residual tumor is less likely to grow. Radiotherapy offers effective treatment for recurrent tumor following subtotal resection.
Total Ossiculoplasty Outcomes with and without a Stapes Footplate Prosthesis
Authors: Cox Matthew D. , Dornhoffer John L.
Published: September 2014

Objectives:

Compare audiologic outcomes of total ossicular replacement prosthesis (TORP) ossiculoplasty performed with and without the placement of a stapes footplate prosthesis (FPP).

Methods:

A retrospective chart review was performed to identify adult patients undergoing TORP ossiculoplasty by the same surgeon at a tertiary care center between 1998 and 2012. Indications for surgery included cholesteatoma, atelectasis/perforation, chronic otitis media, and glomus tumor. Patients with a history of stapes surgery on the ear of interest were excluded from the study.

Results:

A lower rate of prosthesis displacement and statistically better audiologic outcomes were seen in FPP patients. The pure‐tone average air‐bone gap (PTA‐ABG) was closed to <20 dB in 69.8% (37/53) of patients in the study arm and 44.4% (48/108) of patients in the control arm (P <. 001). The PTA‐ABG was decreased by an average of 19.3 dB ± 11.7 dB (standard deviation, SD) and 12.6 dB ± 11.0 dB (SD) in the study and control groups, respectively (P =. 0014).

Conclusions:

Use of the titanium stapes FPP during TORP ossiculoplasty was associated with a statistically significant advantage in short‐term PTA‐ABG closure and a higher rate of successful rehabilitation of conductive hearing loss in this study. A lower rate of prosthesis displacement was seen in the FPP group, but further studies and longer follow‐up periods are needed to validate this observation.
Translabyrinthine Tumor Removal with Concurrent Bone‐Anchored Hearing Aid Placement
Authors: McRackan Theodore R. , Wilkinson Eric P. , Slattery William H. , Brackmann Derald E. , Goddard John C.
Published: September 2014

Objectives:

(1) Describe the safety profile of performing translabyrinthine tumor removal and bone‐anchored hearing aid placement during the same surgical procedure. (2) Describe the overall patient satisfaction of those individuals who underwent the above procedure.

Methods:

Retrospective review from a tertiary neurotologic referral center of 154 patients who underwent concurrent translabyrinthine tumor resection and bone‐anchored hearing device placement between 2004 and 2012. Patient records were reviewed to identify postoperative complication rates and bone‐anchored hearing device usage. A Fisher's exact test was used to compare the qualitative variables and Student t test was used for the quantitative comparison.

Results:

One hundred twenty‐one (78.6%) of 154 patients undergoing concurrent translabyrinthine tumor removal and bone‐anchored hearing device placement had no device‐related complications. The most common device‐related complications were skin overgrowth (8.4%), acute infection (5.2%), and chronic infection (3.2%). The overall and specific complication rates did not statistically differ from published bone‐anchored device complication rates (all P <. 05). One patient (0.7%) developed a cerebrospinal fluid leak at the placement site of the bone‐anchored device. Of the 145 patients with at least 1‐year follow‐up, 137 (95.5%) were still regularly using their bone‐anchored hearing devices.

Conclusions:

Patients undergoing concurrent translabyrinthine tumor removal and bone‐anchored hearing device placement exhibit similar device‐related complication profiles as patients undergoing standard device placement. Based on these outcomes and the high long‐term usage rates, translabyrinthine intracranial surgery and bone‐anchored hearing device insertion can be considered a useful and safe procedure.
Vestibular Testing Data in Migraine‐Associated Vertigo
Authors: Kahmke Russel R. , Keeler Jarrod A. , Garrison Douglas , Piker Erin G. , Tucci Debara L. , Adkins Heather D. , Kaylie David
Published: September 2014

Objectives:

(1) Describe data on comprehensive vestibular testing in migraine‐associated vertigo patients. (2) Delineate specific findings in vestibular testing that can assist in the diagnosis and treatment of migraine‐associated vertigo.

Methods:

A retrospective case review of individuals diagnosed with migraine‐associated vertigo after evaluation by an otologist, a neurologist, and who had vestibular testing between January 1, 2010, and June 31, 2012, at a tertiary referral center. Videonystagmography (VNG), sinusoidal harmonic acceleration (SHA) testing, and cervical vestibular evoked myogenic potential (cVEMP) testing were analyzed.

Results:

Eighty‐three patients met inclusion criteria; 63 had a diagnosis of primary migraine‐associated vertigo. An additional 20 patients had a secondary diagnosis including Ménières disease, intracranial hypertension, and a history of cranial surgery (secondary migraine‐associated vertigo). The average patient was 49 years old, with 82% being female. There was no statistically significant difference between the 2 groups. Overall, 30% of migraine‐associated vertigo patients had abnormal caloric testing with a 60% average unilateral weakness. The unilateral weakness was to the right 77% of the time. When VNG, SHA, and cVEMP testing were combined, 24 patients (29%) had an identifiable vestibular weakness; 75% had a peripheral source and 25% had central vestibular findings. A total of 50% of patients with a peripheral weakness were fully compensated, 33% were partially compensated, and 17% were poorly compensated.

Conclusions:

In patients with primary and secondary migraine‐associated vertigo, approximately two‐thirds of patients were found to have normal vestibular testing. When there was an identifiable vestibular weakness, 75% were peripheral with only 50% fully compensated.
Caregiver‐Reported Outcomes and Indirect Costs of Pediatric Tonsillectomy
Authors: Van Buren Nicholas C. , Curtis Jonathan , Narasimhan Evan , Harvey D. Brandon , Meier Jeremy D.
Published: September 2014

Objectives:

(1) Obtain caregiver reported outcomes including number of missed work days (caregivers) and school (child) after tonsillectomy or adenotonsillectomy (T&A). (2) Quantify the indirect costs associated with caring for a child after T&A.

Methods:

A telephone survey was conducted of caregivers of children from a pediatric otolaryngology clinic who underwent T&A from October 2013 to January 2014. Caregivers were surveyed 2 to 5 weeks after surgery. Information obtained included number of postoperative days the child had symptoms, number of missed school and work days, and caregivers out of pockets costs for medical expenses, child care, and work absence.

Results:

Surveys were attempted with caregivers of 141 pediatric patients and 53 completed surveys were obtained, for a response rate of 37.6%. Mean patient age was 6.1 ± 3.9 years. Patient symptoms persisted for a mean of 10.8 ± 4.4 days after surgery. On average, patients returned to normal activity at 10.1 ± 4.8 days and normal diet at 11.3 ± 5.7 days. The average school absence was 10.0 ± 6.6 days. A total of 38 of 53 (71.7%) caregivers required time off work with a mean work absence of 4.9 ± 3.9 days. The mean income loss (for those missing work) per T&A was $626 ± 444. The combined income loss for the caregivers was $21,922.

Conclusions:

Indirect costs of pediatric T&A are significant due to missed school and loss of income from employment absence. The caregiver reported outcomes and indirect costs measured in this survey could be used in future studies to compare the effectiveness of different tonsillectomy techniques or postoperative pain management protocols.
Causes and Costs for ED Visits after Pediatric Adenotonsillectomy
Authors: Curtis Jonathan , Harvey D. Brandon , Narasimhan Evan , Jacob Joseph R. , Van Buren Nicholas C. , Meier Jeremy D.
Published: September 2014

Objectives:

(1) Review the reasons, timing, management, and costs for children presenting to the emergency department (ED) after tonsillectomy or adenotonsillectomy (T&A).

Methods:

A standardized activity‐based hospital accounting system was used to create an observational cohort of children from an academic pediatric otolaryngology practice who presented to the ED after T&A from 2011 to 2012. The reason for presentation, number of days after surgery, and facility costs for each visit were recorded.

Results:

The study cohort included 176 patients. Five of the patients had visits unrelated to the operation. Of the remaining patients, 21% presented for post‐tonsillectomy hemorrhage, 54% for dehydration, 13% for poorly controlled pain, and 12% for other miscellaneous reasons. The mean postoperative day at the time of ED presentation was 3.7 ± 3.4 days. The mean hospital facility cost when the patient was discharged from the ED was $153 per visit. This increased to $1,634 per encounter when the patient was admitted or observed overnight, and the cost per return to the OR for bleeding was $1,392 per episode.

Conclusions:

A relatively significant portion of children present to the ED after T&A for dehydration, poorly controlled pain, or hemorrhage. The costs from these visits are not insignificant. Developing strategies to reduce these visits may improve outcomes and reduce costs.
Difficult Pediatric Airway Management: A Randomized Trial Comparing Laryngeal Mask Airway, Video‐Assisted, and Direct Laryngoscopy
Authors: Ambrosio Art A. , Perez Colleen , Byrnes Chelsie , Gaconnet Cory , Cornelissen Christopher , Brigger Matthew T.
Published: September 2014

Objectives:

Compare advanced airway placement (1) success rate and (2) time taken between direct laryngoscopy, video‐assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult infant airway simulator.

Methods:

Prospective, randomized trial in an cademic, tertiary medical center. Twenty‐two pediatric residents, interns, and medical students were tested between November 2013 and January 2014. Participants were provided a single training session by faculty from the subspecialties of pediatric otolaryngology, pediatric critical care medicine, and pediatric anesthesiology using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of Pierre‐Robin sequence including features of micrognathia, glossoptosis, and cleft palate. Success was defined as a confirmed endotracheal intubation or correct LMA placement by the testing instructor in 120 seconds or less.

Results:

Direct laryngoscopy demonstrated significantly higher placement success rate (77.3%) than video‐assisted laryngoscopy (36.4%, P =. 0117) and LMA (31.8%, P =. 0039). Video‐assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds, 95% confidence interval [CI] 59.4, 110.1), when compared with direct laryngoscopy (44.9 seconds, 95% CI 33.8, 55.9) and LMA placement (36.6 seconds, 95% CI 24.7, 48.4).

Conclusions:

Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway model of Pierre‐Robin. Video‐assisted laryngoscopy users took significantly more time to establish a successful advanced airway. Given the potential life‐saving implications of advanced airway adjuncts including video laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for in this population.
A Step‐Ladder Protocol to Treat Cervico‐facial Venous Malformations
Authors: Colletti Giacomo , Mandala Marco , Frigerio Alice , Moneghini Laura , Melchiorre Fabio , Grimmer Fredrik J.
Published: September 2014

Objectives:

Venous malformations (VMs) are the most commonly encountered vascular malformation of the cervico‐facial region. Their clinical spectrum is extremely variable as they can present as single small lesions (often confined within muscle fasciae) or huge infiltrating ones. They can be part of a syndrome, as with Bean Syndrome, or in cutaneous mucosal venous malformation syndrome, among others. The aims of the study were: (1) Diagnose and stage a cervico‐facial VM. (2) Describe the available treatment for head and neck VMs. (3) Propose the most appropriate treatment based on the staging of the VM.

Methods:

A review of the pertinent literature was performed to provide the common indications and techniques to treat head and neck VMs. Thirty‐four consecutive cases of VMs have been treated by the authors by means of endovascular sclerotherapy with sodium tetradecyl sulphate, surgery, or both. Only patients with intraosseous VMs (8 total) were treated by surgery alone. Three large, unresectable cervicofacial VMs were treated by means of the “strangling technique.”

Results:

Good to very good aesthetic and functional results were obtained in all 34 patients. All 26 patients who underwent sclerotherapy experienced significant swelling. Six cases of skin or mucosal ulcerations were noted. No damage to the facial nerve was observed. Five patients affected by larger VMs showed partial recanalization/recurrence of the malformation.

Conclusions:

Cervicofacial VMs have to be managed by an experienced, multidisciplinary team. A protocol with increasing invasiveness is proposed to maximize results after their treatment.
Ethnic Disparities among Pediatric Tonsillectomy Patients
Authors: Johnson Romaine F. , Mitchell Ron B. , Chang Andrew
Published: September 2014

Objectives:

Study ethnic disparities in rates of complications in inpatient pediatric tonsillectomy patients.

Methods:

Study Design: Retrospective cohort study. Setting: USA pediatric discharge samples from 2003, 2006, and 2009 calendar years. Method: This study examined inpatient admissions for pediatric tonsillectomy in 2003, 2006, and 2009 using the Kids’ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Outcomes were analyzed for racial disparities. Pearson chi‐squared was used to analyze categorical data and linear regression for continuous variables. Logistical regression and multivariate linear regression models were created to assess for confounding and to create odds ratios.

Results:

The estimated population of inpatient pediatric patients who underwent tonsillectomy was 82,222. Forty‐two percent were female. The ethnic breakdown was: 52% white, 20% black, 19% Hispanic, 2% Asian, 6% other. The mean length of stay was 2.3 days and the complication rate was 18%. The postoperative bleed rate was 13% and 2% required a blood transfusion. Black children had longer hospital stays (3.0 days vs 2.1 days, P <. 01), more respiratory complications (31% vs 21%, P <. 01), higher postoperative intubation rates (7% vs 2%, P <. 01), and needed more blood transfusion (3.6% vs 1.7%, P <. 01). White children were more likely to have postoperative bleeding (17% vs 9%, P <. 01). Approximately 0.06% of patients died with no ethnic predilection.

Conclusions:

Ethnic disparities exist among pediatric inpatient tonsillectomy patients. Further research to understand the etiology of these differences is necessary.
Evaluation of True Vocal Fold Growth as a Function of Age
Authors: Rogers Derek J. , Setlur Jennifer , Raol Nikhila P. , Maurer Rie , Hartnick Christopher J.
Published: September 2014

Objectives:

Evaluate change in true vocal fold length as function of age.

Methods:

Prospective study at tertiary aerodigestive center between 2011 and 2013. A total of 205 patients (ages 1 month to 20 years), of which 87 (42.4%) were female and 118 (57.6%) male, were included. Lengths of total vocal fold (TVFL), membranous vocal fold (MVFL), and cartilaginous vocal fold (CVFL) were measured during direct laryngoscopy. Membranous‐to‐cartilaginous ratios (M/C) were calculated.

Results:

Mean MVFL under age 1 year for females was 4.4 ± 1.3 mm and for males 4.9 ± 1.8 mm. At age 17 years, mean MVFL was 12.3 ± 2.1 mm for females and 14.0 ± 1.4 mm for males. Mean TVFL, MVFL, and CVFL increased 0.7 mm, 0.5 mm, and 0.2 mm per year in linear fashion, respectively (linear regression, P <. 0001). M/C ratio did not significantly change with age (P =. 78). Mean TVFL, MVFL, and CVFL showed trend of being longer in males than females, but these did not reach statistical significance (P =. 27;. 11;. 75, respectively).

Conclusions:

This is the largest longitudinal pediatric study specifically examining vocal fold length as function of age. Each length of true vocal fold appears to linearly increase for both females and males. M/C ratio remained relatively constant unlike previously reported data, possibly due to in vivo versus cadaveric measurements. These findings suggest critical periods of development in females and males are not explainable by changes in vocal fold length alone, and other factors such as vocal fold layers (linear density) need further exploration.
First Branchial Cleft Anomalies: Otologic Manifestations and Treatment Outcomes
Authors: Shinn Justin , Purcell Patricia L. , Horn David L. , Manning Scott C.
Published: September 2014

Objectives:

(1) Describe a presentation of first branchial cleft anomalies. (2) Compare outcomes of first branchial cleft to other branchial cleft anomalies with attention to otologic findings.

Methods:

For this case‐controlled study, databases at Seattle Childrens Hospital were queried by International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes for pediatric branchial cleft cases from 2004 to 2013. Inferential analysis was performed using unpaired t test. Measurements of risk were calculated using Fisher's exact test.

Results:

The query identified 104 subjects; 24 (23.1%) of whom had first branchial cleft anomalies, the remaining 80 (76.9%) had second or third branchial cleft anomalies. First branchial cleft anomalies were diagnosed at an older age, 2.65 years (SD = 3.3) versus 1.66 years (SD = 4), P value. 28 (not significant). They also presented with a range of otologic findings, including otorrhea (25%), otitis media (29.2%), tympanic membrane web (26.1%), and cholesteatoma (16.7%). They had greater risk of requiring primary incision and drainage: 14 (58.3%) versus 3 (3.8%), odds ratio (OR) 15.12, 95% confidence interval (CI) [3.8, 88.9], P value <.0001. They were also more likely to have recurrent disease: 7 (29.1%) versus 3 (3.8%), OR 7.6, 95% CI [1.59, 49.1], P value. 008. They were more likely to undergo additional surgery: 6 (26.1%) versus 4 (5%), OR 4.91, 95% CI [1.07, 25.72], P value. 04, often related to residual ear disease.

Conclusions:

Children with first branchial cleft anomalies present with a range of otologic manifestations that increase the risk of persistent disease and that may require specific treatment such as tympanoplasty.
Impact of the Seven‐Valent Pneumococcal Conjugate Vaccine on Pediatric Tympanostomy Tubes Insertions in Taiwan
Authors: Wang Mao‐Che , Wang Ying‐Piao , Chou Pesus
Published: September 2014

Objectives:

Seven‐valent pneumococcal conjugate vaccine (PCV7) has been proved to be very effective on preventing invasive pneumococcal disease (IPD) and pneumonia in children and having indirect effect on unvaccinated age groups. Previous studies also showed that PCV7 vaccination decreased the incidence of otitis media and tympanostomy tubes (TT) insertions in vaccinated children. However the indirect effect of PCV7 on TT insertions has seldom been mentioned. PCV7 was released in Taiwan in 2005. It is only for high risk group and in the private market. Partial vaccination makes Taiwan a perfect model to study the indirect effect. We tried to examine the indirect effect of PCV7 on TT insertions in a population based setting.

Methods:

This retrospective study used the National Health Insurance databank for the period 2000 to 2009 in Taiwan. Every child under 18 years old who received TT in this 10‐year period was identified and analyzed. The TT insertion rates in different age groups before and after the year 2005 were compared.

Results:

The TT insertion rate of children under 2 years old decreased significantly and increased in children 2 to 9 years after the year 2005. There is no obvious change in TT insertions for children older than 9 years old through the study period.

Conclusions:

The PCV7 may reduce TT insertion rate for children under 2 years old in Taiwan. This effect may be the direct effect or both direct and indirect effect of the vaccine. There was no indirect effect of PCV7 on TT insertions in children older than 2 years old.
Matrix Metalloproteinases and VEGF: Potential Roles in Formation of High‐Flow Vascular Anomalies
Authors: Moak Teri N. , Miller Emily , Wei Ting , Klug Theodore D. , Suen James Y. , Richter Gresham T.
Published: September 2014

Objectives:

Arteriovenous malformations (AVMs) are congenital vascular malformations that result from a defect in vascular morphogenesis. These lesions are slow‐growing, infiltrative, and destructive resulting in significant morbidity associated with cardiac overload and increased susceptibility to massive bleeding. Recent evidence suggests a role of matrix metalloproteinases (MMPs), a family of enzymes functioning in tissue remodeling via degradation of extracellular matrix proteins and cleaving of surface molecules, in the pathogenesis of AVM development and rupture. This study sought to explore the role of MMPs, particularly MMP‐9, in AVM formation and progression.

Methods:

Serum samples from patients with AVM, hemangioma, and pyogenic granuloma were collected and isolated at various stages of development. Relative quantities of MMP‐2, MMP‐9, and VEGF in each group were calculated and analyzed using sandwich‐capture enzyme‐linked immunosorbent assay.

Results:

MMP‐2 concentrations were found to be decreased in AVM serum samples when compared with serum samples from the pyogenic granuloma controls (27.9 ± 5.97 vs 32.84 ± 2.20, P = 6.3 × 10–9); MMP‐9 concentrations were found to be increased in AVM serum samples when compared with hemangioma serum samples (1698.81 ± 410.86 vs 1105.02 ± 239.43, P <. 02); and VEGF concentrations were found to be decreased in AVM serum samples when compared with hemangioma serum samples (52.27 ± 63.02 vs 174.0 ± 9.84, P <. 05).

Conclusions:

The results of this study provide support for a role of MMP‐9 in AVM progression and recurrence. Specifically, an increase in MMP‐9 appears to be associated with AVM formation and may play an important role in its pathogenesis.
National Trends in Tongue Reduction Surgery for Macroglossia in Children
Authors: Patel Anju K. , Mader Nicholas S. , Scott Andrew R.
Published: September 2014

Objectives:

(1) Examine the frequency of partial glossectomy performed for the indication of macroglossia in the United States, assessing for any differences in rates of intervention across various demographics. (2) Identify potential morbidities associated with partial glossectomy in this population and determine how such factors may influence length of stay (LOS) and cost of admission following tongue reduction surgery.

Methods:

Retrospective cross‐sectional study using the 2006 and 2009 KidsTM Inpatient Databases (KID). During the 2‐year study period, partial glossectomy was performed in 80 children under 5 years with macroglossia.

Results:

A disproportionately higher rate of intervention was seen in whites (P =. 001) and patients in the highest socioeconomic quartile (P =. 007). Conversely, a lower rate of intervention was observed in black children (P =. 011). The average age at the time of partial glossectomy was 23 months (mode, 12 months). Patients were classified as isolated (n = 16, 20%) or syndromic macroglossia (n = 64, 80%) based on associated diagnoses. The average length of stay after partial glossectomy for macroglossia ranged from 5 to 11 days. Differences in LOS (mean, 9.5 days) and cost (mean, $9.8k) between isolated and syndromic macroglossia groups were not significant.

Conclusions:

Partial glossectomy for macroglossia is typically performed prior to age 2 years in the United States. Syndromic comorbidities do not seem to contribute to increased LOS or cost of admission. White children and affluent children appear to be undergoing partial glossectomy at a higher rate than their peers.
A Study of Aesthetic Outcomes of Primary Rhinoplasty in Crooked Nose Deformity
Authors: Yadav Samar Pal S. , Gulia Joginder S. , Aggrwal Arpit
Published: September 2014

Objectives:

(1) Rhinoplasty is the treatment of choice for patients with crooked nose deformity. (2) Objective assessment of nasal and facial profile using digital photographs and computer software is an integral part of management. (3) Recognize that subjective evaluation of patient satisfaction regarding aesthetic improvement is an important aspect of rhinoplasty.

Methods:

A prospective study from January 2011 to September 2012. Crooked nose deformity in 20 cases of either sex in the age group of 18 to 40 years. Setting: Pt. BDS Post graduate Institute Medical Sciences Rohtak, India, a tertiary care center. Rhinoplasty was performed through the external approach, and aesthetic improvement was evaluated through photographic analysis. Patient satisfaction was also assessed using a visual analog scale of 1 to 100. Independent Variables: Age, sex, external nasal deformity, and nasal septum deviation.

Results:

Statistical analysis was done using IBM SPSS v.20 software by paired “t” test. The preoperative nasal deviation alignment angle was 13.76° ± 5.21° while in the postoperative period it was 3.07° ± 2.08° (P <. 001). Subjective assessment using visual analog scale showed an improvement from preoperative score of 47.6 ± 7.27 to 81.5 ± 10.69 postoperatively (P <. 001).

Conclusions:

Objective assessment and documentation of nasal deformities is an integral part of rhinoplasty. Subjective evaluation, on the other hand, is a useful tool to assess the degree of patient satisfaction.
An Objective, Anatomically Based Analysis of Pediatric Snoring
Authors: Brietzke Scott E. , Pusz Max D.
Published: September 2014

Objectives:

The implications and anatomical basis of pediatric snoring (PS) remain largely unknown. The objectives of this study are to: (1) Objectively assess PS using home sleep test (HST) technology. (2) Attempt to correlate the objective components of PS to upper airway anatomy. (3) Objectively measure the effects of adenotonsillectomy (±turbinoplasty) on PS.

Methods:

Pediatric patients with a chief complaint of snoring and probable obstructive sleep apnea underwent a HST (SNAP Diagnostics, USA) with a detailed acoustical analysis of snoring prior to adenotonsillectomy (±turbinoplasty). During surgery, detailed anatomical measurements were performed and correlated with snoring analysis results. After surgery, patients were offered another HST with snoring analysis. Data analysis was performed using descriptive statistics and statistical correlation with attention to the multiple comparisons paradox.

Results:

Twenty‐two patients (45% male; mean age, 5.4 years; range, 2.4‐8.4 years) completed the preoperative HST and intra‐operative measurements. Unlike typical adult snoring, only the minority of PS was from palatal flutter (mean palatal component = 24%, median = 10%). The resistance occurrence percentage (ROP, % of breathing events with snoring noise) was associated with body mass index (BMI; Spearmans Rho = 0.55, P =. 017), subjective turbinate size (0.54, P =. 032), lowest oxygen saturation (–0.46, P =. 043), and palatal obstruction (0.62, P =. 008) but not adenotonsillar hypertrophy. Ten patients (45%) completed a postoperative HST. The ROP was significantly reduced (median 20.5% vs 6.5%, P =. 006 Sign rank test) postoperatively. The magnitude of the ROP reduction was directly proportional to the measured volume of the removed tonsils (0.74, P =. 022).

Conclusions:

Pediatric snoring has different acoustical characteristics than adult snoring. Objective PS is associated with BMI, turbinate size, and palatal position/obstruction. Adenotonsillectomy (±turbinoplasty) significantly reduces objective PS.