Abstract
3D-Printed Single- and Two-Stage Tissue Scaffold for Ear Reconstruction
Julia Brennan (Presenter); Ashley Cornett; Zahra Nourmohammadi; Sarah Jo Crotts; Isabelle Lombaert; Scott Hollister, PhD; David A. Zopf, MD
Objectives: To analyze single- vs 2-stage 3-dimensional (3D)–printed auricular tissue scaffolds in an in vivo athymic rodent model.
Methods: This preclinical in vivo study was performed in an athymic rodent model with 2 months’ follow-up. Single- and 2-stage auricular scaffolds were 3-dimensionally (3D) printed by laser sintering poly-L-caprolactone, and each version was implanted subcutaneously in 5 rats. Rats were observed for ulcer formation and site infection, and measurements were taken weekly to assess scaffold contraction. Tissue scaffolds were explanted at 8 weeks and were analyzed using micro–computed tomography, biomechanical testing, and hematoxylin and eosin (H&E) staining to gauge tissue and vascular ingrowth.
Results: Ear tissue scaffold constructs were rapidly manufactured with high-fidelity anatomic appearance. The novel 2-staged tissue scaffold facilitated a modular attachment that was successful in all instances. Subcutaneous scaffold implantation required less than 25 minutes and resulted in superb anatomic appearance and scaffold projection. No statistically significant difference in complications was noted between the single- vs 2-staged implantation. Minor superficial ulcers occurred most commonly at the lateral and superior helix of the scaffold; the incidence of ulceration peaked at 2 weeks and improved thereafter. Evidence of robust angiogenesis was visible on gross examination of explanted scaffolds and on H&E staining.
Conclusions: Single- and 2-stage 3D-printed auricular tissue scaffolds demonstrated unparalleled ease of implantation, superb appearance, and equivalent rates of superficial wound complications in an in vivo athymic rodent model. This promising preclinical small-animal model supports future initiatives to make clinically viable ear tissue scaffolds.
Analysis of Pediatric Firearm Head and Neck Injuries
Thomas Yusin (Presenter); Marcus Hoof; Lena Aiki Hummel; Therese Nguyen; Jessica Friedman; Patrick McGrew, MD; Emad Kandil, MD
Objectives: Recognize that unintentional death and suicide are the most prevalent causes of pediatric death in the United States and that firearm injury is a highly cited mode of these events. Analyze the relationship of firearm injuries of the head and neck to sex, race, type, and location of incident in the pediatric population.
Methods: National EMS Information System (NEMSIS) data from 2010 to 2015 were used. Data collection was from 49 US states. Location of primary injury, sex, race, purpose of incident, type of incident, and location of incident of pediatric firearm injuries were collected.
Results: A total of 9415 pediatric firearm incidents were recorded from 2010 to 2015. Of these, 512 resulted in mortality. A total of 2563 head incidents occurred, and 387 (15.1%) resulted in mortality. Of head incidents for which sex was recorded, 317 (15.6%) incidents in boys and 67 (12.9%) incidents in girls resulted in mortality. Significantly more head incidents occurred among Caucasians (1100, 52.2%) than African Americans (804, 38.16%; P < .05). Assault head incidents was a significantly greater purpose (1141, 44.5%) than self-inflicted harm (735, 28.7%) and accidental (687, 26.8%; P < .05) incidents. Significantly greater mortality was seen among self-inflicted (266, 36.2%) than accidental (31, 4.5%) and assault (90, 7.9%) incidents. Significantly greater head incidents occurred in the home (1476, 74.8%) than at other locations (311, 21.1%; P, .05). Neck incidents were the third highest primary location of injury among mortalities (13, 4.7%).
Conclusions: Head and neck injuries are the most prevalent primary location of injury and result in the greatest rate of mortality of pediatric firearm incidents. Policy changes should address pediatric access to firearms within homes and prevention of self-inflicted harm.
Biodegradable Magnesium Stents: Treatment for Pediatric Laryngotracheal Stenosis
Leila J. Mady, MD (Presenter); Abhijit Roy; Ali Mübin Aral; Jingyao Wu; Prashant N. Kumta; David H. Chi, MD
Objectives: Develop an animal model for endoscopic insertion of a novel biodegradable stent as a treatment approach for laryngotracheal stenosis (LTS).
Methods: We developed a new, high-ductility magnesium alloy and fabricated balloon-expandable stents. We made a microsuspension laryngoscopy device to augment endoscopic application in the rabbit airway. Six New Zealand white rabbits underwent subglottic injury with a nylon brush. One week after injury, stents were implanted by deployment over a balloon dilator. Weekly endoscopy was performed to monitor stenosis progression and stent degradation with euthanasia at 6 weeks (n = 2) and 10 weeks (n = 3) postinjury.
Results: Evaluation 1 week postinjury demonstrated LTS grade 1, 50% (n = 3); grade 2, 33.3% (n = 2); and grade 3, 16.7% (n = 1). Stent deployment failure at the glottis occurred in 2 rabbits, requiring early endoscopy and euthanasia in 1 of these animals. All remaining animals survived follow-up. Of 4 rabbits with successful subglottic stent deployment, 75% (n = 3) demonstrated submucosal integration at 1 week postimplantation; weekly endoscopy demonstrated progressive stent degradation without evidence of local toxicity, necrosis, or restenosis. One rabbit had no stent at 1 week postimplantation, suggesting device migration.
Conclusions: We demonstrated feasibility of a completely endoscopic approach for implantation of a novel biodegradable stent under stenotic conditions. This represents an innovative and clinically viable method for device insertion compared with previously described fluoroscopically guided and open techniques.
Characteristics of Patients with Sleep Disordered Breathing but Negative Elective Polysomnograms
Elizabeth Abraham, MS (Presenter); Michael B. Cohen, MD; Ashank Bains, MS; Jessica Levi, MD
Objectives: To determine factors associated with normal polysomnograms (PSGs) in children with sleep-disordered breathing (SDB) and adenotonsillar hypertrophy.
Methods: We evaluated 2- to 18-year-old patients who had a PSG ordered by the department of otolaryngology at our institution for initial evaluation of SDB from 2012 to 2018. We assessed whether the PSG was indicated under the 2011 American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) guidelines; if not, they were deemed “elective.” For each patient, we evaluated the following criteria: tonsil size, presenting symptoms, medical history, age, obstructive sleep apnea (OSA) severity, and demographic information. We compared the children with no OSA by PSG to all other children who underwent elective PSGs using odds ratios to determine if any of these variables were associated with negative PSG.
Results: There were 778 patients who had a PSG during the study time period; 456 were elective. Of these, 22.6% had normal PSGs (Apnea-Hypopnea Index < 1.0); children age 6 to 12 years were more likely to have negative sleep studies. Children with smaller tonsil size (2+) and absence of witnessed apneas were more likely to have negative sleep studies.
Conclusions: Overall, 22.6% of children with symptoms of SDB who underwent elective PSG had normal sleep studies. The 2011 AAO-HNS guidelines may result in children with negative PSG undergoing adenotonsillectomy. Children age 6 to 12 years were statistically more likely to have negative sleep studies and may benefit from more conservative management.
Cognitive Burden of Illness and School Days Lost in Pediatric Allergic Rhinitis
Alisa Yamasaki (Presenter); Neil Bhattacharyya, MD
Objectives: To analyze the prevalence of pediatric allergic rhinitis (PAR) and recognize its impact on school days lost, cognitive function, and childhood activities.
Methods: The National Health Interview Survey (2014-2017) was analyzed to determine the prevalence of PAR and the number of missed school days in the past 12 months. Associations were determined between the presence of PAR and activities limited by difficulty remembering, limitation in the amount of childhood play, and use of special education/early intervention. Multivariate analysis was used to adjust for age, sex, race, ethnicity, and poverty level.
Results: An estimated 11.1 million (10.6-11.6 million, 95% confidence interval) children (mean age, 9.9 years; 56.9% male) suffered from PAR (15.1%; 14.6%-15.6%). Children with PAR missed 4.0 (3.7-4.4) school days per year vs 2.2 (2.1-2.4) school days for those without PAR (P < .001, adjusted). The presence of PAR was significantly associated with limitation in daily activities due to difficulty remembering (odds ratio = 1.8; 1.2-2.9), limitations in childhood play (3.2; 2.2-4.7), and need for special education (1.6; 1.4-1.8), adjusting for age, sex, race, ethnicity, and poverty level.
Conclusions: PAR is an extremely common condition in childhood and associated with declines in cognitive function and school attendance. Given this significant prevalence and burden of illness, further attention is needed to ensure the timely diagnosis and treatment of PAR.
Comparison of Speech Outcomes in Unilateral and Bilateral Pediatric Cochlear Implants
Neeraj Suri (Presenter); Bhavya BM; Satya Sandilya
Objectives: (1) Compare the speech outcomes in unilateral and bilateral cochlear implants (CIs) in children. (2) Analyze the difference in outcomes of sequential and simultaneous bilateral cochlear implants. (3) Analyze the outcomes of early-age diagnosis and implantation.
Methods: A longitudinal study was carried out. The study included 24 children with bilateral CI and 25 with unilateral implant between age 8 months and 5 years. All the children were operated on at Civil Hospital Gandhinagar, Gujarat, India. SECS, SIR, and CAP scores; speech perception in quiet and noise; sound localization; and comprehension were assessed at regular intervals up to 24 months.
Results: Children with bilateral implants fared significantly better with sound localization, speech comprehension tests, speech production tests, and expressive language subscales than children with unilateral implants, with a significant difference (P = 0006) of mean t-tests between the 2 groups. Children with simultaneous bilateral implants achieved significantly higher scores in vocabulary outcomes and expressive language subscales than children with sequential bilateral implants.
Conclusions: Simultaneous bilateral implants are associated with better expressive language and receptive language when compared with unilateral implantation.
Contralateral Hearing in Pediatric Severe to Profound Sensorineural Hearing Loss
Christopher H. Azbell, MD (Presenter); Nayel I. Khan, MD; Amber Dianne Shaffer; David H. Chi, MD
Objectives: Unilateral sensorineural hearing loss (SNHL) occurs in 6 to 12 per 1000 school-aged children. The prognosis of progressive hearing loss in the contralateral, better hearing ear, however, is not well described. The primary objective of this study was to quantify outcomes of contralateral hearing in pediatric patients with unilateral severe to profound SNHL.
Methods: Thirty-eight patients presenting to a pediatric hearing center at a tertiary care children’s hospital between 2004 and 2016 with severe-to-profound unilateral SNHL had their charts reviewed. Data points were extracted from inpatient and outpatient charts. Independent t-tests, analyses of variance, and logistic regressions were used to compare outcomes across groups.
Results: The median duration from initial to most recent audiogram was 4.2 years (range, 0.4-13.8 years). The mean ± SD decreases in hearing thresholds in the contralateral ear at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were 1.4 ± 8.4, 1.8 ± 6.5, 0.0 ± 6.7, and 1.4 ± 6.1 dB, respectively. Among the patients, 18.9% experienced increases in hearing thresholds at multiple frequencies in the contralateral ear (range 5-20 dB). Longer duration since initial audiogram was associated with increased odds of worsened hearing at 1000 Hz (odds ratio [OR]: 1.30, 95% confidence interval [CI]: 1.04-1.63, P = .022), 2000 Hz (OR: 1.28, 95% CI: 1.04-1.57, P = .022), and 4000 Hz (OR: 1.32, 95% CI: 1.05-1.66, P = .017). Only 9.1% of patients with abnormalities found on imaging of the side of the SNHL had contralateral abnormal findings.
Conclusions: Most pediatric patients who present with unilateral severe-to-profound SNHL will have little change in hearing levels in the contralateral ear.
Disparities in Obtaining Polysomnography for Children with Down Syndrome
Philip D. Knollman, MD (Presenter); Christine H. Heubi, MD; Jareen Meinzen-Derr, MPH; David F. Smith, MD, PhD; Sally Shott, MD; Susan Wiley, MD; Stacey L. Ishman, MD, MPH
Objectives: Evaluate the demographic and medical characteristics of children with Down syndrome (DS) recommended to receive polysomnography (PSG) after the introduction of the American Academy of Pediatrics (AAP) guidelines for universal screening for obstructive sleep apnea (OSA) by age 4.
Methods: Retrospective review of children with DS born between 2007 and 2013 who were seen in a specialized clinic at a tertiary care pediatric medical center. Children with DS who underwent PSG were compared with those who did not regarding sex, race, medical comorbidities, median household income, and insurance status.
Results: A total of 460 children were included; 273 (59.3%) underwent PSG, with a mean age of 3.4 ± 1.9 years at time of first PSG. Compared with children with DS who did not receive a PSG (n = 187, 40.7%), there was no significant difference in the distribution of sex or race. Rates of congenital heart disease were similar between those who received PSG (28.9%) and those who did not (26.1%, P = .34); those who received PSG were more likely to have a diagnosis of hypothyroidism (25% vs 11.1%, P < .0001). Overall, 299 children (65%) were privately insured and 137 (29.8%) were publicly insured, with no significant difference in payer distribution between groups with and without PSG (P = .99). Likewise, median household income was not significantly different (60,525 vs 59,558, P = .61).
Conclusions: Since the introduction of AAP guidelines, approximately 60% of children with DS presenting to our institution received the recommended PSG. No significant differences were noted between patients who received PSG and those who did not in regard to sex, race, and medical coverage. Further studies are needed to determine barriers to care and improve adherence to guidelines.
Duration of Balloon Dilation in Treating Subglottic Stenosis: A Pilot Study
Paul Wistermayer, MD (Presenter); Wesley McIlwain, MD; Derek Escalante, MD; Tyler P. Swiss, DO; Derek J. Rogers, MD
Objectives: To identify effects of balloon dilation duration and Ciprodex application in treatment of subglottic stenosis.
Methods: Thirty-six New Zealand White rabbits underwent subglottic injury in an Institutional Animal Care and Use Committee–approved study. One week after injury, the subglottis of each rabbit was measured and treated with endoscopic balloon dilation using short duration (SD; 3 seconds), long duration (LD; 30 seconds), or LD with Ciprodex application (LDC). The subglottis of each rabbit was remeasured at the study end point (1 month after dilation or after development of life-threatening respiratory distress) during direct laryngoscopy. All measurements of stenosis were performed by 3 unique raters using blinded photos and ImageJ software.
Results: Twenty-seven of 36 rabbits (75%) survived to endoscopic balloon dilation. Sixty-two percent of the subjects developed grade III subglottic stenosis. One-way analysis of variance testing showed no statistical difference in stenosis rates between groups prior to dilation (P = .91). Stenosis rates at study end point were 53% (SD 42%) for BD (n = 9), 41% (SD 30%) for LD (n = 12), and 30% (SD 13%) for LDC (P = .42). Early euthanasia/death rates among the subjects with grade III stenosis were 55% for BD, 33% for LD, and 0% for LDC (P = .07 using Fisher exact test). The interrater agreement between raters’ measurements was excellent using intraclass correlation coefficients (0.87) with absolute agreement.
Conclusions: This is the first study to assess balloon dilation and Ciprodex application in an airway model. No rabbits in the LDC group required early euthanasia or died prior to study completion. Our data have yet to reach statistically significant differences in restenosis or mortality rates.
The Effect of Adenotonsillectomy on Voice
Mohammed A. Gomaa, MD (Presenter); Ahmed Adel Sadek, MD; Zynab Khalaf, MD
Objective: To evaluate the effect of adenotonsillectomy on voice and when voice returns back to normal.
Methods: This is a prospective study that was conducted on 50 children age 4-12 years. All patients were suffering from symptoms of hypertrophied adenotonsillitis and were indicated for adenotonsillectomy in the department of otorhinolaryngology, Minia University Hospital. The patients underwent a full clinical history and acoustic analysis using computerized lab with the MDVP program to register jitter %, shimmer db, and preoperative, 1-month postoperative, and 3-month postoperative HNR. Auditory perceptual assessment of voice and speech was conducted preoperatively, 1 month postoperatively, and 3 months postoperatively. With regard to acoustic analysis, our results show improvement of the following acoustic parameters: jitter %, shimmer db, and postoperative HNR.
Results: There were no significant differences at 1 month postoperation. Jitter %, shimmer db, and HNR showed a significant 1-month difference at 3 months postoperation. HNR showed a nonsignificant 1-month difference postoperatively, but there were elevated values observed at 2 months postoperation. This is explained by the fact that dysphonia is accompanied by low HNR. With regard to auditory perceptual assessment of voice and speech, our study shows improvement of dysphonia and hyponasality between the preoperative assessment and 1- and 3-month postoperative assessments. We emphasize that adenotonsillectomy can improve acoustic parameters, nasality, and dysphonia within 3 months of surgery in children with hypertrophied tonsils and/or adenoids.
Conclusions: Adenotonsillectomy can improve voice quality and improve resonance if it is performed well and there is a well-done preoperative assessment to prevent complications related to resonance. Resonance and dysphonia often change because of adenotonsillectomy in patients with hyponasal speech.
Endoscopic Injection vs Repair of Type 1 Laryngeal Clefts: A Systematic Review
Alisa Timashpolsky, MD (Presenter); Daniel P. Ballard, MD; Sam D. Schild, MD; Richard M. Rosenfeld, MD, MPH, MBA; Ann W. Plum, MD
Objectives: For pediatric patients with type 1 laryngeal clefts, surgical interventions are often considered for those who fail conservative management. Although endoscopic repair has been the mainstay of surgical treatment for many years, interarytenoid injection laryngoplasty has gained popularity as a faster and less-morbid alternative. This study aims to compare outcomes for the 2 surgical techniques.
Methods: Data sources: PubMed, Web of Science, and EMBASE. Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards of English-language articles that included studies of patients with endoscopically confirmed type 1 laryngeal cleft who were managed with injection or endoscopic surgical repair. Two independent investigators assessed study eligibility and extracted data for analysis.
Results: Of 229 studies identified, 22 met inclusion criteria. There were 15 studies, comprising 282 patients, that described endoscopic surgical management and 7 studies, comprising 231 patients, that used injection laryngoplasty. The most common technique used for endoscopic repair was laser-assisted mucosal ablation and suture approximation. The most common material used for injection laryngoplasty was calcium hydroxylapatite. The injection laryngoplasty cohort had complete resolution of symptoms in 120 (52%) patients, improvement in 40 (17.3%) patients, and failure in 71 (30.73%) patients. Endoscopic repair resulted in 151 (53.5%) patients with complete resolution, 62 (22%) with improvement, and 69 (24.4%) with failure. The difference between the 2 groups was not statistically significant.
Conclusions: Injection laryngoplasty for type 1 laryngeal clefts has comparable efficacy to endoscopic surgical repair and should be considered in the treatment algorithm for this clinical entity.
Gadolinium Enhanced Magnetic Resonance Imaging to Predict Hearing Loss in Pediatric Patients with Bacterial Meningitis
Kevin Shi, MS (Presenter); Jeremy Purser; John A. Germiller, MD, PhD; Albert H. Park, MD
Objectives: To determine if gadolinium-enhanced magnetic resonance imaging (GdMRI) can be used as a biomarker to predict hearing loss in pediatric patients diagnosed with bacterial meningitis.
Methods: Our study looked at 42 pediatric patients diagnosed with bacterial meningitis admitted to Primary Children’s Hospital who underwent brain GdMRI during their index hospital admission and also had ear-specific audiometric testing performed. A pediatric neuroradiologist, blinded both to disease and audiometric data, rated cochlear enhancement of each GdMRI (0-3; none to marked), which was ultimately compared with the audiometric data.
Results: Sensorineural hearing loss (SNHL) occurred in 16 of 82 ears (10 of 42 patients; 2 ears were excluded because of preexisting SNHL in 1 ear and the inability to read the GdMRI on the other ear). Moderate enhancement (2 or 3) was noted in 10 of the 16 ears (62.5%) that later developed SNHL and was absent in 66 of the 66 unaffected ears (100%). Thus, GdMRI was 62.5% sensitive and 100% specific for predicting which ears would develop SNHL. In the subgroup with pneumococcal meningitis (n = 29), GdMRI was 50% sensitive and 100% specific. Enhancement was detected as early as 2 days after diagnosis.
Conclusions: Our study showed that using GdMRI as a biomarker can be used to predict hearing outcomes in pediatric patients diagnosed with bacterial meningitis.
Guidelines for Biopsy Modality in Pediatric Head and Neck Lymphadenopathy
Mica Esquenazi (Presenter); Choladda Curry, MD; Kala Kamdar; Nader El-Mallawany; Daniel C. Chelius, MD
Objectives: Assess the use of excisional biopsy and image-guided fine-needle aspirate (FNA) ± core needle biopsy for head and neck lymphadenopathy in children. Produce a clinical pathway to direct selection of appropriate biopsy modalities for persistent pediatric lymphadenopathy.
Methods: We conducted a retrospective study of patients age 22 years or younger treated at a tertiary pediatric hospital from January 2006 to July 2017. Patients who underwent head and neck lymph node or mass biopsy were identified from a cytopathology database. Data collected included patient demographics, final diagnosis, method(s) of biopsy, clinical presentation, and concurrent procedures.
Results: A total of 792 biopsies were identified, representing 764 patients with an average age of 8 years (range, 0.75-21 years) in a 50% female cohort. Excisional biopsy was performed in 84% of cases. Overall, 22% of biopsies identified a malignancy, of which 81% were hematologic. Excisional biopsy identified malignancy in 22% of cases, and image-guided FNA ± core biopsy identified malignancy in 25% of cases. Twenty-seven patients underwent multiple biopsies at the same site. No biopsies required repetition because of pathologic uncertainty. Based on clinical presentation, final diagnosis, and method of biopsy, a clinical decision pathway was developed via collaboration among otolaryngologists, pathologists, and oncologists.
Conclusions: FNA and core biopsies appear to have a useful role in the work-up of persistent pediatric head and neck lymphadenopathy. Similar rates of malignancy were observed across biopsy modalities. No diagnostic uncertainty was found in the image-guided FNA/core cohort. Further guidelines to direct selection of biopsy modalities are warranted.
Hearing Changes by Ear in Children with Asymptomatic Congenital CMV
Vanessa F. Torrecillas (Presenter); Chelsea M. Allen, PhD; Tom H. Greene, PhD; Gail J. Demmler-Harrison, MD; Albert H. Park, MD
Objectives: To determine if the better or poorer hearing ear is a better indicator of progressive hearing loss in children with asymptomatic congenital cytomegalovirus (aCMV) infection and isolated sensorineural hearing loss (SNHL).
Methods: We analyzed hearing thresholds of 16 children with aCMV infection and congenital SNHL (congenital cohort) or delayed-onset SNHL (incidental cohort) from 135 CMV-infected infants. We compared the hearing outcomes of the better and poorer hearing ears for both cohorts.
Results: In the congenital cohort, 5 of 7 aCMV congenitally hearing-impaired infants developed worsening thresholds in the poorer-hearing ear and none for the better hearing ear by age 12 months. When followed to age 18 years, the greater hearing loss found in the poorer-hearing ear persisted. All 7 poorer-hearing ears continued to worsen. Three better-hearing ears worsened, and 4 had no change. Hearing loss first worsened in the poorer-hearing ear at age 2 compared with age 6 years in the better-hearing ear. In the incidental cohort, 5 of 9 patients had worsening thresholds in the poorer-hearing ear, and 1 had worsening in the better-hearing ear. Hearing loss first developed in the poorer-hearing ear at 9.5 compared with age 12 years in the better-hearing ear.
Conclusions: In children with aCMV and isolated SNHL, the poorer hearing ear both for congenital and delayed-onset SNHL is a better indicator of progressive loss than the better-hearing ear. Since the better hearing ear provided more information than the poorer hearing ear in a few instances, both ear thresholds should be determined for each hearing test. These results have important implications for determining clinical trial end points and for audiologic surveillance.
High-Speed, High-Resolution Vertical-Cavity Surface-Emitting Laser of the Neonatal Airway
Brandyn S. Dunn (Presenter); Lily Y. Chen; Jason J. Chen; Gupreet S. Ahuja, MD; Zhongping Chen, PhD; Brian J.F. Wong, MD
Objectives: Pilot clinical study focused on cross-sectional in vivo imaging of the glottis, subglottic, and trachea in intubated critically ill neonates. Characterize compositional changes in tissue and geometrically quantify laryngotracheal airway mucosa and cartilage.
Methods: An optical coherence tomography system using a vertical-cavity surface-emitting laser (VCSEL-OCT; axial resolution ~10 µm) was used to image the neonatal laryngotracheal airway of 5 individuals (age, 6-139 days; total intubation, 3-55 days). A total of 800 helical cross-sections per airway (from epiglottis to trachea) were obtained using a fiber-optic imaging probe. Three-dimensional rendering and analysis of the airway were performed offline. Tissue microanatomy and morphological changes were characterized and correlated with findings obtained by surgical endoscopy.
Results: No complications occurred during imaging. The resulting images demonstrated clear, full-thickness cross-sections of the mucosa (ie, epithelium, basement membrane, and lamina propria) in high resolution. Volumetric data allowed for detailed analysis of airway mucosa and sidewall anatomy at near histologic quality.
Conclusions: VCSEL-OCT allows for detailed evaluation of the airway microanatomy in intubated neonates. Such technological advancements in OCT as the incorporation of VCSEL may facilitate better management in intubation-related subglottic injuries. VCSEL-OCT may have the potential to prevent progression to subglottic stenosis by providing quantitative anatomic correlates for extubation criteria.
How Does Untreated Obstruction Impact Outcomes of T&A for Pediatric OSA?
Erin Kirkham, MD (Presenter); David L. Horn, MD; Kaalan E. Johnson, MD; Maida L. Chen, MD; Sanjay R. Parikh, MD
Objectives: To understand how untreated airway obstruction seen on drug-induced sleep endoscopy (DISE) may affect polysomnography outcome after adenotonsillectomy (AT) in children.
Methods: A retrospective review from a single tertiary care children’s hospital was performed on surgically naive children with obstructive sleep apnea (OSA) who underwent DISE followed by AT alone with pre- and postoperative polysomnography between 2012 and 2016. The Wilcoxon signed-rank test was used to test for a change in polysomnography parameters in children either with or without maximal obstruction seen on DISE but left untreated at additional levels of the airway (velum, tongue base, and/or supraglottis). We hypothesized that sleep test parameters would improve significantly in those without untreated obstruction but not show significant improvement in those with untreated obstruction.
Results: Of 31 individuals, 16 (52%) had obstruction not treated by AT and 15 (48%) did not. Participants were 55% male, 65% white, 41% overweight, 39% syndromic, and age 5.6 years at surgery. For children without untreated obstruction, significant improvements were seen in obstructive Apnea-Hypopnea Index (32 to 8 events per hour, P = .01), Apnea-Hypopnea Index (34 to 10 events per hour, P = .003), oxygen desaturation index (25 to 7 events per hour, P = .05), and oxygen saturation nadir (77% to 85%, P = .02). For children with untreated obstruction, improvements were seen in all 4 parameters, but these changes were smaller and not statistically significant (all P > .05).
Conclusions: Untreated airway obstruction seen on DISE may limit improvement in polysomnography parameters after AT for obstructive sleep apnea.
Impact of Middle Ear Effusion in Pediatric Tympanostomy Tubes over 10 Years
Thomas M. Kaffenberger, MD (Presenter); Michael A. Belsky; Nicholas R. Oberlies; Aarti Kumar; Amber Dianne Shaffer; Joseph Donohue; David H. Chi, MD
Objectives: Bilateral myringotomies and tympanostomy tubes (BMTs) is the most common surgery in the United States. Our prior work found intraoperative fluid to be a risk factor for future BMTs in pediatric patients with recurrent acute otitis media (RAOM). However, the influence of the type of middle ear effusion (MEE) is unknown. Here, we assessed the long-term otologic outcomes of BMT patients based on their type of intraoperative MEE.
Methods: After institutional review board approval, we performed a retrospective review on patients younger than 18 years undergoing BMT between 2008 and 2009 at a tertiary care center. Included patients had a preoperative visit and an operation report. Children with prior otologic surgeries other than BMTs were excluded. Indications for surgery included RAOM and chronic otitis media with effusion (COME), and intraoperative MEE status was recorded. Other variables collected were future BMTs, cholesteatoma, and otorrhea. Chi-squared tests and logistic regression with Holm’s corrections were used for statistical analysis.
Results: Of 1015 patients reviewed, 854 were included. Of these, 707 underwent their first BMT, and 742 patients had RAOM. Serous effusions were noted in 22.3% of cases, mucoid in 32.6%, purulent in 11.4%, and dry middle ears in 33.7%. Of the patients, 26.4% underwent future BMTs. Compared with dry middle ears, kids with mucoid and purulent MEE were more likely to require future tubes (odds ratio [OR]: 1.6, P = .02; OR: 1.9, P = .01). In RAOM patients, purulent effusions increased the odds of future tubes compared with dry (OR: 2.2, P = .004) and increased otorrhea (OR: 1.7, P = .05). Compared with RAOM, COME patients had increased odds of future BMTs (OR: 1.7, P = .011), adenoidectomy (OR: 1.6, P = .028), and hearing loss (OR: 2.4, P = .002).
Conclusions: Intraoperative MEEs were noted in 66.3% of cases, and mucoid and purulent effusions increase the odds of future BMT.
The Incidence of Pediatric Tracheostomy and Its Association among Black Children
Clarice Brown, MD (Presenter); Yann-Fuu Kou, MD; Gopi Shah, MD; Yann-Fuu Romaine F. Johnson, MD, MPH
Objectives: The study aimed to evaluate the incidence of pediatric tracheostomy among black children and to compare their inpatient outcomes with other children in the United States.
Methods: We used the 2003 to 2016 Kids’ Inpatient Database to determine the incidence of pediatric tracheostomy in the United States and identified the odds of placement in black children when compared with other children. We also analyzed the associated diagnoses, length of stay, complications, total charges, and in-hospital mortality.
Results: We studied a total of 24,392 pediatric tracheostomies. The median age was 7 years (interquartile range [IQR] = 0-17); 9994 (41%) were younger than 2 years, and 15,247 (63%) were male. The most common diagnosis was respiratory failure (17,176/24,392, 79%). There were 4859 (20%) black children. When compared with other children, black children were more likely to undergo tracheostomy (odds ratio [OR] = 1.5; 95% confidence interval [CI], 1.4-1.6], which increased among children younger than 2 years (OR = 1.8; 95% CI, 1.6-2.0). This disparity held even after controlling for sex, prematurity, and low birth weight. In addition, black children with tracheostomies were more likely to be diagnosed with laryngeal stenosis and bronchopulmonary dysplasia, injured with a firearm, and have an extended length of stay (P < .001). On the other hand, total charges, surgical complications, and in-hospital mortality were similar (P > .05).
Conclusions: Black children are 1.5 times more likely to undergo tracheostomy in the United States compared with other children. This discrepancy was more pronounced among black infants than other infants even when accounting for sex, prematurity, and low birth weight. Continued research into this disparity is warranted.
In-Office Frenuloplasty: Techniques, Outcomes, and Satisfaction
Madison A. Clinton (Presenter); Arison T. Than, MD; Lynn M. Chuong; David W. Beckman; James H. Liu, MD
Objectives: The aim of this study is to compare the use of scissors and a contact diode surgical laser for ankyloglossia and maxillary lip tie correction performed in the office. Further exploration and discussion of the author’s surgical technique for frenuloplasty is also detailed.
Methods: A retrospective analysis of in-office frenuloplasties was conducted between January 1, 2014, and December 31, 2018. Patient records were identified via electronic medical records and divided into scissor or laser groups. A total of 984 patients had frenuloplasties performed with scissors, and 1448 patients had frenuloplasties performed with the contact diode surgical laser. Patients were then asked to fill out an online questionnaire, either on their own or over the phone. Responses to the surveys, as well as the incidence of surgery-related complications, reoperations, and general patient outcomes, were compared across groups.
Results: Surgical outcomes and patient satisfaction were similar between the included study groups.
Conclusions: The surgical technique as detailed herein is a safe, effective, and well-tolerated procedure for the correction of ankyloglossia and maxillary lip tie, resulting in therapeutic benefits for patients experiencing the possible myriad associated symptoms. Using the contact diode surgical laser for frenuloplasty was similar to frenuloplasty performed with scissors for patient satisfaction and outcome.
Intraoperative Bupivacaine in the Pediatric Adenotonsillectomy Population
Keven Seung Yong Ji, MHSc (Presenter); Nathaniel Howard Greene, MD, MHSc; Eileen M. Raynor, MD
Objectives: Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy in the setting of perioperative opioid use and may be reduced with intraoperative bupivacaine. We aimed to compare the impact of bupivacaine injection on perioperative outcomes.
Methods: This is a 3-year retrospective analysis of pediatric patients who underwent adenotonsillectomy at a tertiary care center. Postanesthesia care unit (PACU) outcomes and readmission and patient characteristics were compared between those who received intraoperative bupivacaine before (preinjection) or after (postinjection) tonsillectomy and those who did not (none) using chi-squared test.
Results: A total of 98 patients were included in the preinjection group, 47 in the postinjection group, and 37 in the none group. Ages ranged from 1 month to 17.3 years. The preinjection group had the greatest proportion of obstructive sleep apnea patients (42.9% preinjection vs 25.5% postinjection vs 18.9% none, P = .012), and 15.3% of preinjection patients, 10.6% of postinjection patients, and 0% of no injection patients were readmitted (P = .042). There was no difference among the groups in arrival or discharge PACU pain scores or perioperative opioid dose used. After stratification by age, 0- to 5-year-olds who did not receive bupivacaine were found to have higher PACU discharge pain scores (mean 2.21 [SD 1.77]) compared with the preinjection (0.55 [1.29]) or postinjection group (0.71 [1.37]; P = .013).
Conclusions: Intraoperative bupivacaine improves pain scores particularly in younger pediatric populations, although it may not affect the rate of perioperative opioid use. A prospective study with a larger sample size is warranted to better outline opioid usage and pain control in this group.
Intratympanic and/or Systemic Steroids for Pediatric Progressive Hearing Loss
Alana N. Aylward, MD (Presenter); James Hunter Ellis; Chelsea M. Allen, PhD; Albert H. Park, MD
Objectives: To investigate the outcomes of children who developed progressively worsening hearing and were treated with intratympanic (IT) and/or systemic steroids.
Methods: Children with worsening hearing of any etiology were identified as they presented to our practice and were treated with prednisone, dexamethasone otic drops, or both. We calculated the average change in hearing thresholds between the first available examination, last examination before starting treatment, and most recent examination.
Results: Thirty-six ears in 24 patients were treated. The average age was 7.8 years (range, 2.0-16.1). Eleven ears received systemic steroids only, 4 IT only, and 21 both. Four patients stopped treatment because of side effects of appetite changes, weight gain, mood changes, or elevated blood glucose. Etiologies included cytomegalovirus in 13 ears, enlarged vestibular aquaduct (EVA) in 5, genetic in 8, and idiopathic in 9. Data covered an average 32 months pretreatment and 6.5 posttreatment. Pretreatment hearing worsened by 5.5 dB at 500 Hz, 4.8 dB at 1000 Hz, 9.8 dB at 2000 Hz, and 11.4 dB at 4000 Hz. Posttreatment, hearing continued to worsen slightly at 1.4 dB at 500 Hz, 3.6 dB at 1000 Hz, and 2.6 dB at 2000 Hz but improved by 0.9 dB at 4000 Hz. Ears receiving systemic and IT steroids did better than either alone with no change at 500 Hz, worsening by 0.8 dB and 1.0 dB at 1000 and 2000 Hz, and 0.3 dB improvement at 4000 Hz. EVA and idiopathic etiologies had the most improvement, by 12 and 1.7 dB, respectively, at 500 Hz, 6.0 and 1.1 dB at 1000 Hz, 6.0 and 0.6 at 2000 Hz, and 22.0 and 0.0 at 4000 Hz.
Conclusions: Despite the small, heterogeneous group, our preliminary data suggest children with progressive hearing loss benefit from IT and or systemic steroid treatment.
Long-term Otitis Media Outcomes in Children with Early Tympanostomy Tubes
Kimberly Luu, MD (Presenter); Sanghoon Park; Amber Dianne Shaffer; David H. Chi, MD
Objectives: Otitis media with effusion (OME) is the most common reason to fail a newborn hearing screen (NBHS). Of these children, 35% to 40% require early tympanostomy tubes. It is unknown whether the need for early tubes predicts the long-term prevalence of middle ear disease. The objective of this study is to review the otologic outcomes of infants who failed the NBHS and received early tympanostomy tubes for OME.
Methods: A retrospective case series was performed on consecutive patients (2009-2017). Patients who failed an NBHS and required tympanostomy tubes for OME before age 5 months were included.
Results: The cohort included 122 patients. Sensorineural hearing loss (SNHL) was subsequently identified in 16.7% of infants after resolution of the effusion. Of the patients with adequate follow-up, 11.9% had at least 3 AOM episodes in year 1, 22.3% in year 2, and 25.3% in year 3. In the subset of 71 patients who were at least age 5 years at the time of data collection, a median of 2 sets of tympanostomy tubes were placed with 22 (31.0%) receiving 1 set, 24 (33.8%) 2 sets, and 25 (35.2%) 3 to 6 sets of tubes. Craniofacial abnormalities were identified in 43.4% of patients, with cleft palate being the most common (40.2% of patients). When stratified into groups with and without cleft palate, 2 of 73 (2.7%) patients without a cleft palate had at least 3 AOM episodes in the first year of life compared with 12 of 49 (24.5%) patients with cleft palate, χ2(1) = 13.7, P < .001.
Conclusions: A high proportion of patients were subsequently found to have SNHL, reiterating the need for postoperative hearing assessments. Infants meeting the indication for early tympanostomy tubes have a high incidence of recurrent AOM and require subsequent tubes in the first 3 years of life.
Management Patterns in Pediatric Complicated Sinusitis
Sean Michael McDermott (Presenter); Patrick C. Walz, MD
Objectives: Examine management outcomes in pediatric patients presenting with complicated sinusitis.
Methods: An institutional review board–approved retrospective review at a single institution from 2008 to 2018 was performed. A total of 183 pediatric patients with complicated sinusitis with orbital and/or intracranial complications were identified. Chandler classification (CC), medical vs surgical management, length of stay (LOS), intensive care unit (ICU) admission, recurrence, need for revision, and complications were recorded. Quantitative data were compared using Student’s t-test.
Results: Orbital and intracranial involvement were seen in 168 (91.8%) and 31 (16.9%) patients, respectively. Overall, 98 (53.5%) patients were managed surgically with sinonasal and endoscopic interventions, with a mean LOS of 10.8 ± 11.0 vs 4.1 ± 1.7 days with medical management (P < .01). ICU admission was required in 2.4% of nonsurgical patients vs 24.4% of surgical patients (P < .01). Ophthalmologic surgery was necessary in 15 (8.2%) patients, with a 20.0% revision rate. Sixteen (8.7%) patients required neurosurgical procedures with a 62.5% revision rate. Eighteen (18.4%) patients required otolaryngology revision. Mean CC in surgical patients was 2.4 ± 1.4 vs 1.9 ± 0.6 in nonsurgical patients (P < .01). There was no significant difference in mean CC for patients requiring revision surgery (P = .41). One (0.5%) medical complication, a drug rash, was reported. Five (5.1%) patients had surgical complications.
Conclusions: Surgically managed patients with complicated sinusitis present with more advanced disease and require longer and more acute care in hospital stays. CC alone does not predict the need for surgical revision. Reintervention is frequent, especially with intracranial extension.
Maxillary Frenulum in Newborns: Association with Breastfeeding
Reena Razdan (Presenter); Levi Daniel Stevens, MD; Renee Saggio, MD; Mary Chafin, NNP; Michele M. Carr, MD, DDS, MEd, PhD
Objectives: To relate maxillary and lingual frenulum configuration to breastfeeding success.
Methods: Newborns and mothers were observed between 24 and 72 hours after birth in the newborn nursery. Mothers were surveyed about their breastfeeding experience. The maxillary and lingual frenulae were examined and scored. Corresponding LATCH scores were recorded.
Results: Seventy-eight mothers with newborns participated (45 male and 33 female). The mean gestational age of newborns was 38.67 weeks (95% confidence interval [CI], 38.42-38.91). Overall, 69.2% had the maxillary frenulum attached to the alveolar ridge crest, 29.5% attached to the fixed gingiva, and 1.3% attached to the mobile gingiva. Moreover, 5.1% had anterior tongue tie, 93.6% had no anterior tongue tie, and 1.3% were not recorded. In total, 53.8% were first-time mothers. Of those, 50% experienced trouble breastfeeding, 69.0% had pain with breastfeeding, with a mean LATCH score of 7.41 (95% CI, 6.74-8.08). Overall, 46.2% of the mothers had other biological children, and 83.3% had previously breastfed. Of mothers with other children, 66.7% had trouble breastfeeding and 69.4% had pain with breastfeeding, with a mean LATCH score of 9.13 (95% CI, 8.75-9.50). No significant difference was found between first-time mothers and experienced mothers for trouble or pain with breastfeeding. There was a significant difference in LATCH scores (P < .001) between these 2 groups. There were no differences in these parameters based on either maxillary or lingual frenulum configuration.
Conclusions: We did not find that maxillary frenulum score correlates with LATCH scores. However, better LATCH scores occurred in experienced mothers. Pain while breastfeeding during the first 3 days is common, suggesting that it is a poor indicator for tongue tie or maxillary frenulum division.
Multi-institutional Study on the Effect of Antacids on Feeding in NICU Neonates
Anya Costeloe (Presenter); Prasad J. Thottam, DO
Objectives: To examine how the use of reflux medications in neonates in the neonatal intensive care (NICU) setting affects feeding. To determine whether there is a difference in oral aversion, dysphagia, and other feeding difficulties between neonates in NICUs that implement acid suppression therapy compared with NICUs that do not.
Methods: Retrospective, multi-institutional study. Neonates <28 days diagnosed with gastroesophageal reflux (GER)/laryngopharyngeal reflux (LPR), who were hospitalized for >6 days, were included in the study. Neonates with anatomical anomalies that interfere with feeding, such as cleft lip/palate, tracheoesophageal fistula, choanal atresia, craniosynostosis, and duodenal atresia, were excluded. The control groups at both institutions consisted of neonates not diagnosed with GER/LPR and thus not treated with antacids. We compared NICUs at 2 hospitals. In one NICU, neonates diagnosed with GER/LPR were placed on antacids, whereas in the other NICU, acid-suppressive therapy was not used. The key outcome variables were weight gain, subjective ease of feeding, oral aversion, and overall wellness of neonates. Statistical analysis was performed using analysis of variance (ANOVA) to compare rates of feeding difficulties between the groups. Between-group differences were compared using ANOVA and chi-squared analyses. A P value <.05 was considered significant.
Results: With an n > 100, we demonstrate that the use of antacids in neonates with reflux decreases oral aversion and improves ease of feeding.
Conclusions: Whether the use of acid suppression therapy prevents oral aversion, dysphagia, and feeding difficulties in the NICU is not well described in the literature. In our study, we demonstrate that the benefits of treating reflux outweigh the risks associated with antacids.
Ototoxicity in Preterm Infants in the Neonatal Intensive Care Unit
Diogo Raposo, MD (Presenter); João Orfão, MD; Marco Peres, MD; Mafalda M.C. Trindade Soares, MD; Ana Guimaraes, MD; Filipe Martins Freire, MD
Objectives: Prematurity is a relevant factor in the maturational process of the auditory pathway. Neonatal risk factors for sensorineural hearing loss are known to impair the auditory brainstem response (ABR), but no conclusive data are available on the effect of prematurity in infants with risk factors. The aim of the present work is to analyze the ABR findings of preterm and term infants in the neonatal intensive care unit (NICU) with neonatal risk factors for sensorineural hearing loss, namely, exposure to ototoxic drugs.
Methods: Retrospective analysis of a cohort of infants admitted in the NICU of Hospital Fernando Fonseca who received an ABR evaluation. Student’s t-test, Mann-Whitney test, and Pearson and Spearman’s correlation coefficients were used for bivariate analysis. Regression was used to model the auditory threshold.
Results: A total of 154 infants were included (83 female, mean age 6.8 ± 3.7 months, 114 preterm, 42 exposed to ototoxic drugs). Exposure to ototoxic drugs significantly increased the auditory threshold and the absolute latency of wave I in preterm but not in term infants (P = .007; P = .044). Length of treatment did not correlate with the auditory threshold or latency of wave I (P = .752; P = .582). Multivariate analysis controlling for sex, Apgar score, gestational week, low birth weight, hyperbilirubinemia, cytomegalovirus congenital infection, meningitis, periventricular hemorrhage, and mechanical ventilation revealed that exposure to ototoxic drugs predicted an increased auditory threshold in preterm infants (P = .036).
Conclusions: These findings suggest that the use of ototoxic drugs significantly impairs the auditory threshold and auditory pathway maturational process in preterm but not in term infants in the NICU.
Outcomes of Treating Pediatric Obstructive Sleep Apnea on Heart Rate Variability
Dylan Gregory Bertoni (Presenter); Ron B. Mitchell, MD; Kevin D. Pereira, MD, MS; Gautam Das; Amal Isaiah, MD, PhD
Objectives: (1) To quantify changes in heart rate variability (HRV) with treatment of obstructive sleep apnea (OSA) by adenotonsillectomy (T&A) or watchful waiting. (2) To identify polysomnographic determinants of changes in HRV associated with treatment of OSA.
Methods: Baseline and follow-up polysomnographic and time-domain HRV data from the Childhood Adenotonsillectomy Trial (CHAT) were obtained through a data use agreement. Changes in 8 time-domain HRV measurements were quantified and compared between children who underwent T&A and those who underwent watchful waiting with supportive treatment. Polysomnographic predictors of these changes were identified using multiple regression analysis. P < .05 was considered significant.
Results: Of the 453 children enrolled in the study, 404 were included based on completeness of the data collected. The mean age was 6.6 (6.4-6.7) years, and the mean body mass index percentile was 69.9 (66.9-72.9). A total of 209 (52%) were female, and 147 (36%) were African American. The differences between changes in HRV were significantly greater with T&A compared with watchful waiting for 6 out of 8 variables (P < .05 for each comparison). Among all the polysomnographic predictors, the decrease in oxygen desaturation index (ODI) best predicted the magnitude of increase in HRV following treatment of OSA (P < .001) and was associated with a medium effect size.
Conclusions: Changes in HRV were best predicted by ODI in the treatment of pediatric OSA. These results support further investigation of ODI as a potential surrogate measure for assessing response to treatment of OSA.
Pediatric Costochondral Graft Harvest: Perioperative and Long-term Complications
Ashley R. Lonergan, MS (Presenter); Andrew R. Scott, MD
Objectives: Autologous costochondral grafting is a commonly employed technique in otolaryngology for reconstructing head and neck defects. Complications include infection, pneumothorax, hematoma, scarring, and pleural leak. Data establishing complication rates among adults undergoing this procedure for nasal reconstruction exist; however, outcomes in children are not widely reported. This study aimed to determine donor site complication rates following rib graft harvest performed by pediatric otolaryngologists in infants and children and to compare this to complication rates reported in adults.
Methods: Case series with chart review and literature review.
Results: Between 2010 and 2018, 34 children underwent airway, mandible, nasal, or auricular reconstruction via autologous rib grafting at an urban tertiary pediatric medical center. There were 44 costochondral graft harvests (62% female; 34% Caucasian, 24% Hispanic, 21% black, 9% Asian). The mean age at surgery was 4.23 years (median, 3 years), and the range of follow-up was 6 months to 9 years. Pooled donor site complications included small pneumothorax not requiring intervention (2.3%), intraoperative pleural leak (2.3%), and infection (2.3%). Drains were not used postoperatively; there were no incidences of postoperative hematoma or seroma. There were 2 instances of hypertrophic scarring (4.5%), both developing in patients who underwent skin excisions for skin graft harvest or scar excision from the same incision.
Conclusions: Autologous rib grafting amounts to a simple, extrapleural chest wall procedure, which may be safely performed in children by pediatric otolaryngologists, with acceptably low complication rates.
Pediatric Paradoxical Vocal Fold Motion Disorder
Rachel Fee, MD (Presenter); Kelly Staricha; Joel H. Blumin, MD; David J. Beste, MD; Thomas C. Robey, MD
Objectives: Describe the typical presentation of pediatric patients with pediatric paradoxical vocal fold motion disorder (PVFMD) and understand its treatment and prognosis.
Methods: Retrospective chart review of patients who presented to a pediatric voice clinic at an academic children’s hospital with a diagnosis of PVFMD between January 2013 and November 2017. Records were reviewed for demographics, history, laryngoscopy findings, and treatment response.
Results: A total of 258 patients were identified. Eighty-one percent of patients were female. The mean presentation age was 13.7 years. Seventy-two percent were referred by either pulmonary or allergy and immunology and 49% carried a diagnosis of asthma. A psychiatric history was noted in 31%. Forty-five patients had been seen in the emergency room previously, and 9 patients had been hospitalized. The most common complaint was chest/throat tightness (90%). Other complaints included inspiratory dyspnea (81%) and stridor (40%). Sports were listed as the most common trigger (90%). Symptoms subsided within 10 minutes of stopping in 64%. Laryngoscopy findings were normal in 48%, whereas only 23% showed hypoabduction or paradoxical motion on inspiration. All patients were sent for laryngeal control therapy (LCT) after receiving an abbreviated session at their appointment. Most patients required only 1 additional session, and only 6 patients reported no improvement; 54% never followed up for this additional LCT session.
Conclusions: The typical pediatric PVFMD patient has classic symptoms with a normal laryngoscopy and is most often a female athlete. LCT appears to be effective in nearly all treated patients, although many do not come back after their initial evaluation. Given the prolonged work-up most patients endure before learning of their diagnosis, opportunities may exist to expedite patients for LCT.
Postoperative Outcomes of Branchial Cleft Cyst Excision in Children and Adults
Robert A. Saadi, MD (Presenter); Annie E. Moroco; Vijay A. Patel, MD; Meghan N. Wilson, MD
Objectives: Branchial cleft cysts are congenital abnormalities that may lead to recurrent drainage and soft-tissue infections. Operative management is elective, but clinical presentation may occur at any age. Our goal was to identify risk factors and determine perioperative morbidity both of children and adults undergoing branchial cleft cyst excision.
Methods: Patients who underwent branchial cleft cyst excision (CPT 42810, 42815) were queried via the adult (2005-2016) and pediatric (2012-2016) American College of Surgeons–National Surgical Quality Improvement Program databases. Outcomes included inpatient vs outpatient admission, length of stay, operative time, readmission/reoperation rate, and postoperative complications.
Results: A total of 1773 children and 675 adults were identified. The average age of children was 4.6 years and that of adults was 38.7 years. Overall, 20.2% of children were younger than age 1 year; 48.2% of children and 45.9% of adults were male. Moreover, 94.0% of procedures in children and 87.1% of adults were performed as outpatient. Readmission and all postoperative complication rates were less than 1%, except for surgical site infection and wound dehiscence, which was significantly higher in the pediatric group than the adult group (2.5% vs 0.7%, P = .005; 1.7% vs 0.1%, P = .002, respectively). The average length of surgery for children was 50.5 minutes and for adults was 81.6 minutes (P < .0001)
Conclusions: Complication rates in children and adults following branchial cleft cyst excision are relatively similar. Operative times may be longer in the adult population, possibly because of increased exposure to infections and scarring in the surgical site. The results of this study will aid in clinical decision making for the elective approach to this procedure.
Posttonsillectomy Bleeding: Blame on Diet?
Tomas Mendes Carvalho (Presenter); Mafalda Oliveira; Aliya Nurdin; Daniela Serras; Paulo Martins; Leonel Luis, MD; Elisabete Fernandes
Objectives: Compare the effects of restricted diet (soft/cold food) vs unrestricted diet on posttonsillectomy bleeding rate (PTBR). Secondary clinical outcomes were defined as pain score, weight change, and return to normal diet.
Methods: Prospective, randomized, controlled trial over a year in a tertiary referral center. In total, 100 children who underwent tonsillectomy (with or without adenoidectomy) were randomly allocated into 2 groups. A total of 48 patients were allocated to the restricted diet group (RD), and 52 patients were allocated to the unrestricted diet group (URD). Bleeding, pain score, and diet were recorded for 15 days after surgery. Patients’ weight was recorded before and 15 days after surgery.
Results: Participants’ age range was 3 to 14 years. The main indication for tonsillectomy was sleep-disordered breathing (57%). One patient in the restricted diet group was admitted to the hospital because of a secondary self-limited bleeding. Difference in PTBR (P = .795), mean pain score (P = .703), and number of days needed for a free pain score (P = .666) were not statistically significant between groups. Weight change before and after surgery was not statistically different in the URD (P = .777); however, there was a statistically significant difference in the RD (P = .000) from 28.46 to 27.63 kg. Time for return to normal diet was 3.32 ± 0.343 days in the URD.
Conclusions: We found no effect of unrestricted diet in PTBR or pain score between groups. Still, restricted diet had an unfavorable effect on weight. These results favor the recommendation for an unrestricted posttonsillectomy diet.
Post-tympanostomy Tube Otorrhea and Streptococcus Pneumoniae Titer Levels
Anna K. Bareiss, MD (Presenter); Maria Carratola, MD; Lawrence Montelibano; Kimsey H. Rodriguez, MD; John M. Carter, MD
Objectives: Determine the association of recurrent acute post tympanostomy tube otorrhea (PTTO) with Streptococcus pneumoniae titer levels in children.
Methods: Retrospective chart review of 32 pediatric patients with recurrent acute PTTO and laboratory data of S pneumoniae antibody titers at a tertiary referral center from 2016 to 2018. Each of 14 S pneumoniae serotype titers was analyzed per patient, with 11 of these included in the pneumococcal 13-valent conjugate (P13C) vaccine series. Patients were considered to have inadequate S pneumoniae titers levels if ≥50% of the respective serotypes were low (<1.3 µg/mL ). S pneumoniae titer levels were examined using all 14 serotypes and again using only those included in the P13C vaccine series.
Results: Considering all serotypes measured, 66% of our study population (21 patients) had inadequate titer levels for protection against the S pneumoniae bacteria. Furthermore, when considering only the serotypes included in the P13C vaccine, 47% of our study population (15 patients) had inadequate titer levels, indicating a poor response to the P13C vaccine series.
Conclusions: An immunological work-up is warranted in children with recurrent acute PTTO. Most of our study population had inadequate titer levels for protection against 14 common S pneumoniae serotypes. Nearly half the children in our study had a poor immunological response to the P13C vaccine series. Further study may demonstrate that treatment with a booster vaccine (such as the pneumococcal vaccine polyvalent) would benefit this patient population.
Predictors of Pediatric Tracheostomy Outcomes in the United States
Tzyynong Liou Friesen, MD (Presenter); Steven Michael Zamora, MPH; Matthew T. Brigger, MD
Objectives: To investigate the outcomes of pediatric tracheostomy as influenced by demographics and comorbidities.
Methods: Data from the Pediatric Health Information System database dated 2010 to 2018 with patients age 0-18 years and procedure codes for tracheostomy were extracted. The primary outcome was total length of stay (LOS) stratified by demographics and comorbidities. The secondary outcomes were complications, readmission, and mortality.
Results: A total of 13,293 patients were analyzed. The median total LOS increased from 63 to 89 days from 2011 to 2017. The LOS was increased by 72 days in neonates and 23 days in infants as compared with adolescents (P < .001). When compared with whites, the LOS was increased by 14 days in African Americans and 11 days in Pacific Islanders (P < .02). The Northeast, Midwest, and South regions demonstrated a 16- to 20-day increased LOS compared with the West (P < .001). Among the comorbidities, children with cardiac, urologic, immunologic/hematologic, and gastroenterologic comorbidities and prematurity were associated with increased LOS (20- to 55-day increase, P < .001). The overall 30-day readmission rate was 26.3%, and none of the variables was associated with an increase. Total mortality rate was 8.8% and was associated with comorbidities in gastroenterology (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.5-3.5), cardiac (OR 2.6, 95% CI 2.3-3.0), and immunology/hematology (OR 1.9, 95% CI 1.6-2.2).
Conclusions: Pediatric tracheostomy requires substantial hospital resources with LOS increasing over the years. Age, race, region, and comorbidities were associated with increased LOS. Mortality was largely associated with comorbidities.
Prevalence of Pediatric Vestibular Symptoms and Diagnoses in the United States
Jacob Brodsky, MD (Presenter); Neil Bhattacharyya, MD
Objectives: Understand the prevalence of vestibular symptoms and associated diagnoses in US children.
Methods: Responses from the 2017 National Health Interview Survey for children age 3 to 17 years were examined to determine the prevalence of vestibular symptoms in the year prior to survey and provider-assigned diagnoses.
Results: Dizziness or imbalance was reported in 3.46 (3.07-3.85, 95% confidence interval) million pediatric patients (5.6%) with a mean age of 11.5 years. Dizziness was reported in 1.23 million patients (2.0%) with a mean age of 12.7 years, and balance impairment in 2.27 million patients (3.7%) with a mean age of 10.6 years. Forty-four percent of patients with imbalance reported onset before age 4 years. Prevalence of dizziness and imbalance did not vary by gender (P = .600, P = .176). Evaluation by a health professional was reported for 41.5% of patients with dizziness and 43.1% of patients with imbalance. 44.8% of patients with dizziness and 48.1% of patients with imbalance reported diagnoses. The most common diagnoses reported for dizziness were depression (11.8%), side effects from medications (11.4%), and head/neck injury or concussion (8.4%). The most common diagnoses reported for imbalance were blurred vision with head motion, “bouncing” or rapid eye movements (9.1%), depression (6.2%), and head/neck injury or concussion (6.1%).
Conclusions: The national prevalence of childhood vestibular symptoms is likely more common than thought, yet few children receive care or a diagnosis. Reported diagnoses varied greatly from the literature, suggesting a need for increased awareness of vestibular dysfunction and its common causes in children.
Quality of Life in Children with Sensorineural Hearing Loss
Evette Anneliese Ronner (Presenter); Liliya Benchetrit; Razan A. Basonbul, MBBS; Michael S. Cohen, MD
Objectives: Assess quality of life (QOL) in pediatric patients with sensorineural hearing loss (SNHL) using the PedsQL 4.0 and HEAR-QL-26/28 survey tools.
Methods: Surveys were administered to patients with SNHL age 2 to 18 years from July 2016 to December 2018 during their first visit to a multidisciplinary hearing loss clinic. Patients older than 7 years completed the HEAR-QL-26/28 and PedsQL 4.0 child self-report tool, whereas parents completed the PedsQL 4.0 parent proxy-report for children younger than 7. Independent t-test and 1-way analysis of variance were used for analysis.
Results: In our cohort of 100 patients, the mean age was 7.7 years (standard deviation [SD] 4.5); 50 were male, 53 had congenital SNHL, 62 had bilateral SNHL, 63 had mild-moderate SNHL, and 37 had severe-profound SNHL. Sixty-eight patients used a hearing device. The mean (SD) total survey scores of the PedsQL 4.0 (age 2-7 and 8-18 years), HEAR-QL-26 (age 7-12 years), and HEAR-QL-28 (age 13-18 years) were 83.9 (14.0), 79.2 (11.1), 81.2 (9.8), and 77.5 (11.3), respectively. PedsQL (age 2-4 years) school function and PedsQL (age 8-12 years) physical function scores were lower in children with bilateral vs unilateral SNHL (P = .006 and P = .012, respectively). Mean QOL scores for individuals with SNHL were significantly lower compared with those of their normal hearing peers based on previously published normative data (P < .0001). Degree and laterality of SNHL did not significantly affect QOL. There was no significant difference in QOL among children with SNHL requiring a hearing device vs those who did not.
Conclusions: It is feasible to collect QOL data from children with SNHL in the setting of a hearing loss clinic. Children with SNHL had significantly lower scores on validated QOL instruments compared with their normal hearing peers. Future study should focus on what interventions most affect the QOL in this group.
Socioeconomic Disparities in Pediatric Single Sided Deafness
Noga Lipschitz, MD (Presenter); Gavriel D. Kohlberg, MD; Michael Scott, AuD; John H. Greinwald, MD
Objectives: To explore socioeconomic disparities in pediatric single-sided deafness (SSD) treatment.
Methods: A retrospective chart review of 190 pediatric patients with SSD was conducted. Socioeconomic variables including race and insurance status were analyzed. Zip codes were used to obtain socioeconomic data from the American Community Survey, including mean and median income, percentage of families below poverty level, and employment status. Treatment outcomes included age at treatment, treatment type, and device use.
Results: There were 105 boys and 85 girls, with a mean follow-up of 55.2 months. The mean age at diagnosis was 4.4 years. Sixty-four percent of children received treatment. Sixty-six children (35.1%) had public (Medicaid) insurance, and 122 children (64.9%) had private insurance. Race distribution included 142 (74.7%) white, 27 (14.2%) black, 9 (4.7%) Asian, 6 (3.2%) Hispanic, and 6 (3.2%) other. No treatment was more common in children with private insurance compared with public insurance (39.3% vs 33%, P = .02). In addition, we observed a significant association between private insurance and consistent device use (47.5% vs 38.9%, P = .02). No association was found between sex or race and treatment outcomes. Age at treatment, treatment status, or device use was not associated with income level, percentage of families below poverty level, or employment status.
Conclusions: Private insurance was associated with lower treatment rates but higher device use in children with SSD. Further research should focus on strategies to reduce treatment costs and improve compliance.
Subglottic Cysts: A Retrospective Case Review of 105 Patients
Philippe F. Bowles, MRCS (Presenter); Jake Reading; Robert Nash; David M. Albert, FRCS
Objectives: Subglottic cysts are a rare cause of airway obstruction. We present the results of a retrospective case notes review from a United Kingdom (UK) tertiary referral specialist children’s hospital. To our knowledge, this the largest reported data set for subglottic cysts.
Methods: We conducted a retrospective case note analysis of 105 pediatric patients with subglottic cysts, diagnosed intraoperatively at microlaryngobronchoscopy between May 1999 and December 2017 at a UK tertiary referral center.
Results: A total of 105 cases were identified (40 girls, 60 boys). The mean age at presentation was 9.9 months (standard deviation [SD] ±8.5). Prematurity was associated with 79% (n = 83) of cases, and the mean gestation was 27.2 weeks (SD ±4.1). A history of intubation was found in 99% of cases (n = 104), with a mean duration of intubation of 24 days. Overall, 86.6% (n = 91) were managed surgically with either microlaryngeal instruments (n = 78) or CO2 laser (n = 13), and 13.3% (n = 14) were treated conservatively. Recurrent cysts following initial treatment occurred in 73.3% of cases (n = 77) requiring a mean of 1.7 (SD ±0.84) further excision surgeries (median = 1, range 0-7). Eighty percent (n = 84) of patients had at least 1 other concurrent airway pathology: subglottic stenosis 43.8% (n = 46), laryngomalacia 6.6% (n = 7), vocal cord palsy 3.8% (n = 4), tracheomalacia 1.9% (n = 2), and other 9.5% (n = 10). The mean duration of follow-up was 47.6 months.
Conclusions: Subglottic cysts represent a reversible cause of airway obstruction. Study findings suggest that subglottic cysts are associated with prematurity, previous intubation history, and concurrent airway pathology, most notably subglottic stenosis. Recurrence is common, requiring repeat procedures.
Surgeon Perspective on the Benefits of Establishing a Neonatal Fiberoptic Endoscopic Evaluation of Swallowing Program
Austin N. DeHart, MD (Presenter); Jacqueline A. Davis, MS, CCC-SLP; Chrystal Lau; Carol Anne Camp, MS, CCC-SLP; Julie Charles, MS, CCC-SLP; Sara Peebles, MD; Abby R. Nolder, MD
Objectives: (1) Report the feasibility and safety of fiber-optic endoscopic evaluation of swallowing (FEES) in the neonatal population. (2) Discuss FEES indications, benefits, and outcomes.
Methods: A retrospective chart review of neonates at a tertiary care hospital who underwent FEES examination during an 18-month period was performed.
Results: Sixty-six neonates underwent inpatient FEES for evaluation of dysphagia. No significant adverse events occurred. A FEES was completed successfully in all infants except for 1 with previously undiagnosed choanal atresia. The most commonly made recommendations were feeding modifications. Patients’ diets were frequently thickened to nectar (29.8%), stiff nectar (24.6%), or honey (15.8%) consistencies. Twenty-one patients (31.8%) received an otolaryngology consult after FEES. Of those, 28.6% needed operative intervention, most frequently microlaryngoscopy, bronchoscopy, and supraglottoplasty. Of all patients, 19% required eventual gastrostomy tube placement.
Conclusions: Neonatal FEES is a feasible, safe, and an effective tool for the evaluation of infant swallowing. Supporting the establishment of a neonatal FEES program avoids radiation in a vulnerable population, allows for objective assessment of breast feeding safety, and facilitates diagnosis of upper aerodigestive pathology. It allows speech pathologists to make safe, informed recommendations for diet modification and helps identify patients who may need operative intervention.
Suture Lateralization Using Lumbar Puncture Needle in Bilateral VC Palsy
Neeraj Narayan Mathur, MS (Presenter)
Objectives: To present the author’s 20-year experience of suture lateralization using a lumbar puncture needle in pediatric patients with bilateral vocal cord palsy.
Methods: The presentation will include video and demonstration on a model of the author’s method of suture lateralization using a lumbar puncture needle in pediatric patients with bilateral vocal cord palsy. This novel method was published by the author in 2004 (Mathur NN, Kumar S, Bothra R. Simple method of vocal cord lateralization in bilateral abductor cord paralysis in paediatric patients. Int J Paed Otolaryngol. 2004;68:15-20). However, this presentation is of continued experience of 20 years in now 135 cases. It uses an 18-gauge lumbar puncture needle and 3-0 silk or Prolene and involves passing it through the neck from one side to the other, once below and next above the cord.
Results: This simple and novel method takes on an average 8 minutes’ operating time. There are no major complications. The minor complications include granuloma formation in neck skin at the suture site in 15.5%. Revision lateralization was needed in 22.2% of cases. It is totally reversible in the immediate postoperative period, and this was required in 1 case. There is no aspiration, and the voice is acceptable. Usually the suture is not visible on laryngoscopy after a few weeks, but the lateralization remains. Since bilateral vocal cord palsy is usually reversible in children within 2 years, the suture lateralization is effective in decannulating about 74.4% of cases. It could be redone if the stridor recurs after decannulation, and this was required in 11.1% cases. Those who failed to decannulate underwent cordotomy/laser cordotomy.
Conclusions: This method is the first-line management in all of our pediatric patients with bilateral abductor cord palsy.
Tonsillectomy Outcomes among Children with Mental Health Disorders in the United States
Yann-Fuu Kou, MD (Presenter); Ron B. Mitchell, MD; Cynthia Wang, MD; Gopi Shah, MD; Mark Sakai, MD; Romaine F. Johnson, MD, MPH
Objectives: Recent evidence suggests that children with mental health disorders are more likely to have complications after surgery. Our aim was to determine if mental health disorders affect postoperative complications after tonsillectomy and adenoidectomy (T&A).
Methods: A cross-sectional analysis using the 2006 to 2012 Kids’ Inpatient Database and the 2014 Nationwide Readmission Database to identify children (age ≤21 years) who underwent T&A. We compared children with mental health disorders (eg, autism, developmental delays, or mood disorders) to those without a mental health disorder. We contrasted sex, race, length of stay (LOS), complications, and 30-day readmissions.
Results: We estimated that of 30,618 children who underwent T&A, there were 2138 (7.0%) diagnosed with a mental health disorder. Children with mental health disorders were older (6.0 vs 5.2 years, P < .001), were more likely to be male (64% vs 36%, P < 00.001), had a longer LOS (4.0 vs 2.2 days, P < .001), and incurred higher total charges even after controlling for LOS ($39,000 vs $27,000, P < .001). These children were also more likely to have a complication (odds ratio [OR] = 1.7; 95% confidence interval [CI], 1.4-2.0; P < .001), including intubation, mechanical ventilation, or both (OR = 2.8; 95% CI, 2.3-3.4; P < .001). The 30-day all-cause readmission rate was also higher (12% vs 4.0%, P < .001). These findings disproportionately affected children with developmental delays, and those with autism, mood disorders, and psychosis were more in line with other children.
Conclusions: Children with mental health disorders, especially developmental delays, have more frequent complications, longer LOS, total charges, and readmissions than children without mental health disorders. Continued examination of this population is therefore warranted.
Transcervical Ultrasound of the Subglottis in Children
Elton M. Ashe-Lambert, MD (Presenter); Brandon Tran, MD; Julina Ongkasuwan, MD
Objectives: To compare ultrasonographic and endoscopic measurements of the pediatric subglottis.
Methods: Thirty-one patients who underwent direct laryngoscopy were recruited into this prospective observational comparison of methods study at a tertiary care children’s hospital from May 2017 to July 2018. Transcervical ultrasound was used to visualize the vocal folds, subglottis, and cervical trachea. The anterior posterior (AP) and transverse (TV) diameters of the subglottic space were measured endoscopically and via ultrasound by 2 independent evaluators. Measurements were compared for correlation, bias, and agreement. A clinically acceptable bias for subglottic diameter was assumed to be 0.5 mm or less.
Results: The median age of patients enrolled was 2.6 years (range, 4 months-13.3 years). Endoscopic subglottic AP and TV measurements ranged from 3.33 mm to 14.81 mm and from 4.44 mm to 11.65 mm, respectively, whereas ultrasonographic AP and TV measurements ranged from 4.57 mm to 9.85 mm and from 3.77 mm to 8.96 mm, respectively. Pearson coefficient showed strong correlation both for endoscopic and ultrasonographic AP (R = 0.8081, P < .0001) and TV (R = 0.8796, P < .001) measurements of the subglottis. Bland-Altman plots revealed a bias (average discrepancy) for AP measurements of 0.22 mm (clinically acceptable) and 0.11 mm for TV measurements (clinically acceptable).
Conclusions: Endoscopic and ultrasonography measurements of the pediatric subglottic airway were strongly correlated. Discrepancy between AP and TV measurements was low and deemed clinically acceptable. Ultrasound of the subglottis may be an alternative to endoscopic assessment of the airway for measurement of the subglottic airway in children.
Trends of Pediatric Head and Neck Cancer in South Korea (2007-2016)
Pona Park (Presenter); Jeong Whun Kim
Objectives: Pediatric cancer is the number one cause of childhood death in Korea. However, the incidence of pediatric head and neck cancer including thyroid cancer is not well understood. The purpose of this study was to analyze the incidence and survival rate of pediatric head and neck cancer by anatomic site in South Korea using the claimed data of Korean National Health Insurance Service (NHIS).
Methods: The study period was from January 2006 to December 2016. Head and neck cancer was defined by the International Classification of Diseases code 10th edition and Korean NHI–specific registration code for cancer. We enrolled children younger than 19 years, and the age groups were classified using 5-year intervals. Head and neck cancers were divided into 4 subgroups: thyroid cancer, salivary gland cancer, nasopharyngeal cancer, and others.
Results: The incidence rate of pediatric thyroid cancer was the highest and statistically increased from 2007 (1.17 per 100,000) to 2016 (2.01 per 100,000; P < .0001). The incidence rate of pediatric thyroid cancer in girls was 3 to 4 times higher than in boys. Five-year survival probability was 99.6% in thyroid cancer, 94.8% in salivary gland cancer, 86.8% in nasopharynx cancer, and 81.6% in others, which was statistically significantly different (P < .0001).
Conclusions: The increase in thyroid cancer in children who do not regularly undergo cancer screening shows that the incidence of thyroid cancer increases spontaneously in children in South Korea. The survival rate of nasopharynx cancer, excepting head and neck cancers in the “other” subgroup, was the lowest among the pediatric head and neck cancer patients.
Weight Gain in Infants with Pierre Robin Sequence in the First Year of Life
Leo Li (Presenter); Andrew R. Scott, MD
Objectives: To compare the growth trends among infants with Pierre Robin sequence (PRS) to normal World Health Organization (WHO) growth standards.
Methods: A retrospective chart review was conducted at an urban academic medical center examining the records of 24 infants with PRS born between 2009 and 2017. Weights were recorded at roughly 1- to 3-month intervals from birth to age 12 months, with ages adjusted for prematurity. The 50th percentile (P50) for this cohort was calculated and compared with the WHO standards.
Results: Twenty-four infants with PRS were included in the analysis (46% female), with 135 weights collected. Infants with symptomatic hypoventilation underwent mandibular distraction osteogenesis (75%), with the remaining newborns managed conservatively. Among all infants, the birth weight P50 was similar to the WHO standard (girls: 0.09 kg above WHO [95% confidence interval {CI}: −0.25 to +0.43], z-score = 0.19; boys: 0.38 kg below WHO [95% CI: −0.77 to 0.00], z-score = −0.79). A slower growth rate was noted in both groups. At month 5, the PRS P50 among girls was 1.42 kg below the WHO standard (95% CI: −1.77 to −1.07; z-score = −1.64). Among boys at month 3, the PRS P50 was 1.68 kg below the WHO (95% CI: −2.12 to −1.24; z-score = −2.19). By month 12, weight deficiencies had resolved in both groups.
Conclusions: Newborns with or without PRS may have similar birth weights; however, the growth rate among male and female infants with PRS may lag behind that of unaffected infants, even when upper airway obstruction has been addressed earlier in infancy.