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Objective: The value of pre-operative coagulation testing for adenotonsillar surgery is controversial. The purpose of this study was to evaluate the role of routine coagulation tests and a standardized questionnaire in children before tonsillectomy and/or adenoidectomy. Results: A total of 143 children were prospectively enrolled in the study between 2013 and 2017, 81 males (56.6%) and 62 females (43.4%), age range 1 to 18 years (median age 5 years). Eighteen bleeding events were documented, three of them required treatment in the operating room. Abnormal coagulation tests were not associated with higher odds of bleeding after surgery. Higher risk of bleeding (p = 0.01) was associated with an abnormal standardized medical questionnaire. [ABSTRACT FROM AUTHOR]

Yeast cells are extensively used as a key model organism owing to their highly conserved genome, metabolic pathways, and cell biology processes. To assist in genetic engineering and analysis, laboratory yeast strains typically harbor auxotrophic selection markers. When uncompensated, auxotrophic markers cause significant phenotypic bias compared to prototrophic strains and have different combinatorial influences on the metabolic network. Here, we used BY4741, a laboratory strain commonly used as a "wild type" strain in yeast studies, to generate a set of revertant strains, containing all possible combinations of four common auxotrophic markers (leu2∆, ura3∆, his3∆1, met15∆). We examined the effect of the auxotrophic combinations on complex phenotypes such as resistance to rapamycin, acetic acid, and ethanol. Among the markers, we found that leucine auxotrophy most significantly affected the phenotype. We analyzed the phenotypic bias caused by auxotrophy at the genomic level using a prototrophic version of a genome‐wide deletion library and a decreased mRNA perturbation (DAmP) library. Prototrophy was found to suppress rapamycin sensitivity in many mutants previously annotated for the phenotype, raising a possible need for reevaluation of the findings in a native metabolic context. These results reveal a significant phenotypic bias caused by common auxotrophic markers and support the use of prototrophic wild‐type strains in yeast research. [ABSTRACT FROM AUTHOR]

Introduction: Skull base lesions in children and adolescents are rare, and comprise only 5.6% of all skull base surgery. Anterior skull base lesions dominate, averaging slightly more than 50% of the cases. Until recently, surgery of the anterior skull base was dominated by open procedures and endoscopic skull base surgery was reserved for benign pathologies. Endoscopic skull base surgery is gradually gaining popularity. In spite of that, open skull base surgery is still considered the “gold standard” for the treatment of anterior skull base lesions, and it is the preferred approach in selected cases. Objective: This article reviews current concepts and open approaches to the anterior skull base in children in the era of endoscopic surgery. Materials and Methods Comprehensive literature review. Results: Extensive intracranial–intradural invasion, extensive orbital invasion, encasement of the optic nerve or the internal carotid artery, lateral supraorbital dural involvement and involvement of the anterior table of the frontal sinus or lateral portion of the frontal sinus precludes endoscopic surgery, and mandates open skull base surgery. The open approaches which are used most frequently for surgical resection of anterior skull base tumors are the transfacial/transmaxillary, subcranial, and subfrontal approaches. Reconstruction of anterior skull base defects is discussed in a separate article in this supplement. Discussion: Although endoscopic skull base surgery in children is gaining popularity in developed countries, in many cases open surgery is still required. In addition, in developing countries, which accounts for more than 80% of the world’s population, limited access to expensive equipment precludes the use of endoscopic surgery. Several open surgical approaches are still employed to resect anterior skull base lesions in the pediatric population. With this large armamentarium of surgical approaches, tailoring themost suitable approach to a specific lesion in regard to its nature, location, and extent is of utmost importance. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Eustachian tube dysfunction and sleep-disordered breathing (SDB) share common pathophysiologic mechanisms. Our objective was to investigate whether children referred for isolated TTI (tympanostomy tube insertion) are at increased risk for snoring and upper airway procedures. Methods: Telephone interviews to parents of children who underwent isolated TTI and to age- and gender-matched controls were conducted. Results: Four hundred fifty-seven children were included in the study; 352 had isolated TTI (study group) and 105 children were controls. Twenty-two percent of children in the study group were reported to snore compared with 7.6% in the controls (p =0.001). Eighteen percent of children in the study group were reported to have undergone adenotonsillectomy compared with 4.8% in the controls (p =0.0005). Future SDB, i.e., either snoring or adenotonsillectomy following TTI, was found in 34% of children in the study group compared with 11% in the controls (p =0.0004). Children who underwent isolated TTI were at increased risk for future snoring (OR=3.4, CI: 1.6–7.2) and future adenotonsillectomy (OR=4.4, CI: 1.7–11.2). Conclusions: Children who undergo isolated TTI are at increased risk for snoring and for adenotonsillectomy. We suggest that these children be followed for symptoms of SDB on a scheduled basis to allow for early diagnosis and intervention. [Copyright &y& Elsevier]

Objectives: We describe the clinical characteristics and management of vocal fold paralysis in infants who were born with a tracheoesophageal fistula (TEA). Methods: This retrospective case series included all infants born with TEFs who presented to our pediatric otolaryngology unit and intensive care unit because of dyspnea or aphonia in the years 2005 and 2006, and who were found to have vocal fold paralysis. Results: Five boys and 1 girl were studied. One infant had stridor before TEA repair, and 5 after it. All children underwent flexible laryngotracheobronchoscopy and were treated in the pediatric intensive care unit before diagnosis of the vocal fold paralysis (5 bilaterally and 1 unilaterally) was made. The ages at diagnosis of paralysis ranged between 14 days and 14 months. Five infants required tracheostomy. Conclusions: Vocal fold paresis in infants is difficult to diagnose. The risk for recurrent laryngeal nerve injury associated with TEA and TEA repair should be emphasized in these children. We recommend that all newborns with TEA should be examined by an otolaryngologist before operation to confirm the mobility of the vocal folds and to rule out other associated airway malformations, and examined after operation if respiratory difficulties develop. [ABSTRACT FROM AUTHOR]

Cochlear dysplasia is a rare congenital anomaly. However, early detection of this anomaly can prevent serious consequences. We describe three cases of cochlear dysplasia that presented with recurrent meningitis and cerebro-spinal fluid (CSF) leak in children in which early diagnosis prevented further complications. [ABSTRACT FROM AUTHOR]

Described is a 15-year-old boy who presented with an ulcerative destructive soft palate lesion, skin lesions, and prolonged history of weakness and abdominal pain associated with abnormal liver functions.A midline destructive lesion was considered. However biopsies revealed chronic inflammation. After thorough investigation including colon, liver, skin and uvular biopsies a diagnosis of Inflammatory Bowel Disease in association of Autoimmune Sclerosing Cholangitis was made. Treatment with steroids improved his symptoms, normalized liver functions and enhanced healing of the skin and palatal lesions.This case demonstrates the involvement of the palate in a rare systemic disease and to our knowledge is the first description of Sclerosing Cholangitis presenting as an ulcerative lesion of the soft palate. [Copyright &y& Elsevier]

Objective: To define the etiology, management and prevention of iatrogenic neonatal nasal obstruction caused by intra-nasal synechia (INS). Design: Case series retrospectively reviewed, years 2001–2002. Setting: Tertiary care children’s hospital Patients: Four neonates, ages 2 weeks to 3 months, evaluated for nasal obstruction and consequent respiratory distress. Endoscopic findings were of intra-nasal synechia caused by previous intra-nasal invasive interventions. Main outcome measures: The procedures inciting the formation of synechia, possible management problems leading to synechia formation, clinical presentation, treatment and results of treatment were documented. Results: Initial incorrect diagnosis and management with an inappropriate intervention was found to be a possible cause of nasal obstruction due to synechia formation in three of these patients (two with associated craniofacial anomalies). In one patient complete nasal obstruction due to synechia was a result of continuous positive airway pressure (CPAP) intra-nasal catheters. Treatment including endoscopic synechiolysis resulted in an improved airway but not a complete cure. All patients required multiple procedures to attain a satisfactory nasal airway. Conclusion: Careful initial diagnosis and management of neonatal nasal obstruction may prevent severe complications caused by synechia in the nasal cavity. [Copyright &y& Elsevier]

Presents a case report of a bone-destructive mucocele involving sphenoid sinus and pneumatized anterior clinoid process. Left eye pain and diplopia in a 49-year-old man; Use of magnetic resonance imaging-aided navigation in endoscopic sinus surgery of the bone-destructive sphenoclinoic mucocele.

Objective: To determine if children with neurological impairment are at additional risk for foreign body aspiration or impaction and if they present with a different clinical course than normal children. Design: Retrospective cohort study. Setting: Tertiary care children''s hospital. Patients and other participants: A retrospective chart review of 328 consecutive procedures for aero-digestive foreign body removal over a 6 year period was performed. Of these patients 52 (15.9%) were identified with neurological impairment. Results: Compared with the non-impaired children, those with neurological impairment were older, diagnosed later, hospitalized longer and had a higher incidence of complications. Conclusion: A greater index of suspicion is needed to timely treat aero-digestive foreign bodies in children with neurological impairment. These children may not be receiving the necessary attention when presenting with non-specific symptoms. [Copyright &y& Elsevier]

This study aims to analyze the demographics, therapeutic approaches, and outcomes of pediatric sarcomas of the head and neck treated at a single tertiary referral center. We retrospectively reviewed the medical charts of all pediatric patients diagnosed with head and neck sarcomas treated at the Tel Aviv Sourasky Medical Center during 2002–2021. Clinical data, oncologic and surgical treatments, and outcome measures were retrieved from electronic medical files. A total of 52 patients met the inclusion criteria. The mean age at diagnosis was 7.25 ± 6.04 years (range 2 months to 20 years), and the male-to-female ratio was 1.4: 1. The leading histological subtypes were rhabdomyosarcoma (RMS) (50%) followed by Ewing sarcoma (23%). The vast majority (96%) of patients were treated with multimodal therapy that included chemotherapy, surgical resection, and/or radiation therapy. Twenty-nine (55.8%) patients underwent surgical resection. The average follow-up was 4.75 years (range 5 months to 13.5 years). The 1-, 5-, and 10-year overall survival rates were 89.5%, 81.3%, and 62.5%, respectively. Male sex, Ewing sarcoma, and non-metastatic disease at diagnosis were associated with better disease-free survival (DFS) (p = 0.008, p = 0.048, and p = 0.038, respectively). Patients with sarcomas suitable for surgical resection and those who received adjuvant therapy had significantly better DFS (p = 0.003 and p = 0.025, respectively). Conclusions: Head and neck sarcomas in the pediatric population are best managed by a multidisciplinary team. Surgical resection and the integration of adjuvant therapy in selected patients confer survival benefit. What is Known: • Head and neck sarcomas pose a considerable challenge to physicians due to their rarity, their heterogenic presentation, and their proximity to vital structures. What is New: • A multimodal therapeutic approach that includes chemotherapy, radiotherapy, and surgical resection when feasible should be provided to these patients in order to optimize survival outcomes. Surgical resection and the integration of adjuvant therapy in selected patients confer survival benefit. [ABSTRACT FROM AUTHOR]

Described is a 2-year-old child who required a tracheotomy for an obstructing laryngeal tumor. Post-operatively the child responded with extreme anxiety and refused to cooperate with tracheostomy care including suctioning, tie changing and cannula change. A novel approach was attempted. We performed a tracheotomy on the child''s favorite doll and taught her to perform all the necessary tracheostomy care on the doll. Once the child became accustomed to treating the doll, it became much easier to care for her tracheostomy and compliance to treatment improved greatly to the point were restraint was no longer required. This model of mock surgery and care of a child''s doll may be helpful in treating young children with tracheotomies. [Copyright &y& Elsevier]

Dysphonia and stridor are not infrequent in the pediatric population. Awake nasolaryngoscopy (ANL) is the primary diagnostic procedure used to evaluate a child with stridor and/or dysphonia. The major limitation of this technique is poor cooperation in children, resulting in inadequate visualization of the larynx. Ultrasound is a widely used noninvasive imaging modality that has yet to be applied to the laryngeal examination. Our goal was to investigate the feasibility and diagnostic potential of laryngeal ultrasound (LUS) in cases of pediatric stridor and/or dysphonia. Prospective blinded cohort study of infants and children 0–16 years of age referred for ANL due to voice disorders and/or stridor. Prior knowledge of the etiology was considered an exclusion criterion. LUS concurred with the ANL in the diagnosis of abnormal vs normal larynx in 28/32 children that were recruited. LUS had a sensitivity and specificity of 87% (95% CI: 69%–96%) and 100% (95% CI: 16%–100%) respectively, for diagnosing overall laryngeal disorders in comparison to ANL. LUS also had an area under the receiver operating characteristic (ROC) curve (AUC) of 0.93, (P = 0.04, 95% CI: 0.84–1). LUS may be applied as an adjuvant diagnostic tool for ruling in laryngeal pathologies in children including dysphonia and stridor. As further experience is acquired the value of LUS in diagnosis will be better understood. [ABSTRACT FROM AUTHOR]

Click here for the corresponding questions to this CME article. [ABSTRACT FROM AUTHOR]

BACKGROUND: To evaluate chorda tympani nerve function as measured by unilateral increases of gustatory thresholds in the presence of ipsilateral acute otitis media. METHODS: Prospective clinical study comparing electrogustometric measurements was conducted to evaluate the taste thresholds of each side of the tongue in a patient during an acute episode of unilateral acute otitis media. Included were patients aged 12-40 who presented to the emergency department and outpatient ear, nose, and throat clinic of a university-affiliate tertiary medical center with unilateral acute otitis media between January 2019 and January 2020 and consented to the study. RESULTS: Eleven patients were initially recruited into the study, and 10 patients aged (mean ± standard deviation) 26.1 ± 11.2 years comprised the final study group. Taste thresholds were significantly elevated on the side ipsilateral to the ear affected by acute otitis media (P < .05). CONCLUSION: Chorda tympani nerve conductance is impaired during the acute stage of acute otitis media. This may have implications in the understanding of peripheral neural properties during acute middle ear inflammatory conditions and on the diagnosis of acute otitis media. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Evaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy. Method: Design: retrospective case series; blinded review. Setting: tertiary care children's hospital. Patients: Children with persistent obstructive sleep apnea. Interventions: Both awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey. Main outcome measures: reviewers scored the following parameters: each structure's contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good). Results: When reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value<0.05). Level of confidence among the four observers was higher in older children and lower in children with severe OSA. Conclusions: Sleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy. [Copyright &y& Elsevier]

Objective: To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. Design: Prospective case series study. Main Outcome Measures: Patients with chronic tympanic membrane perforations were considered candidates for fat graft myringoplasty. Excluded were patients with purulent discharge, suspected ossicular disease, suspected cholesteatoma, or a perforation diameter greater than 6.5 mm. Fat was harvested from the ear lobule or subcutaneous tissue just posterior-inferior to the lobule. Results: The study population comprised 27 adults and 11 children. Twenty-eight perforations were small (73.7%) and 10 were large (26.3%). Altogether, 31 of 38 perforations were successfully repaired (81.6%), including 22 of 28 small perforations (78.6%) and 9 of 10 large perforations (90%). Assessment by age showed that 23 of 27 perforations of the adults (85.2%) and 8 of 11 perforations of the children (72.7%) successfully closed (p = .648). Follow-up ranged from 25 to 53 months (mean 40.6 ± 8.3 months). No recurrence of the perforation during the follow-up period was recorded if the initial results were successful. The speech reception threshold improved significantly (18.5 ± 7.7 dB vs 23.5 ± 8 dB; p = .043). No significant sensorineural hearing loss occurred. Conclusions: Fat graft myringoplasty is a reliable technique for the closure of small- and medium-sized perforations. The grafting results showed excellent long-term durability. Given the simplicity of the technique, its short duration, and the favourable hearing results, fat graft myringoplasty should be considered the procedure of choice in patients with suitable perforations and when not otherwise contraindicated. [ABSTRACT FROM AUTHOR]

Objective: Adenotonsillar hypertrophy (ATH) is the leading cause for obstructive sleep apnea syndrome (OSAS) in children. The peak age for adenoid and tonsillar hypertrophy and related OSAS is 3–6 years. It has been suggested that OSAS due to ATH is extremely rare in infants. The purpose of the present study was to delineate OSAS due to ATH in infants. Methods: Twenty-nine consecutive infants <18 months of age who underwent polysomnography (PSG) and were diagnosed with OSAS due to ATH were studied. A pediatric sleep questionnaire was completed by parents of all infants. Information regarding demographic variables, referring physician specialty, assessment of infant''s development and recurrence of symptoms post treatment was collected. Pre and post surgery body weight and developmental assessment by parents were evaluated. Results: The mean age of adenotonsillectomy was 12.3±3.9 months with the mean duration of symptoms ranging 6.2±3.0 months. 24% of the infants were born preterm. Snoring was the most common finding and appeared in all infants. Other symptoms were sleep apnea (72%), frequent movements during sleep (69%), mouth breathing (62%) and recurrent awakenings (38%). During the preoperative period, mean body weight decreased from the 67th±25 percentile to the 42nd±32 percentile (P<0.00001). 14/29 (48%) of the infants dropped two or more major percentiles before treatment. A significant weight gain to the 59th±31 percentile was observed post surgery (P<0.0001). 5/29 (17%) infants were considered by their parents as having a developmental delay preoperatively, which resolved in 3/5 (60%) post treatment. Clinical symptoms resolved or improved significantly after surgery. Recurrence of symptoms was documented in 6/23 (26%) of infants. Conclusions: Infantile OSAS due to hypertrophic adenoids and tonsils does occur in infants. Unique characteristics for this age group include: male predominance, high incidence of preterm infants, failure to gain weight and high recurrence rate after surgery. Otolaryngologists and pediatricians should be aware to the existence of the “early OSAS” in small infants. [Copyright &y& Elsevier]

Complications from a prolonged nasogastric tube intubation, though seldom reported, are well described. Herein we describe the first two reported cases of velopharyngeal insufficiency secondary to velopharyngeal scarring and immobility from repetitive nasogastric tube insertions and prolonged use. Differing only in location, the proposed pathophysiologic mechanism of injury is identical to that of the nasogastric tube syndrome, a rare and serious, well described entity consisting of bilateral vocal fold paralysis due to pressure-induced ulceration of the posterior cricoarytenoid musculature. [ABSTRACT FROM AUTHOR]

Background: Preoperative planning of open laryngotracheal surgery is important for achieving good results. This study examines the surgeon's perception of the importance of using life size 3D printed models of the pediatric airway on surgical decision making. Methods: Life-size three-dimensional models of the upper airway were created based on CT images of children scheduled for laryngotracheal-reconstruction and cricotracheal resection with anastomosis. Five pediatric airway surgeons evaluated the three-dimensional models for determining the surgical approach, incision location and length, graft length, and need for single or double-stage surgery of seven children (median age 4.4 years, M:F ratio 4:3). They rated the importance of the three-dimensional model findings compared to the direct laryngoscopy videos and CT findings for each domain on a validated Likert scale of 1–5. Results: The mean rating for all domains was 3.6 ± 0.63 ("moderately important" to "very important"), and the median rating was 4 ("very important"). There was full agreement between raters for length of incision and length of graft. The between-rater agreement was 0.608 ("good") for surgical approach, 0.585 ("moderate") for incision location, and 0.429 ("moderate") for need for single- or two-stage surgery. Conclusion: Patient-specific three-dimensional printed models of children's upper airways were scored by pediatric airway surgeons as being moderately to very important for preoperative planning of open laryngotracheal surgery. Large–scale, objective outcome studies are warranted to establish the reliability and efficiency of these models. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay.Methods: Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded.Results: During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE.Conclusions: Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU. [ABSTRACT FROM AUTHOR]

Summary: Background: Pachyonychia congenita (PC) is a rare autosomal dominant genodermatosis caused by a mutation in any one of five keratin genes (KRT6A,KRT6B,KRT6C,KRT16 or KRT17). Characteristic features of PC are painful palmoplantar keratoderma, variable nail dystrophy, cysts, follicular hyperkeratosis and often oral leukokeratosis. Although oral leukokeratosis can go unnoticed, mucosal involvement of the oral cavity and upper airways can manifest with pain during feeding, hoarseness, stridor and, occasionally, life‐threatening obstruction. Objectives: To characterize patients with PC with symptomatic mucosal involvement. Methods: We present a case series of nine children with PC with symptomatic mucosal involvement, all with heterozygous mutations in KRT6A. Seven patients complained of painful feeding problems. Four patients were diagnosed with failure to thrive, three of whom required a feeding tube. Simple feeding solutions were beneficial in most cases. Seven patients had laryngeal involvement and one patient died at 4 years of age from acute laryngeal obstruction. Conclusions: It is important for dermatologists and otolaryngologists to be aware that symptomatic mucosal involvement, and very rarely laryngeal obstruction, can occur in patients with PC. Usually simple feeding solutions may prevent complications and failure to thrive. What's already known about this topic? Pachyonychia congenita (PC) is a rare autosomal dominant genodermatosis due to a mutation in any one of five keratin genes.Symptomatic mucosal involvement is an important clinical feature of PC and appears to be more pronounced in KRT6A mutation carriers.Only leukokeratosis is frequently seen in PC and can be one of the earliest signs of disease.Laryngeal involvement is a less common feature. It might be symptomatic but usually presents as hoarseness, stridor and, occasionally, as a life‐threatening respiratory distress. What does this study add? In most cases of laryngeal involvement, there is no need for any intervention.Although pain and feeding difficulties are usually attributed to the oral leukokeratosis, they can be related to a phenomenon called 'first bite syndrome' (FBS).Symptomatic mucosal involvement with feeding difficulty is important but can be managed in most cases with simple feeding solutions (e.g. softer nipple with a larger hole, thicker formula and feeding with a syringe). Linked Comment:Youssefian and Vahidnezhad. Br J Dermatol 2020; 182:536–537. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic balloon dilation (EBD) is the mainstay of endoscopic therapy for laryngotracheal stenosis (LTS), although there is no evidence that it achieves better results than traditional rigid laryngeal dilators. Rigid bougie dilators are less expensive and easier to use, and confer the advantage of providing tactile information about the stenosis to the surgeon. We analyzed the outcome of endoscopic rigid bougie dilatation of LTS in a large series of children and compared it to the reported results of EBD in the same setting.Patients and methods: All cases of pediatric LTS treated by endoscopic rigid dilatation in a tertiary referral center between 2006 and 2015 were retrospectively studied. They were divided into a primary dilatation group (PDG) and a post-reconstruction dilatation group (PRG). The PDG children had no history of reconstructive airway surgery, and dilatation was the major treatment approach. The PRG children underwent dilatations after airway reconstruction surgery as part of routine postoperative management. A successful primary outcome was defined as improvement of dyspnea and achievement of a functional airway without reconstructive laryngotracheal surgery or need for a tracheostomy at final follow-up.Results: Sixty-two children (68 cases, mean age 5.1 years, range 0.7-17.2) underwent 156 endoscopic rigid dilatations. Successful outcome was achieved in 48 cases (70.6%), 73.0% in the PDG and 67.7% in the PRG. There were no procedure-related adverse events.Conclusions: Endoscopic rigid dilatation is a relatively inexpensive and efficacious tool in endoscopic management of pediatric LTS. Its success rates are in the same range as those of EBD. [ABSTRACT FROM AUTHOR]

Objectives Seven years after the introduction of the pneumococcal conjugate vaccines (PCV) in Israel, its effect on the incidence and severity of episodes of acute mastoiditis (AM) remains unclear. The primary objective of this study was to determine the incidence of AM and describe its clinical features in children during the years that followed the introduction of the PCV13 in comparison with the pre-PCV period. Methods Included in this retrospective comparative case series were all pediatric patients diagnosed with AM between Jan. 2007 and Dec. 2015 in one tertiary medical center. The patients were divided into 3 groups: pre-PCV, post-PCV7 (July 2009 through Dec. 2010) and post-PCV13 (Jan. 2011 through Dec. 2015). The patients' medical records were reviewed, and data on age at presentation, gender, presenting signs, bacterial ear cultures, hospitalization course, complications, surgical interventions, inflammatory response and outcome were retrieved and compared between the groups. Comparison was made between the pre-PCV and the post-PCV13 groups. Results 216 children were identified for analysis, 80 children in the pre-PCV period, 31 in the post-PCV7 period and 105 in the post-PCV13 period. Their mean age was 2.6 years. The number of AM cases per 1000 visits at the emergency room decreased by 46% in the post-PCV13 period compared to the pre-PCV period. There was no difference in the rate of AM between the post-PCV7 and post-PCV13 periods. No differences were found in age, gender, hospitalization length, C-reactive protein level, white blood cell count, rate of surgical interventions (mastoidectomy and incision and drainage) and rate of complications between the 3 groups. Conclusion The incidence of AM was lower in the post-PCV13 period compared to the pre-PCV period. The rate of AM complications, however, has not changed, nor has the number of mastoidectomies. [ABSTRACT FROM AUTHOR]

Objectives To characterise the craniofacial structure by cephalometry, especially the skull base and nasopharyngeal space, in children who underwent adenoidectomy and developed persistent velopharyngeal dysfunction ( VPD). Design Retrospective study. Setting Speech and swallowing clinic of a single academic hospital. Participants Thirty-nine children with persistent VPD following adenoidectomy (mean age 8.0±3.6 years) and a control group of 80 healthy children. Main outcome measures Cephalometric landmarks were chosen; craniofacial linear and angular dimensions were measured and analysed. Results The linear dimensions of the nasopharyngeal area were shorter in the VPD group, S-Ba (41.6±4.2 mm, P<.05) and S-Ptm (42.4±5.1 mm, P<.05). The anterior skull base, N-S, was similar (68.1 mm±6.8). The velum length, Ptm-P was significantly shorter in the VPD group (27.8±4.3 mm, P<.001). The Ba-S-Ptm angle was significantly larger in the VPD group (63.5±5.6°, P<.001). There was no significant difference in cranial base angle ( CBA), Ba-S-N, between the two groups. Conclusions Cephalometry may provide information regarding persistent postoperative VPD. The nasopharyngeal space angle and velar length appear to be risk factors for persistent VPD after adenoidectomy. [ABSTRACT FROM AUTHOR]

To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea. The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus. A total of 78 consensus statements were evaluated by the panelists at the first survey – 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids. This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients. [ABSTRACT FROM AUTHOR]

Objective Informed consent is an important part of the surgical process. Based on our clinical experience, we hypothesized that parents providing consent for their children's tonsillectomy do not comprehend all the information that is given to them by the operating surgeon at the time of a conventional consent process. Materials and methods Parents whose children were scheduled for tonsillectomy with or without adenoidectomy and/or tympanostomy tubes insertion were enrolled. Within one hour after the consent process, they were asked to complete a questionnaire designed to collect demographic data and to evaluate how much of the information that was given to them was actually understood. Results Ninety-seven parents were enrolled between October 2011 and March 2013. The average percentage of correct answers (score) for the 16 multiple-choice questions was 76.3%. The average scores were 84.8% for the native Hebrew-speaking parents and 71.9% for the parents whose first language was other than Hebrew ( p < 0.01). The average scores were 83.3% for the parents who are healthcare system workers and 74.4% for those parents whose profession is not related to medicine ( p < 0.05). Fifty parents (51.5%) responded incorrectly to at least one of two questions that we defined as essential: “What would you do if your child starts to bleed from the mouth” and “What kind of food is recommended for your child during the first week after the surgery”. Conclusion The current conventional method of obtaining informed consent for tonsillectomy is inadequate, as reflected by the low level of parental comprehension of essential information. Further studies which will evaluate methods for improving the consent process are highly warranted. [ABSTRACT FROM AUTHOR]

Adenoid hypertrophy is the most common cause of upper airway obstruction and sleep-disordered breathing in children, yet its pathogenesis remains unclear. The identification of the novel helper T cell subsets, Th17 cells and regulatory T cells (Tregs) could provide new insight into our understanding of the mechanisms involved in the development of this condition. The purpose of this study is to evaluate the adenoidal lymphocyte subsets to describe the percentage of various lymphocyte subsets in hypertrophied adenoids and correlate them with symptom severity. Twenty consecutive children undergoing adenoidectomy were included, and lymphocytes were isolated from their adenoids. T cell subpopulations were detected by flow cytometry using a fluoresceinated monoclonal antibody directed against a number of cell markers (CD4++, CD8++, CD25++, FOXP3 IL17++, and others). We found a significant negative linear correlation between the Th17/Treg ratio and the patients'' clinical scores (R == −−0.71 p < 0.005). The correlation was independent of age and gender. Decreased ratios of Th17/Treg subpopulations may play a role in the pathogenesis of adenoid hypertrophy. [ABSTRACT FROM AUTHOR]

Post-traumatic cerebrospinal fluid leak from the anterior cranial fossa in children may be isolated or combined with severe facial and calvarial injury. Untreated leak may result with meningitis, hydrocephalus, and abnormal neurocognitive development. We present nine children, ages 4–16 years, with complicated craniofacial injury treated by a combined subcranial and intracranial approach. A continuous lumbar drainage was kept for several days, and prophylactic antibiotics and anti-convulsive medications were routinely given. A multidisciplinary approach including discussion before surgery about other surgical options (endoscopic extracranial and intracranial alone) were performed. None of the operated children had episodes of meningitis/leak after the combined approach, suggesting that appropriate sealing of the base of the skull has been achieved. There was no mortality, and the long-term follow-up showed good developmental and cosmetic results. Most of the children had significant brain contusions prior to surgery; however, these did not progress as minimal retraction was enabled by the extensive subcranial and intracranial approach. Child’s age, anatomy of the bone, extent of cranial injury, and clinical parameters should be seriously considered when choosing the technical methods as for sealing base of skull and reconstruction of facial/cranial bones. Young age does not seem to be a contraindication to the combined approach, thus, we recommend considering it in extensive base of skull fractures when concomitant cranial, maxillofacial, and orbital fractures coexist, as alternative options may not suffice in these cases. [ABSTRACT FROM AUTHOR]

Summary: Objective: To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy. Design: A retrospective chart review. Setting: Tertiary-care, university affiliated children''s hospital. Patients: One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002. Interventions: All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call. Main outcome measures: Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions. Results: Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p =0.028) and had more complications (n =17 vs. n =8, p <0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p =0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR. Conclusions: These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series. [Copyright &y& Elsevier]

Summary: Objective: Laryngomalacia is the most common cause of congenital stridor. Laryngomalacia may be associated with other structural and functional airway lesions. While previous studies suggested a 10–45% rate of synchronous airway lesions (SALs), the exact rate and it''s clinical significance is unknown. The purpose of this study was to determine the prevalence of SALs below the glottic level in congenital laryngomalacia, and to investigate possible relations with other clinical findings. Methods: A cohort of 228 infants with congenital stridor who underwent fiberoptic flexible bronchoscopy (FFB) was analyzed. Data was collected from the hospital records. All procedures were reevaluated from the video recordings. Results: SALs below the vocal cords were observed in 7.5% of the case (17/228). The most common SAL was tracheal bronchus followed by tracheomalacia and stenosis of the left main bronchus. No correlation was found between the presence of a SAL below the vocal cords and any other medical condition except for neurodevelopmental disorders. Except for one patient, all cases with SAL did not have any clinical symptoms or signs that would have suggested an accompanying airway lesion. Conclusions: The rate of SALs in infants with congenital stridor due to laryngomalacia is low and most of the additional lesions are benign. The yield of discovering clinically significant SALs below the glottic level is low and the routine search for a synchronous lesion below the vocal cords should be questioned. Except for underlying neurodevelopmental problems, no clear risk factors for the existence of SALs were identified. [Copyright &y& Elsevier]

Summary: We report a rare case of acute otitis media (AOM) complicated by arterial brain infarction, meningitis and orbital cellulitis. Computed tomography (CT) initially showed suspected epidural abscess, coalescent mastoiditis, and orbital cellulitis. Further clinical deterioration occurred following mastoidectomy and evacuation of the abscess. Magnetic resonance imaging (MRI) revealed subacute brain infarction and an extra-axial brainstem abscess. Revision of the initial CT revealed subtle signs suggestive of arterial brain infarction. Although CT with contrast is the standard of care for suspected AOM complications, MRI should be considered as an adjunct when CT is not definitive and neurological signs are present. [Copyright &y& Elsevier]

Objectives: Hyperkinetic laryngeal behaviors may be used to achieve glottal closure in the presence of vocal cord disorders. In adults, the Glottal Function Index (GFI) is a validated self-administered survey used to evaluate glottal insufficiency. In children, the relationships between glottal closure and vocal cord lesions have not been examined. We undertook to evaluate the efficacy of the GFI in detecting disorders of the vocal cords in children. Methods: We evaluated 100 consecutive children who underwent flexible fiberoptic laryngoscopy. A 4-item GFI questionnaire was administered to the parents of each study subject on study entry. The videotapes of the examinations were evaluated and scored by 3 investigators in a blinded manner. The GFI scores were compared in subjects with and without vocal cord findings. Results: The final analysis included 100 children 2 to 16 years of age. The mean age of the study group was 7.3 years (±3.9 years). Of the 100 patients, 54 had vocal cord disorders. The most common was vocal cord nodules, in most cases combined with bowing of the vocal cords; the two variables were highly correlated (p << .01). We performed a receiver operating characteristics test between the presence of vocal cord disorders and the GFI score. We found that the ‘optimal’ score, on which the sensitivity and specificity curves cross, was 3. Of the 54 patients who had vocal cord disorders, the index identified 38 patients (70%), whereas the patients' complaints identified only 30 patients (55.6%). This difference was statistically significant (p < .05). Conclusions: The GFI is a reliable 4-item symptom index with excellent correlation to the presence of vocal cord lesions in children. [ABSTRACT FROM AUTHOR]

RATIONALE: Fiberoptic flexible laryngoscopy (FFL) is the diagnostic procedure of choice in patients with laryngomalacia. Two techniques can be applied, either when the infant is awake or using anesthesia/sedation. The choice of technique may effect the diagnosis. STUDY OBJECTIVES: To compare the two techniques for diagnosing laryngomalacia. PATIENTS AND INTERVENTIONS: A total of 42 infants who underwent awake fiberoptic laryngoscopy for congenital stridor, in whom either laryngomalacia was diagnosed or no cause for stridor was found, underwent a repeat laryngoscopy using anesthesia/sedation. The 84 video recordings of the supraglottic portions were copied onto a videotape along with 25 recordings of normal upper airways without stridor and 31 duplicate cases with stridor. A total of 140 recordings was mixed at random on a videotape. Sound was not included. MEASUREMENTS: Three investigators (Y.S., J.B.A., and A.D.) independently scored each recording using a laryngomalacia scoring system (scoring range, 0 to 8). RESULTS: A threshold score of 2 was the optimal cutoff point for discriminating laryngomalacia from normal condition. The awake technique (WT) missed three cases of laryngomalacia and overdiagnosed one healthy control subject. The anesthesia technique was superior with a sensitivity of 100%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 100% compared with 93%, 92%, 97%, and 79%, respectively, for the WT. CONCLUSIONS: The diagnosis of laryngomalacia with FFL is more accurate using anesthesia/sedation. The WT may be appropriate for screening or for patients with mild cases having a characteristic presentation. [ABSTRACT FROM AUTHOR]

The article focuses on a study that compared the two techniques, which are the awake and the anesthesia, for diagnosing laryngomalacia with fiberoptic flexible laryngoscopy (FFL). Results showed that the diagnosis of laryngomalacia with FFL is more accurate using anesthesia. In addition, results indicated that the awake technique is appropriate only for screening or for patients with mild laryngomalacia.

Summary: Objective:: Otomicroscopic examination with suctioning of ears or other procedures is frequently uncomfortable especially for children. Anxiety and pain with lack of cooperation may result in trauma to the ear, incompletion of the examination, delayed diagnosis and treatment and need for completion of the examination under general anesthesia. The purpose of this study was to evaluate the efficacy and safety of utilizing nitrous oxide–oxygen inhalation for sedation and analgesia in otologic examination and minor surgical procedures performed on the uncooperative child at the outpatient clinic. Methods:: In a prospective pilot case series study conducted at the Pediatric Otolaryngology outpatient clinic of a tertiary medical center, nitrous oxide–oxygen inhalation was administered by the examining otolaryngologist and the assisting nurse. The study group included children over 2 years old, for which an accurate diagnosis of ear pathology could not be made or a minor surgical procedure could not be tolerated because of anxiety and lack of cooperation. Results:: Completion of the indicated procedure was successful in 21 of 24 patients (88%). Full cooperation, where no restraint was necessary was achieved in 20 of 24 patients (83%). The mean rank pain scores, evaluated separately by the patient, parent and staff, were in the mild pain range using a 0–10 coding for Faces Pain Rating Scale. The mean procedure time was 8.9min. An adverse reaction, vomiting, occurred in one patient. Twenty-one of 24 parents stated that they would repeat the procedure if necessary. Conclusion:: This pilot study shows the potential usefulness of nitrous oxide–oxygen inhalation administered by an otolaryngologist in the outpatient clinic. Alleviation of pain and anxiety and avoiding the need for physical restraint is an important goal that can be achieved with this form of sedation. [Copyright &y& Elsevier]

Reconstruction of surgical defects by free tissue transfer following resection of head and neck tumors in children are sparse. This study aims to assess the feasibility and safety of free flap reconstruction following surgical ablation of head and neck and skull base tumors in children based on our experience and the recent literature. Data from medical files of all children and adolescents <18 years of age who underwent free flap reconstruction following resection of head and neck and skull base tumors at our tertiary center between 2000 and 2018 were retrospectively reviewed. Data on early and late complications at the primary and donor sites, functional and aesthetic outcome, and tumor control were analyzed. Twenty-four children (mean age 11.3 ± 5.1 years) were enrolled. Early complications occurred in 14 (56%) and late complications occurred in 8 (32%) of the procedures, with surgical intervention required in 4 (16%). Prior chemoradiation, sarcoma, non-reanimation procedures, and the use of rectus abdominis free flaps were associated with higher complication rates. The final functional and cosmetic outcomes, including mastication, deglutition, and speech, were satisfactory in all patients with one exception. Free flap transfer is a safe and feasible technique for reconstructing head and neck and skull base defects following surgical excision of tumors in children. Early identification and precautionary measures against the effects of potential causes of complications may improve outcome. Larger international cohort studies are warranted. [ABSTRACT FROM AUTHOR]

Direct laryngoscopy in children is usually performed with spontaneous ventilation and monitored by pulse oximetry. It is currently unknown if spontaneous ventilation has an effect on cerebral oxygenation. We hypothesized that cerebral oxygenation may be impeded during direct laryngoscopy with spontaneous ventilation in children. Our objective was to determine if children who undergo direct laryngoscopy under general anesthesia with spontaneous breathing experience significant reductions in cerebral oxygen saturation levels, and whether or not these reductions are accompanied by decreases in peripheral oxygen saturation levels. This pilot study included 16 consecutive children who underwent direct laryngoscopy under general anesthesia and spontaneous ventilation. The INVOS™ system, which is currently used to monitor cerebral oxygen saturation levels during neurosurgery and cardiothoracic surgery, consists of a processing unit and 2 sensors that are applied to the patient's forehead. We used it to record cerebral oxygenation levels throughout the procedure. Peripheral pulse oximetry was recorded simultaneously, and the results were compared to the levels recorded by the INVOS™ system. Cerebral oxygen saturation levels decreased by more than 20% from baseline in 7/10 children with tracheostomy and in 2/6 children without tracheostomy, while peripheral oxygen saturation levels remained intact in all the children. The mean time from induction of anesthesia to significant decrease in the cerebral oxygenation level (rSO2) was 14 ± 6 min for the tracheostomy group and 14.5 ± 1.5 min for the no tracheostomy group. Children who undergo direct laryngoscopy under general anesthesia with spontaneous ventilation may display reductions in brain oxygenation levels that are not detected by standard pulse oximetry, which reflects only peripheral oxygenation levels. Further study is required to explore the possible effect of this phenomenon in children who undergo direct laryngoscopy. [ABSTRACT FROM AUTHOR]

Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p =.03) and tracheal stenosis (p =.02) were significantly associated with decannulation failure. Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies. [ABSTRACT FROM AUTHOR]

An accepted screening question for Obstructive Sleep Apnea (OSA) in children is "Does your child snore". However, this has no correlation to severity. The purpose of this study is to evaluate a simple 2-item questionnaire that reflects the degree of parental concern to predict the severity of Obstructive Sleep Apnea (OSA) in children as measured by Polysomnography (PSG). Prospective analysis of parental concern regarding their children referred for PSG due to suspected OSA. Parents of all study children completed the brief Parental Concern Scale (PCS) questionnaire that we devised and the validated Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder questionnaire (PSQ-SRBD). The PCS consisted of 1 question on the need for surgery and 1 question on concerns about the child's breathing. Both questionnaires were compared to PSG results. Ninety-five children (mean age 4.2 ± 2.5 years, 52% males, mean body mass index z score 0.45 ± 1.8) were recruited. Twenty-three children (24%) had moderate-severe OSA and were referred for adenotonsillectomy. Correlations were found between the need for surgery score and the apnea-hypopnea index (r = 0.22, P =.029), as well as the mean SpO2 levels (r = −0.24, P =.02). The likelihood for the diagnosis of moderate-severe OSA by PSG increased as parental ranking for the need for surgery increased (P =.003). The need for surgery score was the only predictor for moderate-severe OSA (P =.039). Querying parents on their perception of their child's need for surgery is a practical, and easy-to-use tool that can help the clinician in prioritizing referral to PSG. [ABSTRACT FROM AUTHOR]