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Introduction: Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cervicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial. Objectives: This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges. Methods: A modified three-iterative Delphi method was used to establish expert recommendations on the diagnostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. Setting: Multinational, multi-institutional, tertiary pediatric hospitals. Results: Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. Conclusion: The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation. Keywords: Atypical mycobacteria; Cervical lymphadenitis; Consensus recommendations; Non-tuberculous mycobacteria.

Objective To provide guidance for the comprehensive management of children referred for anterior drooling. The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. Methods Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The recommendations are derived from current expert consensus and critical review of the literature. Results Consensus recommendations include initial care and approach recommendations for health care providers who commonly evaluate children with drooling. This includes evaluation and treatment considerations for commonly debated issues in drooling management, initial work-up of children referred for anterior drooling, treatment recommendations, indications and contra-indications for rehabilitation, medical, and surgical management, as well as pros and cons of different surgical procedures in the hands of drooling management experts. Conclusion Anterior drooling consensus recommendations are aimed at improving patient-centered care in children referred for sialorrhea.

Introduction Burkitt lymphoma (BL), an aggressive form of B-cell non-Hodgkin's lymphoma, arising from the nose and paranasal sinuses is relatively rare. It can present with various symptoms leading to potential misdiagnosis and delayed treatment. BL is fatal if left untreated, while early identification and treatment can improve prognosis. Objectives 1) To review clinical presentations and sites of involvement of six cases of pediatric BL with rhinologic manifestations and compare these with the current literature. 2) To raise awareness on the variety of presentations of BL in this particular anatomic location. Methods A series of six cases of pediatric (0–18 years) BL with rhinologic manifestations is presented. Age, sex, ethnicity, symptoms, imaging, staging, treatment and outcome were recorded. A systematic review of literature was also conducted using PRISMA guidelines. The search strategy used keywords related to rhinologic manifestations of BL (nasal cavity, nasopharynx, paranasal sinus etc.; Burkitt etc.) and included studies published in English and French describing patients 0–18 years of age. Results 42 patients were included (six from case series and 36 from current literature). Most common presenting symptoms were: nasal obstruction (29%), facial swelling (24%), headache (21%) and proptosis (19%). Most frequent sites of presentation were: nasopharynx (40%), maxilla (40%) and sphenoid (33%). More than half (60%) had systemic involvement, of which the most common locations were: kidney (19%), pancreas (17%) and liver (17%). Mortality from BL in children from this study population was correlated with a longer duration of symptoms prior to presentation, as well as a misdiagnosis preceding the final diagnosis of BL. Conclusions This study brings understanding to the numerous presentations of the same aggressive disease, promotes high clinical suspicion when evaluating common otolaryngologic symptoms and can guide healthcare providers in diagnosing pediatric BL with rhinologic manifestations.

To assess the evidence for pediatric sialolithiasis, including its demographic characteristics, diagnosis, and demonstrate the shift in its treatment paradigm.A systematic review of sources from the Medline and Embase databases was conducted from inception to Dec 4, 2020. Two researchers independently extracted data and assessed quality.Patients under the age of 18 with sialolithiasis were included.Study design, cohort size, age, sex, symptoms, stone characteristics, diagnostic modality and intervention were collected data points.Forty-one studies with 243 patients were included in the review, of which 40 were case reports or series. Most stones were found in the submandibular gland (n = 210, 85.4%) and were single stones (n = 101, 71.1%). Average stone size was 7.7 mm. The most common diagnostic imaging modality used was ultrasound (n = 73, 47.4%), shifting from plain radiograph which was favoured in earlier years. Similarly, open gland excision was historically preferred, but since 2000, sialoendoscopy comprised 40.5% of all treatment modalities and continues to increase in prevalence, up to 52.1% by 2020. Extracorporeal shock wave lithotripsy was associated with the highest complication rate of 54.2%.The pediatric sialolithiasis diagnostic and therapeutic landscape has changed with ultrasound replacing plain radiographs, and sialoendoscopy replacing submandibular gland excision. Further high-level quality evidence research is required to refine the indications, effectiveness, and safety of sialoendoscopy in pediatric sialolithiasis.

Objective To provide guidance for home care tracheostomy management in the pediatric population. The mission of the IPOG is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. Methods Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). Results Survey results provide guidance for caregiver teaching, the reuse of tracheostomies and suction catheters while inpatient and following discharge, acceptable sterilization practices for tracheostomies, tracheitis workup and management, and outpatient follow-up practices. Conclusion This presentation of common home tracheostomy care practices are aimed at improving patient-centered care in the pediatric population.

Bib count is a frequently used measure amongst pediatric otolaryngologists to quantify drooling status. The plethora of bibs used, including important differences in material, size, and shape, makes one question the validity of bib count as an accurate surrogate measure of drooling frequency or severity. To date, no study has addressed this question in the literature. We evaluated the correlation between drooling frequency, drooling severity, and number of bibs changed to better guide clinical practice in saliva management in a large pediatric patient population.This was a retrospective cohort study comprising 414 pediatric patients from 2014 to 2019. Patients were included if there was presence of drooling and completed the Daniel Drooling Impact Score Questionnaire. The primary outcome was the severity of drooling, frequency of drooling, and number of bibs changed. Age, sex, feeding type and diagnosis were also data points collected. Pearson's coefficient of correlation and multiple regression analysis were used to analyze association between variables.Bib count, frequency of drooling, and severity of drooling were all positively correlated. The strongest positive correlation was between drooling frequency and drooling severity (r = 0.659; p 0.01), followed by bib count and drooling severity (r = 0.541; p 0.01), then bib count and drooling frequency (r = 0.416; p 0.01). In multivariate regression analysis, only bib count was a statistically significant positive predictor of drooling severity (β=1.14, p 0.01). Feeding type and underlying diagnosis also influenced bib count.The number of bibs changed per day is an accurate predictor of sialorrhea that correlates positively with drooling severity and frequency despite the variability and lack of standardization in bibs. Consistent definitions of what constitutes a bib and its characteristics should be collected during drooling evaluation.

Introduction Tympanostomy tube placement is the most common surgical procedure performed in children. Medial migration of a tympanostomy tube is a rare occurrence where the tube migrates into the middle ear cavity as opposed to its normal extrusion into the external auditory canal. Whether medialized tympanostomy tubes should be surgically removed in asymptomatic patients is controversial. The objective of this study was to determine experience and management approach of medialized tympanostomy tubes among pediatric otolaryngologists. Methods A 12-question cross-section survey was designed and distributed to the American Society of Pediatric Otolaryngology (ASPO) members. The survey study was granted McGill University institutional review board and ASPO research committee approval. The survey data were filtered and cross-tabulated. Descriptive statistics were generated. Results 128 pediatric otolaryngologists completed the 12-question survey. The majority of respondents had experienced at least one case of medialized tympanostomy tube (90.6%). The majority of patients (82.0%) were asymptomatic. 74 out of 128 respondents (57.8%) indicated that they would not remove a medialized tube in an asymptomatic patient. However, 7.0% of those respondents clarified that they would proceed to surgical removal if the patient were undergoing general anesthesia for another surgery. 30.5% of respondents indicated that they would surgically remove the tube even if the patient were asymptomatic. 6.3% of respondents indicated that opted management in children would be based on a shared decision with parents. Most respondents (80.5%) did not experience complications with surgical removal nor with elected observation. Conclusion There is no consensus among pediatric otolaryngologists regarding the necessity of surgically removing a medialized tympanostomy tube in asymptomatic patients. The survey suggests that both options are acceptable. If observation is chosen, it is important that parents are well informed of the potential long-term sequelae of a medialized tube and advised to consult if symptoms occur.

Objective Temporary conductive hearing loss due to amniotic fluid accumulation in the middle ear cavity may lead to failure (false positive) in newborn hearing screening tests. The aim of this study was to identify whether amniotic fluid index has association with failure of the initial newborn otoacoustic emission (OAE) screening test. Methods A cohort study in a tertiary hospital center (Royal Victoria Hospital, Montreal) was constructed from 70 newborns that failed the OAE test, but passed a subsequent auditory brainstem response (ABR) test, and 75 randomly selected newborns that passed initial otoacoustic emission testing. Maternal (including the amniotic fluid index in the third trimester) and newborn clinical data were extracted from medical records. Statistical association models were built to determine variables that influenced hearing screen passage or failure. Results The two arms of the cohort had no significant differences in maternal or child clinical indices, including in amniotic fluid index. Calculated as individual odds ratios, maternal tobacco [95% CI of odds ratio: 0.04, 0.59, p = 0.0078], and drug use [95% CI of odds ratio: 0.0065, 0.72, p = 0.058] [borderline significance] were associated with failing the otoacoustic emission testing. Conclusions Amniotic fluid index was not found to be associated with failure of otoacoustic emission screening in newborns. However, our study unveiled an interesting unexpected association of OAE failure with maternal smoking and/or drug use. This finding can help alleviate some of the time, cost and parental anxiety related to failed OAE screening. In selected cases of maternal smoking or drug use we might want to replace or add OAE to the ABR test in newborn hearing screening protocols, that don't perform both tests before discharge.

Background Leukodystrophies consist of degenerative neurogenetic diseases often associated with comorbidities that extend beyond the neurological system. Despite their impacts on patients' quality of life and risks of complications, head and neck symptomology is poorly reported in the literature. The objective of this study was to identify and quantify the main head and neck complaints among a cohort of patients diagnosed with leukodystrophies and define the role of the otolaryngologist as part of a multidisciplinary team for treating these patients. Methods During the First Canadian National Conference on Leukodystrophies held at the Montreal's Children Hospital, a cohort of 12 patients diagnosed with leukodystrophies were recruited and evaluated by a multidisciplinary team. An otolaryngology-focused assessment was done through history and physical examination, and included a screening questionnaire for 23 common otolaryngology issues. If families reported a history of sialorrhea, a validated questionnaire (Drool Quality of Life Assessment Questionnaire (DroolQoL)) was subsequently distributed. Results from the questionnaires were then compiled and analyzed. Results Of the 12 recruited patients, 83% (10/12) were known to an otolaryngologist. Drooling affected 67% (8/12) of patients although only 37.5% (3/8) of patients had undergone medical or surgical therapies for this issue. Four patients experienced at least one aspiration pneumonia. 58% (7/12) of the patients had dysphagia, of whom 43% (3/12) were fed exclusively via gastrostomy tube and 28% (2/7) required thickening of feeds. Two patients, despite suspicion of dysphagia and aspiration, had never undergone evaluation. As for otologic issues, it was noted that 25% (3/12) of patients had a history of pressure equalizing tubes (PETs) and one patient had a history of hearing loss. Conclusion Head and neck comorbidities affect children with leukodystrophies. Therefore, the otolaryngologist should be part of the multidisciplinary team, specifically for the management of dysphagia and sialorrhea.

Objective To delineate the auditory functional improvement and peri-operative outcomes of the Sophono™ transcutaneous bone conduction device. Methods Eligible articles presenting patients implanted with the Sophono™ were identified through a comprehensive search of PubMed and Embase electronic databases. All relevant articles were reviewed to justify inclusion independently by 2 authors. Studies that successfully passed critical appraisal for directness of evidence and risk of bias were included. Results From a total of 125 articles, 8 studies encompassing 86 patients using 99 implants were selected. Most patients (79.1%) were children. Ear atresia (67.5%) was the most frequently reported indication for Sophono™ implantation. Overall pure tone average auditory improvement was 31.10 (±8.29) decibel. During a mean follow-up time of 12.48 months, 25 patients (29%) presented with post-operative complications from which 3 were deemed as serious implant-related adverse events (3.5%). Conclusions The Sophono™ transcutaneous bone conduction device shows promising functional improvement, no intra-operative complications and minor post-operative skin related complications. If suitable, the device could be a proposed solution for the rehabilitation of hearing in children meeting eligibility criteria. A wearing schedule must be implemented in order to reduce magnet-related skin complications.

Introduction The diagnosis and management of type I laryngeal clefts can be controversial and varies across centers and surgeons. Using existing peer-reviewed literature to develop an expert-based consensus will help guide physicians in the treatment of these patients as well as develop research hypotheses to further study this condition. Objective To provide recommendations for the diagnosis and management of type I laryngeal clefts. Methods Determination of current expert- and literature-based recommendations, via a survey of the International Pediatric Otolaryngology Group, using a modified Delphi method. Setting Multinational, multi-institutional, tertiary pediatric hospitals. Results Consensus recommendations include diagnostic workup, medical management, pre-operative, intra-operative and post-operative considerations for type I laryngeal clefts. Conclusions This guide on the diagnosis and management of patients with type I laryngeal clefts is aimed at improving patient care and promoting future hypothesis generation and research to validate the recommendations made here.

Objective To provide recommendations for the comprehensive management of airway obstruction in patients with Robin Sequence. Methods Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). Results The consensus statement provides recommendations for medical specialists who manage infants with Robin Sequence including: evaluation and treatment considerations for commonly debated issues in post-natal airway obstruction, assessment of antenatal obstruction and perinatal airway management. Conclusion Consensus recommendations are aimed at improving management of airway obstruction in patients with Robin Sequence.

Medulloblastoma is the most common pediatric malignant brain tumor and carries a relatively grim prognosis despite recent advances in multimodality therapy. Delays in diagnosis and treatment initiation may contribute to worst outcomes. Signs of increased intracranial pressure and ataxia are known presentations of posterior fossa tumors, but sensorineural hearing loss (SNHL) is a seldom reported symptom. We report the case of a 2-year-old girl who had progressive unilateral SNHL since birth, which was later found to have a posterior fossa medulloblastoma when a head magnetic resonance imaging was ordered following subsequent progression to bilateral hearing impair. We further report our review of 17 additional cases of medulloblastoma presenting with SNHL and their associated head and neck findings. The present study provides insight into the current state of the literature on this rare symptom of a commonly encountered diagnosis, while highlighting the need to consider dedicated brain imaging in pediatric unilateral SNHL when a syndromic etiology or inner ear anomaly is not readily identified on initial investigations.

Objective To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia. Methods A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations. Results Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging. Conclusion Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

Introduction Tracheal pathology can be life-threatening if not managed appropriately. There are still some surgical limitations today for certain pathologies, such as in severe tracheomalacia, or when long segments of trachea need to be resected. Poly(e-caprolactone) (PCL) is a polymer that has recently gained popularity for its use in tracheal surgeries in animal models and in certain human pediatric cases in hopes of addressing these difficult situations. PCL can be 3D printed or manufactured through molds to create tracheal stents, splints, patches and even to reconstruct full circumferential tracheal defects. Objective To perform a scoping review, and explore insights into the applications of PCL for tracheal surgeries in-vivo. Methods A literature search in Embase, MEDLINE, and BIOSIS was performed to include all articles available prior to December 21, 2018 without any language restrictions. We included all original research that investigated the use of a PCL implant, stent, splint, scaffold, or graft in tracheal surgeries in-vivo. Assessment of all articles were performed by two independent authors prior to inclusion for analysis. Results A total of 27 articles were included in the study. All articles were original research studies, primarily consisting of interventional studies (92.4%), there was also 2 case reports (7.4%). Articles were published in the last decade, publications range from 2009 to 2019. The most common animal model used for the tracheal surgeries were the New Zealand rabbits (n = 19, 70%). Two studies (7%) also described the use PCL in a total of 4 human cases. To investigate the PCL reconstructed airways, histology and bronchoscopy were the most commonly implemented methods of analysis in 88.9% and 70.4% respectively. Airway analysis was also done using imaging modalities including CT scan (n = 9, 33.3%), MRI (n = 2, 7.4%), X-ray (n = 1, 3.7%). 17 (62.9%) of the studies used 3D printing processes to create their PCL implants. Conclusions Overall, this review demonstrates the feasibility of PCL in tracheal reconstruction and tracheal stenting/splinting. It highlights common trends and the limitations of the literature thus far on this topic.

Objectives Newborn hearing screening includes testing with otoacoustic emissions and the auditory brainstem response. Unfortunately, both tests are affected by the presence of material in the ear canal and middle ear such as vernix, meconium, and amniotic fluid. The objective of this study was to determine to what extent occlusion of the ear canal as seen on otoscopy affects wideband energy reflectance measurements in newborns. A secondary objective was to obtain additional normative wideband reflectance data in newborns. Methods Newborns from a well-baby nursery were enrolled. Wideband energy reflectance measurements and otoscopy were done immediately after the hearing screening. Occlusion of the ear canal as seen on otoscopy was described on a scale of 0–100%. Results A total of 156 babies were enrolled (mean age = 25 hours). A statistically significant difference in the reflectance at ambient pressure was found between the 0–70% and 80–100% occlusion groups. There was no significant difference in reflectance between the right and the left ears. The median reflectance pattern generally followed that of previous studies but in certain frequency regions the present reflectance values were higher. Conclusion A significant increase in reflectance occurs when 70%–80% of the ear-canal diameter is occluded. Taking otoscopy findings into account may improve the interpretation of reflectance measurements. However, further studies are required to better establish the relationship between canal occlusion and reflectance.

Objective To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia. Methods Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). Results Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy. Conclusion Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

Introduction Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation. Objective Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy. Methods Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method. Results Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: • on a standard definition of Suprastomal Collapse • that there is clinical importance between significant and insignificant collapse • that the gold standard diagnostic modality is endoscopic examination under anesthesia • that the severity of collapse is a major determinant in the surgical approach • that surgical intervention is the first line management in combined anterior and lateral Suprastomal Collapse. Conclusion This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

Objective Vocal fold paralysis (VFP) in adducted position remains a challenge for airway surgeons. Alternatives to tracheostomies such as lateralization, cordectomy, and posterior rib grafting disrupt the laryngeal tissue or framework and carry an increased risk of aspiration. Laryngeal reinnervation using nerve-muscle pedicle (NMP), carries the distinct advantage of preserving the larynx, sparing the recurrent laryngeal nerve, and obtaining an active VF abduction. The aim of this study was to evaluate the success and complications of laryngeal reinnervation using nerve-muscle pedicle (NMP) in pediatric patients presenting with dyspnea related to VFP in adducted position. Methods In this case series performed at a tertiary care referral center, review of medical records on all pediatric patients with VFP in adduction treated with laryngeal reinnervation using NMP between 1999 and 2017. Data were collected on the preoperative flexible laryngoscopy, suspension micro-laryngoscopy, and laryngeal electromyography as well as post-operative clinical assessment of the voice and airway. All patients underwent surgery consisting of the transfer of an innervated omohyoid muscle pedicle onto the paralyzed posterior cricoarytenoid muscle. The main outcomes measured were the clinical and fiberoptic laryngoscopic airway assessment monthly for the first 6 months, then at 12 months and annually thereafter. Clinical assessment included dyspnea evaluation based on a visual analog scale and voice assessment using the GRBAS scores. Complications from the treatment were also noted. These outcomes were determined before collection of data. Results 16 cases were identified, with a mean age of 4 years. The recurrent laryngeal nerve paralysis was bilateral in 3 cases and unilateral in 13 cases. There were no peri or postoperative complications. After a mean follow-up of 7 years, vocal fold abduction was observed in 10 out of 16 cases and disappearance of paradoxical inspiratory adduction in 3 cases. Persistent dyspnea was noted in 7 cases (44%), and moderate dysphonia was present in 11 cases (69%). Finally, additional procedures were necessary in 2 patients (13%) to achieve the outcomes. Conclusions Laryngeal reinnervation using NMP may be used in pediatric patients. This procedure, is safe and allows us to spare the recurrent laryngeal nerve while obtaining an active VF abduction in the majority of cases, and an improvement in breathing in most cases. Quality of evidence 4.

Objective To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery. Methods Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. “Consensus” was defined by >80% respondent affirmative responses, “agreement” by 51–80% affirmative responses, and “no agreement” by 50% or less affirmative responses. Results Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure. Conclusions Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.

Objective Few cases of medial migration of tympanostomy tubes have been reported and its optimal management has not been well delineated especially in asymptomatic patients. The aim of this review is to present all cases of medialized tympanostomy tubes reported in the literature in order to provide the most beneficial management option. Methods Eligible articles were identified through a comprehensive search in Cochrane, Embase and Medline electronic databases. Two reviewers independently screened the data sources, using pre-defined inclusion criteria to generate a list of eligible articles. Data extracted included patient demographics, diagnosis, type of tube, timing of migration, presenting symptoms, examination outcomes, treatment and follow up. Results 10 articles were chosen for data extraction from which 29 patients presenting with medial migration of tympanostomy tube were identified. Conclusion The low complications associated with removing a medialized tube and the risk of leaving foreign objects in the middle ear cleft make myringotomy for removal of the tube a practical and safe management option for medialized tubes even in asymptomatic patients.

Objective To determine if laryngeal contrast pooling on a videofluoroscopic swallowing study increases the risk for pneumonia in the following 6 months in children with dysphagia. Secondarily, to determine in the same population, if laryngeal abnormalities or syndromic disorders increase the risk for pneumonia in the same timeframe. Study design Retrospective cohort study. Methods A chart review of pediatric patients that presented to the swallowing and dysphagia clinic at the Montreal Children's Hospital for a videofluoroscopic swallowing study in the last three years was conducted. Videofluoroscopic findings, patient characteristics, demographic data, and pneumonias occurring within 6 months after the study were recorded for all patients. Patients with unsuccessful swallowing studies, incomplete charts, extra-laryngeal etiologies for recurrent pneumonia, or who were lost to follow up were excluded. Results Of the 287 children who presented to the clinic, 239 patients remained after exclusion, of which 40 (16.7%) exhibited pooling and 199 (83.3%) did not. Children with pooling on videofluoroscopic swallowing study did not have significantly more pneumonias than patients without pooling (22.5% vs 17.1%, P = 0.42). Secondary analyses revealed that laryngeal abnormalities were a significant independent risk factor (P = 0.02) for pneumonia at 6 months, while being diagnosed with a syndrome was not (P = 0.18). Conclusion In this study of contrast pooling in videofluoroscopic swallowing study, there was no significant difference in pneumonia occurrence in patients with and without pooling at 6 months post study. Future prospective studies should be conducted to confirm these findings. The present review showed that feeding changes should not be made based on pooling alone.

Objectives Management of recurrent thyroglossal duct cysts (TGDC) remains a clinical challenge to otolaryngologists – head and neck surgeons. The purpose of this systematic review is to determine the best surgical management for recurrent TGDC. Methods A comprehensive search for relevant articles was carried out on electronic databases named Ovid Medline, Ovid Medline in process and Other Non-Indexed Citations, Embase, Ovid OldMedline, and Ovid Medline Daily. Articles published in English until 2014 were eligible for review. Using predefined inclusion criteria, published articles on surgical outcomes in the management of recurrent thyroglossal duct cyst, were selected, reviewed, and their findings synthesized. Results Nine studies met the inclusion criteria for this systematic review comprising a total of 66 patients who underwent 114 secondary surgeries. Better outcomes were observed with en bloc neck dissection vs. a revision Sistrunk with a recurrence rate of 20% vs. 30.12% respectively. In addition two new surgical approaches, suture-guided transhyoid pharyngotomy and Koempel's suprahyoid technique reported 100% success rate. Conclusion Recurrence after primary surgical management remains a clinical challenge. We highlight the outcomes of the 4 main surgical techniques reported in the literature, repeat Sistrunk procedure, en bloc neck dissection, suture-guided transhyoid pharyngotomy, and Koempel's suprahyoid technique. Although this review reports a 100% success rate with the 2 latter techniques, further prospective studies and additional experience with these same techniques by other surgeons/institutions with or without a randomized trial could provide additional confirmation of improved outcomes using these specific surgical procedures.

Objectives There is no literature about the average size of the salivary glands in the pediatric population with drooling (sialorrhea). Studies have shown that some pathologies affect the functionality of the salivary glands. We assessed via ultrasonography the sizes of the submandibular and parotid glands in 9 healthy children who were not suffering from local or systemic diseases that could affect the salivary glands. We also compared this group with a group of 9 patients with sialorrhea. Methods Volunteers were matched based on age, gender, and BMI. Body weight did not differ more than 20% from ideal weight. The parotid and submandibular glands of 9 patients with sialorrhea without any previous treatment were measured via ultrasound and matched to a healthy control. Children with various causes for drooling were included (neurological disorders, neuromuscular disorders, lack of oral motor control). Results Dimensions of the parotid glands in drooling and healthy patients were: surface area 2.96 cm 2 (SD ±0.90) and 2.81 cm 2 (SD ±0.54); in depth 1.68 cm (SD ±0.24) and 1.61 cm (SD ±0.27); in the axis longitudinal to the horizontal mandibular ramus 3.18 cm (±0.46) and 3.15 cm (SD ±0.45) in drooling and healthy groups respectively. The means of submandibular glands of drooling and healthy patients measured in surface area: 3.20 cm 2 (SD ±0.66) and 3.08 cm 2 (SD ±0.65); anterior–posterior length 1.55 cm (SD ±0.23) and 1.46 cm (SD ±0.23), medio-lateral length 3.07 cm (SD ±0.39) and 3.07 cm (SD ±0.32). There was no statistical significance in comparison with the healthy group control. Conclusion The parotid and submandibular salivary glands in the pediatric population do not differ in size in children with or without drooling. Measuring the glands at baseline and post treatment with botulinum toxin injections allows one to evaluate if there are changes in the gland related to the treatment.

Thyroglossal duct cyst (TGDC) is one of the most common congenital anterior midline neck masses in children. Sistrunk operation is considered as the cornerstone in TGDC removal. Nevertheless, 5% to 7 % of patients have been reported to show a recurrence even after adequate resection. This necessitates at times multiple resections with potential complications. One interesting emerging technique is sclerotherapy of TGDC remnants post resection. We present here a case of a child who had a successfully treated recurrent TGDC using sclerotherapy with doxycycline.

Objective The aim of the present study is to examine the effects of tea tree oil on hearing function and cochlear morphology after intratympanic administration in a chinchilla animal model. Methods Nine chinchillas received intratympanic injection of 3% tea tree oil dissolved in olive oil in one ear, whereas the contralateral control ear received olive oil only. Outcome measures included auditory brainstem responses conducted before treatment and at 10 days and 30 days following the injection. Post-mortem cochlear morphology was assessed using scanning electron microscopy. Results At 10 and 30 days following the injection, there was no significant change in auditory brain response thresholds at 8, 16, 20 or 25 kHz. Scanning electron microscopy imaging showed no damage to auditory hair cells. Conclusion Tea tree oil (3%) does not appear to be ototoxic in a chinchilla animal model. Future preclinical and clinical studies are required to establish the effectiveness of TTO in treating otitis.

Background and objectives Otoacoustic emission (OAE) tests are currently used to screen newborns for congenital hearing loss in many Universal Newborn Hearing Screening programs. However, there are concerns about high referral and false-positive rates. Various protocols have been used to address this problem. The main objective of this review is to determine the effects of different screening protocols on the referral rates and positive predictive values (PPV) of the OAE newborn screening test. Methods Eligible studies published in English from January 1990 until August 2012 were identified through searches of MEDLINE, Medline In-Process, Embase, PubMed (NCBI), ISI Web of Science, and the Cochrane Central Register of clinical controlled trials. Two reviewers independently screened the data sources, using pre-defined inclusion criteria to generate a list of eligible articles. Data extracted included the number of newborns screened, age at screening, OAE pass criteria, frequencies screened, number of retests, referral rates, and the number of newborns identified with permanent congenital hearing loss. Results Ten articles met the inclusion criteria, with a total of 119,714 newborn participants. The pooled referral rate was 5.5%. Individual referral rates ranged from 1.3% to 39%; the PPV from 2 to 40%. Increasing the age at initial screening and performing retests reduced the referral rate. Likewise, screenings involving higher frequencies had lower referral rates. Conclusion Delaying newborn hearing screening improves test results but may not be practical in all contexts. The use of higher frequencies and more sophisticated OAE devices may be useful approaches to ensure better performance of the OAE test in newborn hearing screening.

Objectives High levels of unconjugated bilirubin have been associated with neuronal damage. The auditory brain nuclei and the inferior colliculi are often the first part of the brainstem to be involved, often leading to hearing abnormalities. A systematic review of clinical studies was conducted to evaluate the effect of hyperbilirubinemia on hearing in term newborns, to show the relationship between hearing function and bilirubin levels as well as the effect of treatment. Methods Eligible studies were identified through searches of electronic databases Ovid MEDLINE, Ovid MEDLINE In-Process, Embase, PubMed and The Cochrane Library. Articles obtained were independently reviewed by 2 authors using inclusion criteria to identify eligible studies. The search was restricted to articles written in English, French and Spanish and published between 1970 and 2010. Data extracted included study type, number of patients, bilirubin levels, hyperbilirubinemia criteria, hearing assessment methods, time of hearing assessment and outcome measures. Results The nineteen articles included showed heterogeneity regarding the time of hearing test and hyperbilirubinemia criteria. The incidence of hearing loss at initial testing ranged between 13.2–83.3% and 6.7–14.3% at 3 months follow-up. Five studies showed a rising incidence of hearing loss with increasing levels of serum bilirubin. Conclusions Hyperbilirubinemia resulted in abnormal hearing assessment in up to 83.3% of term newborns. Greater hearing abnormalities were observed with rising serum bilirubin levels. Treatment of hyperbilirubinemia led to a considerable decrease in the incidence of hearing loss.

Objective To conduct an updated systematic review on the outcome of Bell's palsy (BP) in children following steroid treatment. Data sources MEDLINE, EMBASE, Cochrane Library and BIOSIS Previews electronic databases were searched obtaining articles published between 2000 and 2010 without any language restriction. Review methods Articles describing children aged 0–18 years with BP treated solely with corticosteroids were included. In studies including various etiologies for facial palsy; cases of BP treated with steroids were selected and when available, untreated patients as well for comparison. The outcome measure was facial movements following steroidal treatment based on different clinical scales. Controlled clinical trials, prospective and historical cohort studies, cross sectional studies and case series were included. Results A total of 2293 papers were initially identified. Following review by two authors, 68 papers were analyzed in a hard-copy format. Finally, 6 studies were eligible to be included in the systematic review. Four of the studies included children with BP exclusively while the remaining studies described various etiologies of facial palsy. Type of steroid and duration of treatment were inconsistently specified. Outcome measures used include the House–Brackmann scale, Yanagihara grading system and clinical evaluation. Studies analyzed were retrospective cohorts or case-series and were categorized as level 4 of evidence. Conclusion There were no controlled trials and level 4 publications predominate. Therefore, the role of steroid treatment for BP in children is still inconclusive. Further studies are required.

Objective The aim of this study was to revalidate and reproduce a chronic tympanic membrane perforation animal model. Study design Prospective, animal study. Methods Eight female chinchillas underwent bilateral thermal myringotomy. The edges of the perforation were folded inward using microflaps. The perforations were followed over time to monitor the course of closure. Results Two animals were excluded from the study because of ear infection. None of the other tympanic membrane perforations remained open. The closing time varied from 4 to 6 weeks. Conclusions Our findings demonstrate that the thermal myringotomy combined with infolding technique is not a reliable and consistent method to create a chronic tympanic membrane perforation. The closing time is shorter than expected and varies among the study subjects. There is a clear need for developing a reliable chronic tympanic membrane perforation model.

Familial dysautonomia is a rare disease affecting the nervous system. Symptoms include speech and movement problems, anterior sialorrhea (drooling) due to hypersalivation as a consequence of poor oropharyngeal coordination; dysphagia and aspiration pneumonia secondary to recurrent posterior sialorrhea. The treatment for sialorrhea in this population is very challenging. Traditional drugs carry a number of side-effects that are difficult to control in this disease. We report the first documented case series of 3 patients with this condition that successfully responded to Onabotulinum toxin A injection into their salivary glands. This is an innovative, safe method for drooling control in this population.

Castleman's Disease is a rare lymphoproliferative disorder. In the literature, only 29 cases, associated with the neck presentation in children, have been reported. This is another case report regarding a 5-year old child who presented with a persistent cervical lymphadenopathy. Final pathology, after undergoing exploratory neck dissection and surgical excision, revealed Castleman's Disease. This report, augmented with a literature review of all the 29 cases, compares the clinical course of this patient with the other cases. In conclusion, although Castleman's Disease carries a favorable prognosis in children, surgical excision is recommended to confirm the diagnosis and to rule out other causes.

Summary Background Retropharyngeal and parapharyngeal abscesses or phlegmons are relatively uncommon. Since the tonsils and adenoids are part of the lymphoid tissues of the nasopharynx and oral cavity, one may hypothesize that their removal would lead to an increased susceptibility to pharyngeal infections. Objective Determine whether there is an association with a history of adenotonsillectomy and the development of retro- and parapharyngeal abscesses/phlegmons. Methods A case–control study was performed. The charts of 180 children admitted to a tertiary care pediatric hospital between 1996 and 2006 were reviewed. The patients were age-matched to 180 children having visited the emergency department of the same hospital. The charts of these children were reviewed and used as controls. Results 13.9% of children admitted with a retro- or parapharyngeal abscess or phlegmon had previously undergone an adenotonsillectomy as compared to only 2.2% of children in the control group. The calculated odds ratio was 7.10 (95% CI [2.52–19.93], p Conclusion In conclusion, the development of a retropharyngeal or parapharyngeal abscess or phlegmon is strongly associated with a history of adenotonsillectomy.

Summary Objective There is a significant debate over the need for tonsillectomy to rule out lymphoma in cases of unilateral tonsillar enlargement. Several publications have suggested that the presence of unilateral tonsillar enlargement in children was an ominous sign of the possibility of underlying lymphoma. More recently, some authors have recommended that routine tonsillectomy in this context is not indicated given the low incidence of tonsillar lymphoma in the pediatric population and the high cost associated with this procedure. The aim of this study is to determine whether or not children diagnosed with tonsillar lymphoma originally presented with unilateral tonsillar enlargement. Methods We queried the tumour board registry records at a pediatric tertiary care institution from 1949 to January 2006 for all cases of tonsillar lymphoma. We examined the clinic, pre-operative and operative notes as well as the pathology results and noted the presenting signs and symptoms with a specific interest in the presence of unilateral tonsillar enlargement. Results Our query returned six patients with a diagnosis of palatine tonsil lymphoma. All six identified patients presented at their first visit with clinically apparent asymmetry of the tonsils. In all six cases B symptoms were absent at the first visit. Conclusions We conclude that even though the majority of patients who have unilateral tonsillar enlargement will not have tonsillar lymphoma, most patients with tonsillar lymphoma will have unilateral tonsillar enlargement as one of their presenting signs. Therefore, despite the low incidence of this malignancy in children, careful close follow-up of these patients is warranted until the diagnosis has been ruled out given the potentially devastating consequences of missing this diagnosis or prolonging the time to treatment. Moreover, a low level of suspicion should warrant a tonsillectomy.

Objectives To determine whether children with laryngeal penetration on videofluoroscopic swallowing study are at higher risk for pneumonia than those with normal findings. Methods We reviewed the charts of 235 pediatric patients presenting to our Swallowing and Dysphagia clinic for videofluoroscopic swallowing study over a 3-year period. Patients with unsuccessful swallowing studies, incomplete charts, extra-laryngeal etiologies for recurrent pneumonia, or who were lost to follow up were excluded. Out of the 165 patients remaining, 58 had normal findings, 59 had laryngeal penetration, and 48 had tracheobronchial aspiration. The number of cases of pneumonia, aspiration events, and demographic data were recorded for all patients. Results Children with laryngeal penetration on videofluoroscopic swallowing study had significantly ( P = 0.032) more pneumonia than patients with neither penetration nor aspiration (median 2 vs. 0; mean 2.22 vs. 1.60). Furthermore, analysis revealed that glottic abnormalities (e.g. laryngeal cleft) represented a significant independent risk factor ( P = 0.004) for pneumonia and aspiration, while being diagnosed with a syndrome did not ( P = 0.343). Conclusion To our knowledge, this is the first study to demonstrate that laryngeal penetration on videofluoroscopic swallowing study is associated with significantly more cases of pneumonia in children. While this remains a retrospective study demonstrating a weak association, the results suggest a need for future prospective studies to evaluate this important clinical question in children.

Objectives The aim of this study is to evaluate the correlation of the Drooling Quotient (DQ) score with the questionnaire-based Drooling Severity and Frequency Scale (DSFS) and the number of bib changes in a day. It is hypothesized that there is a significant positive correlation between these methods of assessment. Methods Using a prospectively collected database from a cohort of one hundred and fifty five children referred to our saliva management clinic, a comparison of the following three measurements was made to assess the level of correlation between them: (1) Drooling Quotient (DQ) (performed in two 10-min sessions), (2) Drooling Severity and Frequency Scale (DSFS) (as judged by parents or caregivers) (3) number of bib changes (as reported by parents or caregivers). Results The results showed that there is a high level of agreement between the Drooling Quotient and the Drooling Severity and Frequency Scale. However, the Drooling Quotient and number of bib changes did not show significant correlation. Conclusions The Drooling Severity and Frequency Scale (DSFS) has been shown to be a quick and accurate measure of drooling that can be used to help guide clinical management of drooling, particularly in patients who are unable to undergo the Drooling Quotient assessment.

Objective To determine the safety of Earigate™ as an ear wax softening product. Study Design Prospective, controlled animal study. Methods Bilateral wide myringotomies were performed in eleven chinchillas. In each animal, Earigate™ was delivered to a randomly selected experimental ear canal as 2 puffs twice a day. Auditory brainstem response (ABR) was used to assess the hearing of the animals before, 3 days and 10 days following the local application of Earigate™. The ABR threshold shifts were compared for both experimental and control ears. Results The mean hearing threshold shifts in the experimental animals were comparable at all frequencies and at days 3 and 10. No statistically significant differences were observed in the mean threshold shifts for all of the frequencies evaluated, between the control and experimental ears. Conclusions The administration of Earigate™ to the middle ear of chinchillas did not cause any ototoxicity as assessed by ABR.

Objective: With the miniaturization of electronic devices, the demand and usage of button batteries has risen. As a result, button batteries are more readily available for young children to handle and potentially mishandle. They are frequently inadvertently placed by children in their ears or noses. Occasionally they are swallowed and lodged along the upper aerodigestive tract. Methods: We outline the pathophysiology of button battery-induced trauma and present key radiological features of button batteries that are important in preventing delayed diagnosis after pediatric ingestion. Results: Button batteries of all sizes have a distinctive double contour on radiographs. Conclusions: Button battery ingestion requires prompt diagnosis and removal. A high index of suspicion along with radiographs help assist with the diagnosis. Potential tragic complications can be averted with expeditious removal.

Salivary fistula is an epithelial track between the salivary gland or its duct and the skin, through which saliva is discharged. Parotid fistula is considered one of the most serious postoperative complications after parotid gland surgery and occurs also after accidental trauma [1,2]. In adults, the most common cause of parotid fistulas is parotidectomy. The literature has showed that injury to the parotid gland after a parotidectomy is usually a glandular injury rather than a ductal injury [1,3,4]. Salivary gland fistulas are more unusual in children and can be congenital or secondary to trauma [5]. Salivary congenital fistulas are more often derived from minor salivary glands or accessory parotid glands [6]. More often, as in adults, parotid fistulas in children are secondary to trauma, occurring mainly after surgical procedures. It was reported by Wax and their team that postparotidectomy fistula rate is about 14% [7]. Furthermore, another study done by Laskawi et al. documented 4% parotid fistula after parotidectomy in the treatment of parotid pleomorphic adenomas [8].

Nontuberculous mycobacteria (NTM) are an increasingly recognized cause of chronic suppurative otitis media in children with tympanostomy tubes. Treatment of this condition is difficult and typically requires a combination of systemic antibiotics and surgical debridement. We present the first case of a 2-year-old male with chronic suppurative otitis media due to NTM who failed systemic antibiotic therapy and was successfully managed with topical boric acid powder. This report highlights the challenges involved in treating this infection, and introduces boric acid as a potentially valuable component of therapy.

Numerous authors have sought to describe genotype-phenotype correlations in cystic fibrosis (CF), notably to pancreatic insufficiency and lung disease. However, few studies have focused on the association between the F508del genotype and response to sinus surgery. The objective of this study is to assess the effect of the F508del genotype on sinonasal disease severity and outcomes following functional endoscopic sinus surgery (FESS) in a pediatric population.A retrospective chart review of 153 children with CF seen at a tertiary care pediatric hospital from 1995 to 2008 was performed. Patients were classified into one of three groups according to F508del genotype, either as homozygous, heterozygous or not carrying a F508del mutation. The sinonasal disease phenotype of the three groups was compared based on clinical and radiological findings, extent of endoscopic sinus surgery and rate of revision surgery.The relationship between the F508del genotype and pancreatic insufficiency was confirmed (p0.05). There was no association between the F508del genotype and increased need for FESS (p=0.75). Moreover, no association was established between F508del homozygosity and presence of nasal polyps, Lund-Mackay score, extent of surgery or length of postoperative hospitalization. The rates of revision surgery did not differ significantly among the three genotypes analyzed (p=0.59).There is no clear association between the F508del genotype and an increased need for FESS, extent of surgery, or revision surgery. Given the phenotypic variability of sinonasal disease in patients with CF, a prospective study is needed to better understand outcomes following FESS and the contribution of gene modifiers to this effect.

Cisplatin is a commonly-used chemotherapeutic agent that is highly-effective against a variety of pediatric cancers. Unfortunately, it may lead to ototoxicity, with serious consequences on the quality of life of survivors. Patients remain at risk of progression of ototoxicity even after completion of treatment. We report the case of a medulloblastoma survivor with previously documented normal hearing, who developed significant hearing loss and tinnitus following exposure to excessive noise at a nightclub three years after completion of treatment. We highlight the importance of long-term audiological follow up and education about the increased risk of hearing loss in this population.

Objective Bone-anchored hearing aid (BAHA™) is a proven tool to improve hearing. Nevertheless, there are patients who are candidates for BAHA™ implants that end up refusing the surgery. The objective of this study is to review our BAHA™ experience with particular emphasis on reasons behind the refusal of some candidates. Methods A prospective cohort of 100 consecutive new candidates referred to The BAHA™ program in a tertiary health care center. Candidates’ demographics, hearing status, Co-morbidities and audiometeric tests were all recorded. Patients’ acceptance or refusal was noted alongside the reasons to refuse BAHA™. Results 100 new candidates were seen for BAHA™ assessment, 10 patients were excluded due to incomplete data. There were 68 children and 22 adults. Unilateral Conductive Hearing Loss was the most common reason for consultation (40%), followed by unilateral SNHL (23.3%). Aural Atresia was the commonest clinical finding (36.6%). The commonest reason for refusal was social acceptance by the parents due to concern with cosmesis. Conclusion The main reason of BAHA™ surgery refusal, in otherwise eligible candidates, is related to cosmesis. Patients with congenital anomalies were the most likely candidates to accept BAHA™ implants.

The purpose of this study is to identify the clinical characteristics of children above 6 years of age with chronic otitis media with effusion (COME) who have required pressure equalizing tube (PET) insertions.A retrospective chart review was performed of all children above the age of 6 years, who underwent PET insertion due to chronic OME, between 2000 and 2009 at a tertiary care institution. Children were also divided into those with a single PET and those with ≥ 2 PET. Comparison of various characteristics between the two groups was undertaken.290 children were identified as having at least one PET insertion after the age of 6 years. 45.5% of the children underwent a single PET insertion while 54.5% underwent 2 procedures or more. No significant gender-based difference was observed. In those patients requiring ≥ 2 PET, 65.2% also underwent tonsillectomy and/or adenoidectomy compared to only 53.8% of children with a single PET intervention (p0.05). Asthma, trisomy 21 and cleft palate, were more common in those children who had undergone ≥ 2 PET (p0.001, p0.01 and p0.05, respectively).Children above 6 years of age who have undergone ≥ 2 PET insertions for COME demonstrated an increased rate of tonsillectomy and adenoidectomy. Trisomy 21, cleft palate and particularly, asthma, were also found to be risk factors for COME necessitating ≥ 2 PET insertions.

The traditional treatment of cricoid cartilage fractures concurrent with subglottic stenosis in pediatric patients usually requires an open approach with a high rate of complications and morbidity. We present here a case report of a successful treatment of a cricoid cartilage fracture concurrent with a subglottic stenosis in an adolescent patient using balloon dilation. The mentioned procedure reduced the fracture and allowed us to prevent a tracheostomy and its complications.

Objective Baby oil is commonly used to soften ear wax in order to aid its removal. The aim of this study was to determine the potential ototoxicity of baby oil. Method A prospective controlled animal study was conducted using ten chinchillas with normal hearing function. Each had bilateral myringotomies. One ear was randomly assigned to receive 1 ml of baby oil while the other ear received an equal volume of 0.45% NaCl. Distortion product otoacoustic emissions (DPOAEs) and Auditory Brainstem Response (ABR) measurements were recorded at baseline (post myringotomy and pre application of product) and on days 5 and 15 after application. Two months after application of baby oil, the cochleae were processed for light microscopy and qualitative comparisons were made between the cochleae of both control and experimental ears. Results There was no statistically significant difference in DPOAE between experimental and control ears at 5 and 15 days after treatment. ABR results did not reveal ototoxicity at days 5 and 15 post treatment. None of the animals developed facial paralysis or any signs of vestibular toxicity. There were no overt mucosal changes in the middle ear of the ears exposed to baby oil compared to the control ears. Light microscopy showed comparable features in the organ of Corti, stria vascularis, spiral ligament and the spiral ganglion cells of both groups of cochleae. Conclusion Baby oil did not produce ototoxic effects when applied ototopically in chinchillas with non-intact tympanic membrane.

NHL usually presents with lymphadenopathy or symptoms related to compression by the primary tumor of surrounding structures. While the head and neck region is a common site of involvement, blindness is rarely a presenting symptom. We report here the case of a child who presented to the emergency room with acute bilateral loss of vision and no other symptoms. Cranial imaging studies revealed a solid mass of the skull base with compression on optic nerves. Diagnosis of Burkitt's lymphoma was confirmed after biopsy. The patient had partial vision improvement two days after optic nerve decompression which was done immediately at the night of presentation.

Objective To assess the long-term ototoxicity effect of platinum chemotherapy in a series of pediatric patients. Design A prospective cohort study. Methods Patients who received platinum chemotherapy were identified through review of the pharmacy records from 2000 to 2005. Audiograms pre- and post-treatment with cisplatin were noted. The patients were brought back long after treatment for a repeat audiogram and a questionnaire to assess the impact of ototoxicity on their quality of life. Results Forty-nine patients received platinum chemotherapy. Patients’ exclusion: two had no pre-chemo audiograms, one had retinoblastoma with congenital hearing loss, three were lost to follow up, five deceased, and seven refused participation. The total number of patients included was 31 with long-term follow up total of 21 patients. The follow up period ranged from 1.5 to 6.6 years (median of 3.4 years). Fourty-two percent (13/31) of the patients suffered from otoxicity (3 mild, 3 moderate, 7 severe-profound). Thirty-three (7/21) of audiograms worsened on long-term follow up. Questionnaire revealed 70% subjective hearing loss with 40% requiring hearing aids. Conclusion Ototoxicity after platinum chemotherapy can present or worsen years after completion of therapy. Therefore, we recommend long-term follow up.