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Objective: 1) Review surgical preparation methods for pediatric otolaryngology fellows and fellowship directors, focusing on surgical video usage., Study Design: Cross sectional survey., Methods: Structured survey querying preparation methods for surgical cases was distributed to current pediatric otolaryngology fellows and fellowship program directors (FD's)., Results: 84 surveys were distributed (47 fellows, 37 FD). Overall response rate was 44% (37/84); fellow response rate was 55% (26/47) and FD response rate was 30% (11/37). Most respondents used videos (84%) and textbooks (95%) to prepare for surgery; fellows were more likely than FD's to use videos (96% vs. 55%, p < 0.01). 89% of respondents used YouTube to prepare; C-videos was the next most common platform used (27%). Fellows were more likely to have used YouTube than FD's (100% vs 63%, p < 0.01). 45% of FD's did not know or did not think their fellows use videos to prepare for cases. Mean helpfulness of surgical videos on a 5 point scale was 3.41 (95% CI 3.0-3.8). Videos were considered most helpful for illustrating technical portions of cases (51%), visualizing the case (27%) and reviewing anatomy (24%). Survey respondents mentioned poor quality (59%) and irrelevance to a particular institutions approach (19%) as weaknesses of available surgical videos., Conclusions: Surgical videos are commonly used by pediatric otolaryngology fellows to prepare for cases, and can assist in building anatomic knowledge and illustrating technical details of complex cases. YouTube is the most commonly utilized platform accessed by fellows, but poor quality and limited generalizability may restrict the usefulness of current video resources., Level of Evidence: 4., (Copyright © 2020 Elsevier B.V. All rights reserved.)

A case report of a 10 year old male illustrates the effect of damage to the tongue base, hypopharynx, cricopharyngeus, and esophagus on the sensory and motor components of the swallowing mechanism. The characteristics of the dysphagia were manifested clinically, radiographically, and endoscopically. A myectomy was required to restore functional swallowing as scar tissue formation in the cricopharyngeus severely interfered with the dynamic components of swallowing. A collaborative approach facilitated communication and effective treatment planning; the multidisciplinary components in the management of this case are discussed., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: Although commonly performed, pediatric tonsillectomy is not necessarily a low risk procedure due to potentially life threatening perioperative complications. There is paucity of literature on lethal anesthesia and surgical complications of tonsillectomy. In this article, we have reviewed both minor and serious complications following tonsillectomy. Hemorrhage, burn injuries, respiratory complications, postoperative nausea and vomiting, and pain management are discussed. We have highlighted our practice of pain management at Cincinnati Children's Hospital after tonsillectomy recent warning about codeine by the FDA on children undergoing tonsillectomy. We describe post-tonsillectomy outcomes including postanesthesia care unit stay, post discharge maladaptive behavioral outcomes and finally effective ways to identify children at risk for anesthesia and a few preventive strategies., Methods: In addition to literature review, the LexisNexis "MEGA™ Jury Verdicts and Settlements" database was reviewed from 1984 through 2010 for deaths and complications during and following tonsillectomy. Data including year of case, cause of death, surgical, anesthetic and postoperative opioid related complications, injury, case result, and judgment awarded were collected and analyzed., Results: The results of this analysis are presented with an emphasis on hemorrhage and on anesthesia and opioid related claims and their characteristics. Two hundred and thirty-three claim reports were reviewed. There were 96 deaths (41%) and 137 perioperative injuries (59%). Deaths were primarily related to surgery (n=46, 48%) with post-tonsillectomy bleed the most frequent cause (n=38, 40%) followed by opioid toxicity (n=17, 18%) and anesthesia complications (n=9, 9%). Non-fatal injuries included, postoperative bleeding (n=59, 25%), impaired function (n=29, 12%), anoxic events (n=20, 9%) and postoperative opioid toxicity (n=20, 8.6%). Anoxic event was noted to have the highest monetary award with a mean award at $9,017,379. Injuries (including anoxia) had higher mean monetary awards than deaths., Conclusion: Tonsillectomy in children carries a high risk of perioperative complications and malpractice claims. Though postoperative bleeding is the most common complication associated with malpractice claims, anoxia related to anesthesia and opioids had the greatest overall risk from a monetary standpoint., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: Temporal bone imaging in children has several inherent limitations. Computed tomography has the disadvantage of ionizing radiation, possible sedation, cost and accessibility. Magnetic resonance imaging has most of these disadvantages, with the exception of radiation, and provides bone images of limited resolution. Recent advances in ultrasound have led to its increased application in numerous medical fields. The purpose of this study was to investigate the ability of four-dimensional ultrasound (4DUS) to image middle ear ossicles in vitro and determine if this technology should be adapted for future clinical use., Methods: Thirty cadaveric ossicles (10 malleus, 10 incus, and 10 stapes) were randomized and measured by two evaluators under a microscope. The ossicles were then immersed in a cold water bath and imaged, randomized, and measured using four-dimensional ultrasound by the same two evaluators. A separate cadaveric temporal bone, modified to allow the ultrasound probe to rest on the tympanic membrane, was imaged to visualize the ossicles in situ and evaluate whether or not the tympanic membrane and malleus would impede visualization of more medial structures., Results: Microscopic measurements were: malleus (h=8.0 mm+/-0.32, w=2.7 mm+/-0.20), incus (h=6.8 mm+/-0.41, w=5.3 mm+/-0.46), stapes (h=3.5 mm+/-0.34, w=2.4 mm+/-0.17). Inter-rater reliability was 0.8. Measurements were in agreement with previously published values. Ultrasound measurements were: malleus (h=8.0 mm+/-0.51, w=2.9 mm+/-0.27), incus (h=6.8 mm+/-0.49, w=5.5 mm+/-0.42), stapes (h=3.6 mm+/-0.41, w=2.5 mm+/-0.19). Inter-rater reliability was 0.7. Mean intra-class correlation coefficient for microscopic and ultrasound measurements was 0.7. Images of the ossicular chain in continuity in the temporal bone specimen were not as clear as images of individual ossicles that were disarticulated and imaged under water., Conclusions: 4DUS provides reasonable images of ossicles disarticulated and mounted in underwater medium. However, images of the intact ossicular chain in a modified cadaveric temporal bone were not as clear, making interpretation difficult. Further investigation into the development of a thinner ultrasound probe that can pass through the external auditory canal and into overcoming limitations of air in the middle ear cleft are warranted. This could allow for a clinically relevant, faster, lower cost and lower risk alternative to current imaging techniques., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: Post-operative management of children undergoing airway reconstruction has been well-described. However, many of these patients develop post-operative fevers. We conducted a retrospective review in an attempt to define the significance of post-operative fever following pediatric airway reconstruction., Method: Retrospective analysis of 78 pediatric laryngotracheoplasties (LTPs) from May 1, 2006 - April 30, 2007 at a tertiary care pediatric hospital. Fever was defined as temperature >or=38.5. A fever was "significant" if accompanied by a positive sputum, blood or urine culture, or an elevated WBC. Chest radiograph (CXR) results and co-morbidities were examined., Results: Forty-five percent of cases (35/78) had fever. Of those febrile, 46% (n=16) had significant fever. Overall, 20.5% had significant fevers. Fifty-two cases were single-stage LTP (SSLTP) with 31 febrile and 26 cases were double-stage LTP (DSLTP) with 4 febrile. SSLTP cases were at a significantly greater risk for post-operative fever compared with DSLTP, 59% vs 15% respectively (p=0.0002). 42% of febrile SSLTPs (n=13) had significant fevers compared to 50% (n=2) of febrile DSLTPs (Fisher's Exact p=1.0). 81.5% of cases with CXR findings had fevers, but only 50% of these fevers were significant. Subjects with post-operative atelectasis were more likely to have a fever compared to subjects with no post-operative atelactasis (93% vs. 33% respectively, p<0001). 30.8% of those with atelectasis had significant fever, compared to 52% of those without atelectasis (p=0.2) and 25 of SSLTPs vs. 3.9% of DSLTPs had atelactasis (p=0.027). No comorbidities were shown to be significant risk factors for post-operative fever., Conclusion: Based on our review, most children undergoing LTPs will have insignificant fevers. Those children undergoing SSTLP and/or having post-operative atelectasis are at higher risk for post-operative fever. Fevers in children with double-stage procedures or all reconstruction cases with CXR findings other than atelectasis should have a thorough fever work-up., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To develop a new method of using existing bronchoscopic video technology to generate a 3D model of the airway for clinical purposes., Design: Prospective pilot study with clinical correlation., Methods: A Storz 7200 bronchoscope was used to obtain video of a standardized tube. The images were then processed using "open source" tools which detected feature points. A three dimensional model was then constructed using these feature points. An in-house 3D image program was then used to compare the 3D model with the standardized tube. Video from a representative airway patient who had previously had a CT of the chest and a bronchoscopic examination was also analyzed using this technique. The 3D model was correlated with CT images to clinically validate this technique., Setting: Tertiary care hospital., Patients: One airway patient video was used for clinical validation., Outcome Measures: (1) Average diameters of the 3D video derived tube model were compared to the actual tube and (2) a cross section of the 3D video derived patient model was compared to the patient CT derived model., Results: Repeated measures on standardized tubes demonstrated that is it possible to construct an airway model using this novel technique with a less than 5% error. Further, it is possible to construct a 3D model from patient video using existing bronchoscopic technology., Conclusions: It is possible to extract 3D data from a sequence of 2D images. Further, this 3D model can be used for the purposes of management and planning and is quantitatively accurate and reliable. Initial data suggests that these measurements correlate with actual airway size and may provide a better instrument with which to make surgical decisions.

Objectives: We report on four cases of thyroglossal duct cyst (TGDC) excision using the Sistrunk procedure (resection of the mid-portion of the hyoid bone in continuity with a thyroglossal duct cyst tract) in which the airway was significantly injured. The patterns of injury, their treatment and outcomes as well as preventative measures are detailed., Methods: Retrospective analysis of four patients referred to a tertiary medical center after sustaining injury to the cricothyroid membrane and/or thyroid cartilages while undergoing a Sistrunk excision of a TGDC., Results: Three patients were repaired after a delay; one patient was immediately repaired. All four patients required application of cartilage grafts, and all ultimately required tracheotomy. Decannulation was achieved in the four patients after an average of 4.5 months, and none suffered from aspiration. Voice outcomes were poor in 3/4., Conclusions: The Sistrunk procedure has been advocated for TGDC excision, citing a low recurrence rate. However, if the thyroid cartilage is mistaken for the hyoid bone, significant airway injury occurs. Urgent laryngotracheoplasty is indicated, but poor voice outcomes are anticipated., Significance: Surgeons employing the Sistrunk procedure to excise TGDC must remain oriented to midline cervical anatomy, particularly as the hyoid my override the thyroid notch in young children, placing the larynx at risk for significant injury.

Objective: Patients who undergo open airway reconstruction procedures are likely to experience some degree of post-operative dysphagia. This retrospective review describes the duration of post-operative dysphagia and the use of compensatory strategies in a group of 30 pediatric patients., Methods: A retrospective chart review of pediatric patients referred for post-operative swallowing assessment following airway reconstruction during a six-month period was completed. Age, sex, surgical procedure, stent type, co-morbid factors, duration of dysphagia, and use of compensatory dietary modifications and swallowing strategies was summarized and compared., Results: Dysphagia was generally of short duration (1-5 days) in patients undergoing single stage procedures with anterior or anterior/posterior grafts. Duration of swallowing difficulty was increased in patients undergoing posterior grafts in combination with T tubes (10-14 days). The longest duration of difficulty (>2 weeks) occurred in patients who had anterior and posterior grafting with T tubes, combined with additional procedures such as vocal fold lateralization, epiglottic petiole repositioning, and/or arytenoidectomy. There was a greater likelihood of oral feeding difficulty post-operatively in patients presenting with pre-operative feeding issues such as oral aversion or specific texture refusal, and the pre-morbid need for supplemental tube feeding to supplement oral intake. Compensatory swallowing strategies were effective in decreasing aspiration associated with swallowing in oral feeders post-operatively, and in facilitating return to baseline swallowing skills., Conclusions: The duration of dysphagia overall was increased in patients undergoing anterior/posterior grafts in conjunction with in-dwelling T tubes, especially when combined with additional procedures. Compensatory strategies to assist with swallowing were found to be effective in the post-operative phase and included the use of a modified supraglottic swallowing sequence to assist with compensatory airway closure during swallowing in conjunction with diet modifications. Post-operative feeding difficulty occurred in patients with pre-existing feeding issues such as oral aversion and/or texture resistance regardless of reconstructive surgical procedure type.

Objective: Define the clinical presentation, diagnostic value of preoperative imaging, surgical management, and outcomes of treatment of congenital cervical thymic remnants in children., Design: Retrospective cohort., Setting: Single tertiary care institution., Patients: 20 children who underwent excision of cervical thymic remnant, 1975-2006., Main Outcomes Measured: Utility of preoperative imaging to diagnose cervical thymic anomalies; success of surgical treatment of cervical thymic remnants., Results: A total of 20 children were identified, with an average age of 6.98+/-5.63 years. All ectopic thymus tissue was found in the embryonic distribution area associated with the third branchial pouch. Fourteen patients underwent excision of a cystic ectopic thymus. Four of these patients exhibited lesions isolated to the cervical region, and 10 patients displayed lesions involving cervicomediastinal areas. Six patients underwent excision of solid ectopic cervical thymus, and each of these was an unanticipated mass encountered during surgical dissection for other procedures. 83% of patients with solid ectopic cervical thymus presented at age 3 or younger. Physical exam and preoperative imaging correctly diagnosed thymic remnants in 15% patients. Resection of thymic remnants was successful in all patients, and there were no recurrences., Conclusions: Though rare, thymic remnants should be considered in the differential diagnosis of masses presenting in locations associated with derivatives of the third branchial pouch. Though preoperative imaging is helpful in identifying the extent of these lesions, congenital thymic remnants prove difficult to diagnosis radiologically. Surgical excision is the diagnostic and therapeutic treatment of choice in the management of cervical thymic remnants.

Background: Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature., Methods: FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries., Results: Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices., Conclusions: Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.

Lingual choristomas or foregut duplication cysts are infrequently reported congenital anomalies that typically present in the perinatal period, and can cause respiratory or feeding problems. These cysts are lined by epithelial cells characteristic of the upper aerodigestive tract. We describe two children who presented shortly after birth with lingual cysts lined with squamous epithelium and foci of respiratory epithelium. Unlike previously reported lingual choristomas, these cysts did not contain gastrointestinal epithelium. In both these cases, the lingual cysts were successfully excised via a transoral approach. This article will discuss the histological findings in these two cases, the differential diagnosis and attempt to classify these lesions in the context of existing terminology.

Objective: Chronic esophageal foreign bodies (CEFB) are associated with a high incidence of morbidity and mortality in adults. However, the presentation, management and outcome of chronic esophageal foreign bodies in children are not well described., Methods: We performed a retrospective chart review of children with chronic esophageal foreign bodies admitted to the Children's Hospital Medical Center, Cincinnati, OH, between May 1990 and January 2002. A chronic esophageal foreign body was defined as a foreign body estimated to have been present for over 1 week., Results: Over the inclusion period, 522 children were admitted with esophageal foreign bodies, 41 (8%) of which were chronic. The most common foreign bodies were coins. Seventy-six percent of patients presented with a primary complaint of respiratory symptoms, with respiratory distress being the most common followed by asthmatic symptoms and cough. Twenty-two percent of patients had primarily gastrointestinal symptoms including nausea/vomiting and dysphagia. One patient was asymptomatic on presentation. A perforated esophagus was identified in 18 patients, with 17 of these being a technically perforated esophagus and one case being a classic esophageal perforation. There were no deaths or permanent morbidity in this series., Conclusions: Respiratory symptoms are more common than gastrointestinal symptoms in pediatric patients with chronic esophageal foreign bodies. Removal by rigid esophagoscopy is recommended. A small proportion of cases require open removal of the foreign body. Conservative management is appropriate for the technically perforated esophagus. A good outcome should be anticipated for the majority of cases.

Velopharyngeal insufficiency (VPI) refers to the mobility of the velopharyngeal sphincter to adequately separate the nasal cavity from the oral cavity during speech. The auditory result of this structural problem is hyperrhinophy, abnormal resonance and the production of distracting noises during speech created by turbulent airflow escaping from the nasal cavity.

Objective: Identify differences in adenoidectomy performed by curettage versus electrocautery ablation., Design: To receive adenoidectomy by curettage or electrocautery ablation 38 patients undergoing adenoidectomy or adenotonsillectomy were prospectively randomized. The study was completed by 24 patients. All tonsillectomy patients received electrocautery dissection of the tonsils. Preoperative and at least 1 month postoperative video-nasopharyngoscopy was performed. Video tapes were reviewed by the authors blinded to patient identity and procedure to evaluate choanal obstruction. Preoperative and postoperative lateral neck radiographs were obtained. Blood loss and postoperative complications were recorded., Setting: A single, tertiary care pediatric facility., Interventions: Electrocautery ablation of the adenoid was performed with suction cautery. Curettage was performed with standard adenoid curettes., Main Outcome Measured: A grading system for adenoid size was developed using radiographs and endoscopic parameters. The grade of preoperative and postoperative adenoid tissue was compared between the curettage and electrocautery ablation groups. Operative blood loss was compared between the groups. The postoperative course and complications were compared., Results: The preoperative grade of choanal obstruction in both groups was the same. No differences could be found in the postoperative grade between the curettage and the electrocautery ablation groups. No postoperative complications were recorded in either group. The estimated blood loss in the curettage group was 54.5 ml (S.D. 50.7) while the electrocautery ablation group averaged 3.75 ml (S.D. 6.4; p = 0.0053)., Conclusion: There are no differences in the postoperative results of adenoidectomy performed by electrocautery ablation or curettage. There are no complications recorded in either group. Estimated blood loss was lower in the electrocautery ablation group. Decreased blood loss during the procedure makes the electrocautery ablation method of adenoidectomy attractive.

Cervical thymic cysts are among the rarest congenital neck masses. They are probably more frequent than the number of cases reported as many of these lesions are asymptomatic and only discovered incidentally. The initial embryologic development of the thymus begins in the neck, followed by migration into the superior mediastinum. For this reason, extension of cervical thymic anomalies into the mediastinum is possible. Although it is the least common lateral cystic neck mass, it must be differentiated from other pediatric cystic neck masses, the majority of which are anomalies of the branchial system. Due to the possibility of mediastinal extension, the management of these lesions is different than other congenital neck masses. We report two cases of thymic anomalies with mediastinal extension and review the embryology, diagnosis, and management of cervicomediastinal thymic cysts.