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OBJECTIVES Juvenile onset recurrent respiratory papillomatosis (JORRP) can cause severe or disseminated disease. Surgical treatment may be inadequate. Systemic bevacizumab has shown initial success for severe JORRP. The objective of this systematic review was to assess usage, effectiveness, and safety of this treatment. METHODS We searched PubMed, Embase, and Web of Science for studies of humans with JORRP treated with systemic bevacizumab. Two researchers independently reviewed the studies to determine inclusion and aggregate data on patient characteristics, dosing protocols, treatment response, adverse events, and level of evidence. RESULTS Of 80 identified articles, 12 studies were included detailing 20 distinct cases. At a mean age of 12.8 years (range = 1-43 years) patients received initial dosing of 5 to 10 mg/kg of bevacizumab followed by ongoing doses at a mean 3-week intervals (range = 2-5 weeks). All patients had clinically significant disease reduction with reduced need for surgery. Six patients (30%) had complete response in at least one involved anatomic site. Eleven (55%) required no surgery after initiating treatment. There was recurrence in all four patients whose treatment was stopped, but had rapid improvement with treatment resumption. Six (30%) experienced mild or moderate adverse events. CONCLUSIONS Marked improvement in severe JORRP has been reported from systemic bevacizumab. Treatment protocols vary, and treatment discontinuation was not feasible in any reported patient. Based on currently available data, systemic bevacizumab can be considered for severe JORRP as it appears to be well tolerated and effective. A clinical trial could enhance the understanding of its safety and efficacy for this indication. Laryngoscope, 131:1138-1146, 2021.

Objectives Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post-tonsillectomy hemorrhage onset relative to the time of day. Methods We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition [ICD-9] 998.11, ICD-10 J95.830 at two hospitals within a tertiary academic health system in a 10-year period). Patient demographics, time of bleed onset, emergency room [ED] arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am-12 pm), afternoon (12:01 pm-6 pm), evening (6:01 pm-12 am), or overnight (12:01 am-6 am). Chi-square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05). Results A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post-tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007). Conclusion In this cohort, post-tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations. Level of evidence 4 Laryngoscope, 130:1823-1827, 2020.

Objective Tympanostomy tube (TT) placement is common in children; however, family-centeredness and utility of online information used for decision making and understanding is unknown. We evaluate the quality of leading Internet resources describing TT placement. Study design Cross-sectional descriptive design. Methods We performed a Google (Menlo Park, CA) search for terms related to TTs. We defined quality using scaled readability measures (Flesch Reading Ease and Flesch-Kincaid Grade-Level), understandability and actionability (Patient Education Materials Assessment Tool), shared decision-making centrality (Center for Medicare and Medicaid Services informed consent guidelines), and clinical practice guideline (CPG) compatibility. Three reviewers coded each measure. Fleiss κ interrater reliability analysis was performed. Results Ten most frequently encountered websites were analyzed. One of 10 met national health literacy standards (mean 10th-grade level reading, median 9th, range 6-15th). All sites were understandable (mean understandability 81.9%, range 73%-92%). Most had low actionability scores (7 of 10, median 47%, mean 44.6%, range 0-80). Shared decision-making centrality was high (mean 5, range 4-6), but most did not list alternative treatment options. Although CPG compatibility was high (mean 3.4, range 1-4), many websites contained inconsistent recommendations about tube duration, follow-up, and water precautions. There was inter-rater agreement for understandability scoring (κ = 0.20; P = 0.02). Conclusion Internet resources about TT placement vary in quality pertaining to health literacy, principles of shared decision making, and consistency with practice guidelines. With growing emphasis on patient-/family-centered engagement in healthcare decision making, standardization of content and improved usability of educational materials for common surgical procedures in children such as tympanostomy tube placement should be a public health priority. Level of evidence NA. Laryngoscope, 128:496-501, 2018.

Objectives/Hypothesis To evaluate the accuracy of three-dimensional (3D) airway reconstructions obtained using quantitative endoscopy (QE). We developed this novel technique to reconstruct precise 3D representations of airway geometries from endoscopic video streams. This method, based on machine vision methodologies, uses a post-processing step of the standard videos obtained during routine laryngoscopy and bronchoscopy. We hypothesize that this method is precise and will generate assessment of airway size and shape similar to those obtained using computed tomography (CT). Study Design This study was approved by the institutional review board (IRB). We analyzed video sequences from pediatric patients receiving rigid bronchoscopy. Methods We generated 3D scaled airway models of the subglottis, trachea, and carina using QE. These models were compared to 3D airway models generated from CT. We used the CT data as the gold standard measure of airway size, and used a mixed linear model to estimate the average error in cross-sectional area and effective diameter for QE. Results The average error in cross sectional area (area sliced perpendicular to the long axis of the airway) was 7.7 mm2 (variance 33.447 mm4). The average error in effective diameter was 0.38775 mm (variance 2.45 mm2), approximately 9% error. Conclusion Our pilot study suggests that QE can be used to generate precise 3D reconstructions of airways. This technique is atraumatic, does not require ionizing radiation, and integrates easily into standard airway assessment protocols. We conjecture that this technology will be useful for staging airway disease and assessing surgical outcomes. Level of Evidence N/A. Laryngoscope, 123:2880–2887, 2013

Objectives/Hypothesis Salivary gland stones (sialoliths) are a common cause of salivary gland enlargement, but such stones are uncommon in children. Low-flow vascular malformations of the head and neck region may develop phleboliths. Phleboliths within a venous malformation may be mistaken for a salivary stone given the similar calcified nature and location. We present two children who were referred to us for evaluation of submandibular gland sialoliths but were found to have venous malformations containing phleboliths. Multiple calcifications, calcifications > 1 cm, within a soft tissue mass separate from the substance of the submandibular gland suggest a diagnosis, of phleboliths within a venous malformation as opposed to a sialolith. Laryngoscope, 124:2826–2828, 2014

Objectives/Hypothesis: Human papillomavirus (HPV) types 6 and 11 are associated with recurrent respiratory papillomatosis (RRP). Although a prophylactic vaccine has been developed that protects against HPV infection, a therapeutic vaccine is still needed for those patients infected with and/or suffering from persistent disease. Therefore, we developed a novel, therapeutic DNA vaccine targeting HPV-11 and characterized the in vivo immunologic responses generated against HPV-11 E6 and E7 after DNA vaccination in a preclinical model. Methods: We generated a DNA vaccine that encodes the HPV-11 E6 and E7 genes in a pcDNA3 backbone plasmid. We then vaccinated C57BL/6 mice with the pcDNA3-HPV11-E6E7 DNA plasmid. Splenocytes were harvested from these vaccinated animals and were incubated with overlapping peptides spanning either the HPV-11 E6 or E7 protein. The frequency of interferon-γ–releasing CD8+ T cell responses was then analyzed by flow cytometry. Results: Vaccinated mice with the HPV11-E6E7 DNA generated strong CD8+ T cell responses against the E6aa44-51 peptide. We determined that the epitope is presented by the MHC class I H2-Kb molecule. No significant E7 peptide-specific T cell responses were observed. Conclusions: We developed a novel DNA vaccine that targets the E6 gene of HPV-11. Characterization of the immunologic responses elicited by this DNA vaccine reveals that the E6aa44-51 peptide contains the most immunogenic region for the HPV-11 viral type. Knowledge of this specific T cell epitope and generation of a RRP preclinical model will allow for the development and evaluation of novel vaccine strategies targeting the RRP patient population. Laryngoscope, 2010

Salivary gland stones (sialoliths) are a common cause of salivary gland enlargement, but such stones are uncommon in children. Low-flow vascular malformations of the head and neck region may develop phleboliths. Phleboliths within a venous malformation may be mistaken for a salivary stone given the similar calcified nature and location. We present two children who were referred to us for evaluation of submandibular gland sialoliths but were found to have venous malformations containing phleboliths. Multiple calcifications, calcifications 1 cm, within a soft tissue mass separate from the substance of the submandibular gland suggest a diagnosis, of phleboliths within a venous malformation as opposed to a sialolith.

Objective: Functional laryngeal dyskinesia (FLD) is characterized by signs and symptoms of airway obstruction without anatomic basis. Failure to recognize its features often leads to inappropriate diagnostic studies and therapies. A systematic approach is presented for the recognition and management of patients with this disorder. Design: A retrospective case series at a large, urban tertiary care academic hospital. Methods: Retrospective review of charts of adults and children diagnosed with FLD between 1979 and 1996. Presenting symptoms and signs of FLD were categorized and methods of diagnosis were recorded. Therapeutic interventions and resolution of FLD at follow-up were also analyzed. Results: Ten patients were identified with FLD, seven females and three males, with mean age of 25.9 years at diagnosis (range, 10–59 y). Patients were hospitalized a mean of three times (range, 1 to 6 admissions) before FLD was correctly diagnosed. Nine patients were receiving treatment for asthma prior to diagnosis. Flow volume loops most often showed a fixed extrathoracic inspiratory. Arterial blood gas and radiographic data were essentially normal. The most useful diagnostic test was fiberoptic laryngoscopy, which showed abnormal adduction of the vocal cords on inspiration in the nine patients in this series who underwent laryngoscopy. Conclusions: The authors' experience with FLD shows that its early recognition is associated with fewer interventions and their accompanying risks. A high degree of suspicion is required in these patients, who are often young and well educated. They present with stridor that may disappear while they are asleep or after distraction techniques. Laryngoscope, 108:1520–1523, 1998

Objective/Hypothesis: To report the feasibility and early results of a new surgical technique for excision of nasoglabellar dermoid cysts. Study Design: Retrospective case series. Methods: Patients with nasoglabellar dermoid cysts without intracranial communication were treated with the endoscopic-assisted, closed rhinoplasty approach. Data pertaining to patient characteristics, surgical outcome, and cosmetic results were obtained by retrospectively reviewing medical records. Results: Three patients were included in the study. The endoscopic-assisted, closed rhinoplasty approach was utilized in all patients. In each case, complete excision was achieved without violation of the cyst wall. All patients had satisfactory cosmetic results as assessed by subjective evaluation by the parent(s) and surgeon. Conclusions: The endoscopic-assisted, closed rhinoplasty approach allows for safe and complete excision of uncomplicated nasoglabellar dermoid cysts. This new surgical technique should be considered in children with benign, midline nasal, and forehead masses due to its ease and excellent cosmetic results. Laryngoscope, 2010

Objectives: To develop and pilot test an objective assessment of technical skills instrument for evaluation of residents' surgical performance of pediatric direct laryngoscopy and rigid bronchoscopy, with emphasis on feasibility, validity, and interrater agreement. Study Design: Prospective, unblinded educational quality-improvement project combining paired and unpaired observations. Methods: Objective Structured Assessment of Technical Skills (OSATS) evaluation instruments were developed from detailed faculty input. Two instruments were created: a surgical checklist and a global assessment of surgical performance. The instruments were tested in a simulation bronchoscopy course and in the operative suite. Paired observations were used to determine interrater agreement, whereas multiple evaluations were used to calculate construct validity and internal consistency. Results: Forty-four assessments were completed for 19 residents. Seven faculty members evaluated residents as they performed laryngoscopy and bronchoscopy in an animal simulation laboratory and in the operating room. The evaluation tool was found to be feasible. The interrater agreement for both instruments was significant at 80.4% to 84.6% (P ≤.0001). Construct validity was confirmed with increasing mean global and task specific scores by postgraduate year (P

Objectives/Hypothesis: We sought to determine the effectiveness of powered intracapsular tonsillectomy and adenoidectomy (PITA) in the treatment of children with moderately severe obstructive sleep apnea and to measure changes in quality of life that occur with such treatment. Study Design: Prospective, nonrandomized clinical trial in an academic pediatric otolaryngology practice. Methods: Convenience sample of children ages 3 to 12 years diagnosed with obstructive sleep apnea of moderate severity, defined as an apnea-hypopnea index (AHI) between 5 and 20 on polysomnography. Children with recurrent streptococcal pharyngitis, chromosomal abnormalities, craniofacial abnormalities, neuromotor disease, sickle cell disease, obesity, or coagulopathy were excluded. PITA was performed by using the microdebrider. Polysomnography was performed before surgery and repeated 4 to 8 weeks after surgery. The Obstructive Sleep Apnea (OSA)-18 questionnaire was completed at surgery and at the time of postoperative polysomnography to assess quality of life changes. The main outcome measure was cure of obstructive sleep apnea, as defined by a postoperative AHI of 1 or less for complete cure and less than 5 for partial cure. Improvements in quality of life were assessed by changes in the OSA-18 questionnaire. Results: Nineteen children underwent PITA for moderate obstructive sleep apnea syndrome (OSAS), and 14 completed postoperative polysomnography. All 14 subjects who completed the study achieved at least partial cure. Thirteen of 14 (93%) subjects had a complete cure of OSAS after PITA. The median preoperative AHI was 7.9, and the median AHI after surgery was 0.1. The mean number of arousals per hour before surgery was 9.5, and this was reduced to a mean of 5.6 after surgery. Quality of life measures on OSA-18 also improved, with large improvements in total quality of life scores and in all five domains seen after surgery. Conclusions: PITA cures otherwise healthy children with obstructive sleep apnea of moderate severity, at least in the short-term, as documented by postoperative polysomnography. Improvements in quality of life measures, as documented by changes in OSA-18, were seen in all children as well.

The effects of functional endoscopic sinus surgery (FESS) on sinus and midfacial development remain unclear. The authors report five children who, at a median age of 30 months, underwent FESS for refractory sinusitis. Three of the children had cystic fibrosis, and two had asthma. Preoperative computed tomographic (CT) scanning showed symmetric maxillary sinus development with varying degrees of mucosal disease. At a mean of 42 months after surgery, CT scans were obtained to evaluate recurrent symptoms in the five children. The scans showed unilateral maxillary hypoplasia in four children and bilateral maxillary sinus hypoplasia in one child. No child had clinically apparent facial asymmetry or midfacial hypoplasia. The authors also discuss the factors involved in maxillary sinus pneumatization, the possible effects of sinus surgery on sinus development, and the clinical implications of "acquired" maxillary sinus hypoplasia.

Fifteen children with nontuberculous mycobacterial adenitis of the head and neck underwent surgical treatment between July 1991 and July 1994. Fine-needle aspiration for biopsy and culture allowed early diagnosis in nine children. Positive cultures grew Mycobacterium avium-intracellulare complex in 12 children and M. chelonei in one child. Total excision was performed in 10 cases with combinations of lymphadenectomy and salivary gland excision. Curettage was used to successfully treat five children. One patient required local flap coverage for primary wound repair. Two patients required more than one surgical procedure. Our approach to early diagnosis and surgical treatment of cervicofacial nontuberculous mycobacterial adenitis is presented.

Objectives: Recognition of the developmental consequences of unidentified congenital hearing loss has prompted universal hearing screening of newborns. We sought to identify the incidence of infants discharged from the neonatal intensive care unit (NICU) without hearing screening and identify factors associated with failure to screen. Study Design: Retrospective case-control study of all infants admitted for >48 hours to a tertiary care NICU in 2005-2006 (N = 958). Methods: Statistical analysis was performed using simple and multiple logistic regression. Results: A total of 644 of 958 (67.2%) infants underwent hearing screening prior to discharge. Gestational age less than 30 weeks (OR 3.91, P 50 days of age in the MLR (multiple logistic regression) (P =0.002, P

Bilateral enlargement of the parotid glands has been noted in five patients who are seropositive for antibody to the human immunodeficiency virus. A characteristic cystic appearance has been noted in these lesions on clinical and radiographic examination. A benign lymphoepithelial infiltrate with cystic degeneration is found in parotid specimens from these patients. The presence of human immunodeficiency virus ribonucleic acid in inflammatory cells infiltrating the parotid specimen was confirmed by an in situ hybridization technique. The clinical manifestations of sicca syndrome were not present nor were opportunistic infections diagnostic for the acquired immunodeficiency syndrome.