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

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

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

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

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

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

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

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

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

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

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

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