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Objective: Validation of a contemporary International Classification of Diseases, 10th Revision, Clinical Modification (ICD‐10‐CM) congenital esophageal atresia/tracheoesophageal atresia (EA/TEF) cohort in the Pediatric Health Information System (PHIS) database. Study Design: Database study, validation. Setting: Tertiary care center. Methods: Search methods used to validate an ICD‐9‐CM EA/TEF cohort in PHIS were modified for ICD‐10‐CM. A retrospectively and prospectively maintained clinical database at a single high‐volume EA/TEF center was used for comparison. Patients treated between October 1, 2015 and July 31, 2022 were included. Searches progressively narrowed the cohort by ICD‐10‐CM diagnosis codes, expansion to include incorrectly coded as 'iatrogenic, age less than 30 days, and use of at least 1 ICD‐10‐CM procedure code. Results of PHIS data and institution data were compared for accuracy. Results: The most refined search of PHIS and the EA/TEF clinical database yielded 93 and 84 patients, respectively. The sensitivity was 99% and positive predictive value was 94%. A PHIS search using these methods and encompassing 49 children's hospitals yielded an EA/TEF cohort of 2479 patients. Conclusion: We present a validated search method in the PHIS database to identify a high‐fidelity cohort of EA/TEF patients for multi‐institutional study. We have demonstrated that a carefully maintained clinical database may be used to validate cohorts in PHIS. This cohort allows for improved practice variability and outcomes study of EA/TEF patients. Similar methods may be employed to generate other rare disease cohorts in PHIS. Level of Evidence: Level 4. [ABSTRACT FROM AUTHOR]

Introduction: Children undergoing cervical and/or thoracic operations are at risk for recurrent laryngeal nerve injury, resulting in vocal fold movement impairment (VFMI). Screening for VFMI is often reserved for symptomatic patients. Objective: Identify the prevalence of VFMI in screened preoperative patients prior to an at‐risk operation to evaluate the value of screening all patients at‐risk for VFMI, regardless of symptoms. Methods: A single center, retrospective review of all patients undergoing a preoperative flexible nasolaryngoscopy between 2017 and 2021, examining the presence of VFMI and associated symptoms. Results: We evaluated 297 patients with a median (IQR) age of 18 (7.8, 56.3) months and a weight of 11.3 (7.8, 17.7) kilograms. Most had a history of esophageal atresia (EA, 60%), and a prior at‐risk cervical or thoracic operation (73%). Overall, 72 (24%) patients presented with VFMI (51% left, 26% right, and 22% bilateral). Of patients with VFMI, 47% did not exhibit the classic symptoms (stridor, dysphonia, and aspiration) of VFMI. Dysphonia was the most prevalent classic VFMI symptom, yet only present in 18 (25%) patients. Patients presenting with a history of at‐risk surgery (OR 2.3, 95%CI 1.1, 4.8, p = 0.03), presence of a tracheostomy (OR 3.1, 95%CI 1.0, 10.0, p = 0.04), or presence of a surgical feeding tube (OR 3.1, 95%CI 1.6, 6.2, p = 0.001) were more likely to present with VFMI. Conclusion: Routine screening for VFMI should be considered in all at‐risk patients, regardless of symptoms or prior operations, particularly in those with a history of an at‐risk surgery, presence of tracheostomy, or a surgical feeding tube. Level of Evidence: 3 Laryngoscope, 133:3564–3570, 2023 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: The recurrent laryngeal nerve (RLN) is at risk during pediatric cervical, thoracic, and cardiac surgery. We aim to determine the feasibility and effectiveness of RLN monitoring techniques in all pediatric patients. Study Design: Retrospective case series. Methods: Retrospective review of patients/procedures with RLN(s) at risk and RLN monitoring at Boston Children's Hospital July 2019–October 2020. Primary outcomes: pre/postoperative vocal fold mobility by awake flexible fiberoptic laryngoscopy (FFL). Results: One hundred one patients (median [interquartile range, IQR] age 14.6 months [4.6–49.7 months], weight 10 kg [5.2–16.2 kg]) underwent 122 procedures with RLN(s) at risk. RLN monitoring attempted 111 cases, successful 96 (84%). Surgical indications: esophageal atresia/tracheoesophageal fistula, and tracheobronchomalacia. Sixty‐two (56%) procedures in reoperative field. Median follow‐up 112 days (IQR 41–230). Pre/postoperative FFL performed 84 procedures (69%), 19 new postoperative RLN injuries (16%), median age 12 months, reoperative fields 11 (18%). Prass probes: 34 cases (28 successful, 82%), 6 injuries (18%), age 12.2 (5.8–23.6) months. Dragonfly electrodes: 45 cases (37 successful, 82%), 8 injuries (18%), age 7.5 (3.8–19) months. Nerve integrity monitoring (NIM) integrated electrode endotracheal tube: 33 cases (33 successful, 100%), 5 injuries (15%), age 90 (58.8–136.7) months. Automatic periodic stimulation (APS): 16 cases, 13 successful (81%), four injuries (25%), age 7.2 (5.3–20.6) months. NIM RLN monitoring is significantly more successful than Prass, Dragonfly (95%CI −0.3 to 0.02, P =.02; and 95%CI 0.05–0.31, P =.008). Rates of injury are not different between types of RLN monitoring (P =.94), with APS use (P =.47), or with monitoring success (95%CI −0.36 to 0.09, P =.28). Conclusions: RLN monitoring is feasible in pediatric patients of all ages. Although NIM type RLN monitoring success is superior, all forms offer similar rates of nerve protection. Level of Evidence: 3 Laryngoscope, 132:889–894, 2022 [ABSTRACT FROM AUTHOR]

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Objectives: Gender disparity exists in medicine, such as differences in pay and promotion opportunities. We hypothesize that there is also a gender difference in graduate medical education as manifested by operative case volume. This study compares surgical case volume by gender for graduating US otolaryngology residents.Study Design: Cohort study.Methods: With data use approval from the Accreditation Council for Graduate Medical Education, we evaluated the key indicator case log summaries of graduating otolaryngology residents from 2009-2017. Mean and standard deviation were used for all cases, and t-tests were used to compare cases by resident gender. The Bonferroni method was used to adjust for multiple comparisons across years.Results: Data from 1740 male and 804 female residents were evaluated. Across all years, the average number of key indicator cases reported was 778.8 and 813.6 by female and male residents, respectively, with an average difference of 34.8 cases per graduating year (95% confidence interval [CI] 19.4, 50.2; P < .001). When a resident self-reported the role of resident surgeon/supervisor, the average number of key indicator cases reported was 602.6 and 643.9 by female and male residents, respectively, with an average difference of 41.3 cases per graduating year (95% CI, 28.0, 54.6; P < .001).Conclusion: Gender-based discrepancies in surgical case volume exist among graduating otolaryngology residents. This disparity is partially attributed to the self-reported role in the surgery. This study has identified those discrepancies so that training programs can implement strategies to ensure improved gender parity.Level Of Evidence: 2b Laryngoscope, 130:1651-1656, 2020. [ABSTRACT FROM AUTHOR]

Objective: To discuss the presentation, evaluation, and management of pediatric laryngeal web.Study Design: Retrospective case series.Setting: Single tertiary care center.Subjects: All patients with laryngeal web at Boston Children's Hospital in the past 22 years.Methods: No exclusion criteria. Charts mined for age at presentation, presenting symptoms, degree/location of web, associated syndromes, number/type of surgical procedures, and postoperative outcomes.Results: Thirty-seven patients were included (13 male, 24 female). Average age at diagnosis was 3.7 years (0-19.5 years). Mean follow-up was 4.4 years (range, 0-16.4 years). There were 26 congenital webs (70.2%) and 11 acquired webs (29.8%). Presenting symptoms were vocal (29 patients, 78.4%) and respiratory (22 patients, 60%). Underlying syndromes or synchronous airway lesions included the following: premature (n = 5), congenital heart disease (n = 18), subglottic stenosis (n = 5), 22q11.2 deletion syndrome (n = 10), and recurrent respiratory papillomatosis (n = 4). There were 20 type 1 webs, 6 type 2 webs, 8 type 3 webs, and 3 type 4 webs; 10 had subglottic extension of the laryngeal web. Twelve patients were managed conservatively with observation. Eighty-four interventions were performed: 18 open and 66 endoscopic (sharp division, 32; dilation, 33; mitomycin C, 14; laser, 5; keel, 6; triamcinolone injection, 8; stent, 15; removal of granulation tissue, 5). Tracheotomy was required in 11 patients, and 5 patients were decannulated. Voice improved in 12 patients, with respiratory symptoms in 12 patients. Web recurred in 17 patients. One patient died due to airway complications.Conclusions: Pediatric laryngeal web is an uncommon but challenging lesion. Patients need to be evaluated for comorbid syndromes and synchronous airway lesions. Management includes open and endoscopic procedures. Procedures should be tailored to the child's presentation. [ABSTRACT FROM AUTHOR]

Small studies have aimed to assess the parity of these exams in children.[2] LITERATURE REVIEW VFSS (also known as modified bariums swallow study, or MBSS) was first described in children by Logemann et al. in 1983.[3] Frequently referred to as the "gold standard", this is likely because VFSS was the first reliable instrumental assessment available in the pediatric population.[4] VFSS is usually performed by a speech language pathologist (SLP) and a radiologist. Instrumental swallow assessments, including video fluoroscopic swallow studies (VFSS) and fiberoptic endoscopic evaluation of swallow (FEES), are complimentary to clinical feeding evaluations. [Extracted from the article]

ER results in the greatest rate of lasting symptom improvement and resolution though are associated with higher complication rates than IIA and conservative therapy. IIA is safe and can be considered in place of a conservative treatment to determine which patients are likely to improve from ER, and may result in permanent improvement or resolution in a minority of patients. As many as 52% (37%-66% 95% confidence interval (CI)) of patients with symptomatic T1LC improve with only conservative management, including feeding therapy, thickened liquids, and reflux management. [Extracted from the article]

This may allow for pre- and postoperative evaluations of vocal fold mobility in patients undergoing procedures that place the recurrent laryngeal nerves at risk, such as cardiothoracic or cervical surgeries, especially when it may not be feasible for an otolaryngologist to be available to perform screening FFL. Vocal fold immobility (VFI) can cause significant morbidity for pediatric patients, including respiratory distress, poor airway protection resulting in aspiration and recurrent respiratory tract infections, and dysphonia. [Extracted from the article]

Objectives: Simulation-based boot camps have gained popularity over the past few years, with some surgical specialties implementing mandatory national boot camps. However, there is no consensus in otolaryngology on boot camp timing, learner level, or curriculum. The purpose of this study is to examine the current landscape and gather opinions regarding future curriculum and standardization of boot camps in otolaryngology.Methods: A survey was developed to examine current resident participation and boot camp content while also seeking opinions regarding improving boot camp enrollment and standardizing curriculum. A cross-sectional survey of all otolaryngology residency program directors in the United States and Puerto Rico was performed via SurveyMonkey. Responses were collected anonymously, and results were analyzed by descriptive statistical analysis.Results: Of the 45% (48 of 106) who responded, 76.6% reported their residents participate in boot camps. The most common skills taught were basic suturing and airway management skills. The majority (95%) was likely to send residents to a local boot camp, with 56% favoring early postgraduate year (PGY)-1 participation and 42% favoring a 1-day boot camp. Subsidized expenses, improved regional access, and supplementary boot camp information would help the program director in their decision to send residents to boot camp. Only 32% felt boot camps should be standardized, and 27% felt they should be mandatory.Conclusion: Many otolaryngology residency programs participate in boot camps. Additional data on the benefits of boot camps, improved access, and reduced financial burden may improve participation. Further discussion of ideal timing, PGY level, and standardized curriculum should occur in conjunction with the otolaryngology academic societies and oversight from accreditation and certifying bodies.Level Of Evidence: NA Laryngoscope, 129:2707-2712, 2019. [ABSTRACT FROM AUTHOR]

Objective: To describe the impact of timing of tympanostomy tube insertion on the number of tubes received and complications in children with routine tube placement. Design: Retrospective case series. Setting: Tertiary care children's hospital. Participants: Records from a consecutive sample of 401 children with cleft palate were reviewed. Sixty-five patients with isolated cleft palate and 82 patients with cleft lip and palate had follow-up until 5 years of age and were included. Interventions: Tympanostomy tubes. Main Outcome Measure(s): Number of tubes received and tube-related complications. The hypothesis was formulated prior to data collection. Results: Males comprised 55.8% of included patients, and tubes were placed in 98.6% of patients at a median age of 6.5 months. Effusion was documented at first tube placement for 96.5% of patients. Most (67.4%) patients required replacement of tubes, and 10.6% required long-term tubes. Complications included otorrhea (71.0%), myringosclerosis (35.2%), granulation (22.8%), perforation (17.9%), retained tubes (5.5%), and cholesteatoma (1.4%). Cleft lip and palate (P <.001) and otorrhea (P =.023) were associated with tube placement before palatoplasty. Patients with tube placement before palatoplasty (P =.033), genetic disorders (P =.007), failed newborn hearing screen (P =.012), otorrhea (P <.001), and granulation (P <.001) received more tubes. Conclusions: Nearly universal effusion in patients with cleft palate supports the need for routine tube placement. The potential for otorrhea and requiring more tubes should be weighed against the risks associated with prolonged effusion when considering tube placement before palatoplasty. [ABSTRACT FROM AUTHOR]

Background: Recurrent Respiratory Papillomatosis (RRP) is a rare disease characterized by the growth of papillomas in the airway and especially the larynx. The clinical course is highly variable among individuals and there is poor understanding of the factors that drive an aggressive vs an indolent course. Methods: A convenience cohort of 339 affected subjects with papillomas positive for only HPV6 or HPV11 and clinical course data available for 1 year or more, from a large multicenter international study were included. Exploratory data analysis was conducted followed by inferential analyses with frequentist and Bayesian statistics. Results: We examined 339 subjects: 82% were diagnosed prior to the age of 18 years, 65% were infected with HPV6, and 69% had an aggressive clinical course. When comparing age at diagnosis with clinical course, the probability of aggressiveness is high for children under five years of age then drops rapidly. For patients diagnosed after the age of 10 years, an indolent course is more common. After accounting for confounding between HPV11 and young age, HPV type was minimally associated with aggressiveness. Fast and Frugal Trees (FFTs) were utilized to determine which algorithms yield the highest accuracy to classify patients as having an indolent or aggressive clinical course and consistently created a branch for diagnostic age at ~5 years old. There was no reliable strong association between clinical course and socioeconomic or parental factors. Conclusion: In the largest cohort of its type, we have identified a critical age at diagnosis which demarcates a more aggressive from less aggressive clinical course. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes. Design: Retrospective cohort study. Setting: Tertiary care children’s hospital. Participants: Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained. Main Outcome Measure: Number of tubes. Results: Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years). Conclusion: Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population. [ABSTRACT FROM AUTHOR]

Objective Describe the impact of hearing loss, tympanostomy tube placement before palatoplasty, and number of tubes received on speech outcomes in children with cleft palate. Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods Records from 737 children born between April 2005 and April 2015 who underwent palatoplasty at a tertiary children's hospital were reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, sensorineural or mixed hearing loss, no tubes, first tubes after palatoplasty, or first clinic after 12 months of age. Data from 152 patients with isolated cleft palate and 166 patients with cleft lip and palate were analyzed using Wilcoxon rank-sum, χ2, and Fisher exact test and logistic regression. Results Most patients (242, 76.1%) received tubes before palatoplasty. Hearing loss after tubes, but not before, was associated with speech/language delays at 24 months ( P = .005) and language delays ( P = .048) and speech sound production disorders (SSPDs, P = .040) at 5 years. Receiving tubes before palatoplasty was associated with failed newborn hearing screen ( P = .001) and younger age at first posttubes type B tympanogram with normal canal volume ( P = .015). Hearing loss after tubes ( P = .021), language delays ( P = .025), SSPDs ( P = .003), and velopharyngeal insufficiency ( P = .032) at 5 years and speech surgery ( P = .022) were associated with more tubes. Conclusion Continued middle ear disease, reflected by hearing loss and multiple tubes, may impair speech and language development. Inserting tubes before palatoplasty did not mitigate these impairments better than later tube placement. [ABSTRACT FROM AUTHOR]

Objectives: Fine-needle aspiration biopsy (FNAB) has a well-established role in the evaluation of an adult head and neck mass (HNM) but remains underused in children. The objectives of this study were to assess the diagnostic accuracy, safety profile, use of anesthesia, and influence on surgical decision making of FNAB of HNM in the pediatric population.Study Design: Case series with chart review.Setting: Tertiary care children's hospital.Subjects and Methods: In total, 257 consecutive patients with HNM who underwent 338 FNABs from July 2007 to July 2014 were reviewed. Patients ranged in age from 0 to 21 years (mean, 9.3 years); lesions ranged in size from 0.3 to 12.5 cm (mean, 2.4cm). Fine-needle aspiration biopsies were performed in the interventional radiology suite, operating room, clinic, or ward.Results: The most common patient final diagnoses included reactive lymphadenopathy (n = 99, 38.5%), benign thyroid colloid nodule (n = 31, 12.1%), malignancies (n = 21, 8.2%), and atypical mycobacterial infection (n = 15, 5.8%). On surgical histopathologic and clinical follow-up, overall sensitivity of FNAB was 94.6% and specificity was 97.7%. The complication rate was 2.1%, and general anesthesia or sedation was used for 73% of FNAB. Surgery occurred only 9 times following the 191 patients with negative FNAB results, indicating that 95.3% of unnecessary surgeries were avoided with the assistance of the FNAB result.Conclusions: Fine-needle aspiration biopsy is an accurate and safe diagnostic tool for guiding management of persistent lymphadenopathy, thyroid nodules, and other HNM in pediatric patients. Negative FNABs can often obviate the need for surgical intervention. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Despite careful selection processes, residency programs face the challenge of training residents who fall below minimal performance standards. Poor performance of a resident can endanger both patient safety and the reputation of the residency program. It is important, therefore, for a program to identify such residents and implement strategies for their successful remediation. The purpose of our study was to gather information on evaluation and remediation strategies employed by different otolaryngology programs.Study Design: Cross-sectional survey.Methods: We conducted a national survey, sending a questionnaire to the program directors of 106 otolaryngology residency programs. We collected information on demographics of the program, identification of problematic residents, and remediation strategies.Results: The response rate was 74.5%, with a 2% cumulative incidence of problematic residents in otolaryngology programs during the past 10 years. The most frequently reported deficiencies of problematic residents were unprofessional behavior with colleagues/staff (38%), insufficient medical knowledge (37%), and poor clinical judgment (34%). Personal or professional stress was the most frequently identified underlying problem (70.5%). Remediation efforts included general counseling (78%), frequent feedback sessions (73%), assignment of a mentor (58%), and extra didactics (47%). These remediation efforts failed to produce improvement in 23% of the identified residents, ultimately leading to their dismissal.Conclusions: The apparent deficiencies, underlying causes, and remediation strategies vary among otolaryngology residency programs. Based on the results of this survey, we offer recommendations for the early identification of problematic residents and a standardized remediation plan.Level Of Evidence: NA. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Evidence shows a positive association between quality of surgical training received and patient outcomes. Traditionally, improved patient outcomes are linked with increased operative volume. However, generalizing this finding to surgeons in training is unclear. In addition, reduced exposure due to work-hour restrictions calls for alternative methods to determine the quality of training. The purpose of this study was to identify the indicators of high-quality training by surveying the trainees and trainers.Methods: A questionnaire was developed based on input from faculty and previous studies. The survey was divided into three sections asking about the indicators of quality training, methods to measure them, and interventions for improvement. The questionnaire was administered to program directors (PDs) and senior residents of otolaryngology training programs nationwide.Results: The strongest indicators of quality training that were agreed upon by both residents and PDs were having faculty development as an ideal trainer while having a balanced level of supervision and independence, logbooks for exposure to volume and variety of pathology, continuous evaluation and provision of feedback. However, structured teaching, simulation-based training, and trainee exam scores failed to reach an agreement as a metric of high-quality surgical training.Conclusion: Measuring quality of a residency training program is imperative to produce competent surgeons and ensuring patient safety. The results of this study will help the residency programs to better train their residents and improve the quality of their teaching.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To determine the proportion of female otolaryngologists in leadership positions relative to their number in the specialty, their membership in various otolaryngology organizations, and age. Study Design: Cross-sectional analyses of otolaryngology organization membership with a subgroup analysis on female membership and leadership proportion comparing 5-year male/female cohort groups. Methods: Information on the number of members and leaders was obtained from various specialty societies by direct communication and from their Web sites between June and December 2010. The number of female and male otolaryngologists and their age distribution in 5-year age groups was obtained from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Statistical analyses were used to determine whether women had proportional membership and leadership representation in various specialty societies. Additionally, female representation in other leadership roles was analyzed using the male/female ratio within the 5-year cohort groups. Results: Female otolaryngologists were found to constitute approximately 11% of practicing otolaryngologists. The American Society of Pediatric Otolaryngology had a higher proportion of female members (22%) compared to five other societies. When the gender composition within each organization was taken into account, female representation in specialty society leadership positions was proportionate to their membership across all societies. When gender and age were considered, women have achieved proportionate representation in each of the specialty societies' leadership positions. There was also proportionate representation of females as program directors, American Board of Otolaryngology directors, Residency Review Committee members, and journal editors/editorial board members. Finally, fewer female chairs or chiefs of departments/divisions were seen, but when age was taken into consideration, this difference was no longer significant. Conclusion: Women have achieved parity in otolaryngology leadership positions. As the number and seniority of women increase, the specialty should continue to monitor representation of women in leadership positions. Laryngoscope, 2012 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To determine whether the characteristics of acute mastoiditis in children have changed in the post-heptavalent pneumococcal conjugate vaccine (PCV7) era. Study Design: Case series. Methods: Clinical data for all patients admitted for acute mastoiditis at an urban tertiary children's hospital from July 1, 1996, to June 30, 2009, were reviewed. Patients with a known immune deficiency or cholesteatoma were excluded. Patients were divided into pre-PCV7 (July 1996 to December 2002; n = 38) and post-PCV7 (January 2003 to June 2009; n = 58) groups. Statistical analyses were used to compare the two groups. Results: Ninety-six children met the inclusion criteria. There was a 53% increase in admission for acute mastoiditis in the post-PCV7 era. The pre- and post-PCV7 groups had similar demographic features, presenting history, signs and symptoms, laboratory study results, and medical management. Computed tomography scan abnormalities seen in the two groups were similar except for subperiosteal abscess, which was seen more frequently in the post-PCV7 group. Streptococcus pneumoniae was the most common pathogen isolated in both groups. The patients in the post-PCV7 group had shorter hospital stays, despite undergoing more extensive surgery to address their disease. Conclusions: The number of acute mastoiditis admissions did not decrease with the widespread use of PCV7. Computed tomography findings and surgical procedures required to address acute mastoiditis indicate that the post-PCV7 group had more advanced disease. S pneumoniae remains the main pathogen in acute mastoiditis, and its nonsusceptibility to penicillin and ceftriaxone may be increasing. [ABSTRACT FROM AUTHOR]

Summary: A 2-year-old girl presented with a left middle ear cholesteatoma. A CT scan showed a mass in the left middle ear starting from the mesotympanum extending through a bony canal defect into the parapharyngeal space, deep to the facial nerve and ending in the submandibular region. The patient underwent surgical excision of the first branchial cleft cyst by superficial parotidectomy with facial nerve dissection and mastoidectomy with middle ear exploration. This case illustrates a rare presentation of a first branchial cleft cyst with histologic and anatomical features of both types of Work''s classification of brachial cleft anomalies. [Copyright &y& Elsevier]

Background: RRP is a devastating disease in which papillomas in the airway cause hoarseness and breathing difficulty. The disease is caused by human papillomavirus (HPV) 6 or 11 and is very variable. Patients undergo multiple surgeries to maintain a patent airway and in order to communicate vocally. Several small studies have been published in which most have noted that HPV 11 is associated with a more aggressive course. Methodology/Principal Findings: Papilloma biopsies were taken from patients undergoing surgical treatment of RRP and were subjected to HPV typing. 118 patients with juvenile-onset RRP with at least 1 year of clinical data and infected with a single HPV type were analyzed. HPV 11 was encountered in 40% of the patients. By our definition, most of the patients in the sample (81%) had run an aggressive course. The odds of a patient with HPV 11 running an aggressive course were 3.9 times higher than that of patients with HPV 6 (Fisher's exact p = 0.017). However, clinical course was more closely associated with age of the patient (at diagnosis and at the time of the current surgery) than with HPV type. Patients with HPV 11 were diagnosed at a younger age (2.4y) than were those with HPV 6 (3.4y) (p = 0.014). Both by multiple linear regression and by multiple logistic regression HPV type was only weakly associated with metrics of disease course when simultaneously accounting for age. Conclusions/Significance Abstract: The course of RRP is variable and a quarter of the variability can be accounted for by the age of the patient. HPV 11 is more closely associated with a younger age at diagnosis than it is associated with an aggressive clinical course. These data suggest that there are factors other than HPV type and age of the patient that determine disease course. [ABSTRACT FROM AUTHOR]