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

OBJECTIVE. This project aims to prospectively and objectively assess otolaryngological manifestations and quality of life of children with primary ciliary dyskinesia (PCD) and compare these findings with healthy pediatric controls. STUDY DESIGN. Cross-sectional. SETTING. Two high-volume pediatric PCD specialty centers. METHODS. Standardized clinical assessment; Sino-Nasal Outcome Test 22 (SNOT-22); Hearing Environment and Reflection Quality of Life (HEAR-QL); Reflux Symptom Index (RSI); standardized physical examination of the sinonasal, laryngeal, and otological systems; and investigations including pure-tone audiograms (PTAs) and sinonasal cultures were collected. RESULTS. Forty-seven children with PCD and 25 control participants were recruited. Children with PCD had more upper airway symptoms than healthy children. They had significantly higher scores in both SNOT-22 and RSI, indicating worse sinonasal and reflux symptoms, with worse quality of life on the HEAR-QL index compared to healthy children (P < .05). Fifty-two percent of children with PCD-related hearing loss were not aware of their hearing deficit that was present on audiological assessment, and only 23% of children who had ventilation tubes had chronic otorrhea, most of which was easily controlled with ototopic drops. Furthermore, although all children with PCD had chronic rhinosinusitis, only 36% of them were using topical nasal treatment. The most common bacteria cultured from the middle meatus were Staphylococcus aureus in 11 of 47 (23%), followed by Streptococcus pneumoniae in 10 of 47 (21%). CONCLUSION. This multisite cohort highlights the importance of otolaryngology involvement in the management of children with PCD. More rigorous otolaryngological management may lead to reductions in overall morbidity and improve quality of life for children with PCD.

OBJECTIVE This study aims to assess and compare the reliability of the Holgers, the IPS, and the Tullamore scales for skin tolerability assessment of postoperative bone-anchored hearing implant images. STUDY DESIGN A survey study and retrospective review of percutaneous osseointegrated auditory implant images for scoring using three skin classification scales. SETTING McGill University Health Center, Montreal, Quebec, Canada. PARTICIPANTS Healthcare workers experienced and inexperienced with osseointegrated auditory implant skin classification scales. MAIN OUTCOME MEASURES Participation involved completing: 1) survey questionnaires assessing experience with osseointegrated auditory implants and related skin reactions and 2) scoring postoperative osseointegrated auditory implant with surrounding skin images using the Holgers Classification, the IS (of the IPS) scale, and the Tullamore Classification. Participants were asked to rate 12 images of postoperative osseointegrated auditory implant and surrounding soft tissue. This process was repeated until participants scored all images using the three scales; each rater graded 36 images in total. The order in which scales were presented occurred at random. Intraclass correlation coefficients were calculated to assess reliability. RESULTS Thirty-one participants were recruited to the study. Fourteen (45.2%) had experience with at least 1 osseointegrated auditory implant skin classification scale, while 17 (54.8%) did not have experience. The wide and overlapping 95% confidence intervals of the intraclass correlation coefficients results do not provide us with enough evidence to define a well-established degree and hierarchy of reliability when comparing the scales. Among experienced raters, all scales presented moderate to good reliability. CONCLUSIONS The Holgers Classification, the IPS scale, and the Tullamore Classification all present moderate to good reliability when used by experienced raters to assess skin reactions following surgical implantation of an osseointegrated hearing device. As a result, clinicians should use these scales with a degree of caution. The findings of this study do not provide us with enough evidence to single out one of the scales as a standard to follow, but more extensive studies are required to assess the reliability of the scales.

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

Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal.Blinded modified Delphi consensus process.Tertiary care center.A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items.The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus.It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated.5. Laryngoscope, 131:1168-1174, 2021.

OBJECTIVE To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of children who present with signs and symptoms of congenital cholesteatoma. METHODS A two-iterative Delphi method questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group, on the preoperative work-up, the perioperative considerations, and follow-up. RESULTS Twenty-two members completed the survey, in 14 tertiary-care center departments representing 5 countries. The main consensual recommendations were: a precise otoscopic description of the quadrants involved, extensive audiological workup (bilateral tonal, vocal audiometry, and BERA), and a CT scan are required. Facial nerve monitoring and a combination of microscope and telescope are recommended for surgical removal. Clinical and audiological follow-up should be pursued yearly for at least 5 years. First MRI follow-up should be done at 18 months postoperatively if the removal violated the matrix. MRI follow-up duration depends on the initial extent of the cholesteatoma. CONCLUSION The goal of preoperative and follow-up consensus from International Pediatric Otolaryngology Group participants is to help manage infants and children with congenital cholesteatoma. The operative techniques may vary, and experienced surgeons must perform these procedures.

Tympanometry provides an objective measurement of the status of the middle ear. During tympanometry, the ear-canal pressure is varied, while the response of the ear to sound pressure is measured. The effects of the pressure on the mechanics of the middle ear are not well understood. This study is a continuation of our previous work in which the vibration response of the gerbil eardrum was measured in vivo under quasi-static pressure steps. In this study, we delivered a continuous pressure sweep to the middle ear and measured the vibration response at four locations for six gerbils. Vibrations were recorded using a single-point laser Doppler vibrometer and glass-coated reflective beads (diameter ~ 40 µm) at the umbo and on the mid-manubrium, posterior pars tensa and anterior pars tensa.The vibration magnitudes were similar to those in the previous step-wise pressurization experiments. Most gerbils showed repeatability within less than 10 dB for consecutive cycles. As described in the previous study, as the frequency was increased at ambient pressure, the vibration magnitude on the manubrium increased slightly to a broad peak (referred to as R1) and then decreased until a small peak appeared (referred to as R2), followed by multiple peaks and troughs as the magnitude decreased further. The low-frequency vibration magnitude (at 1 kHz) decreased monotonically as the pressure became more negative except for a dip (about 500 Pa wide) that occurred between - 700 and - 1800 Pa. The lowest overall magnitude was recorded in the dip at mid-manubrium. The vibration magnitudes also decreased as the middle-ear pressure was made more positive and were larger than those at negative pressures. R1 was only visible at negative and small positive middle-ear pressures, while R2 was visible for both positive and negative pressures. R2 split into multiple branches after the middle-ear pressure became slightly positive. No magnitude dip was visible for positive middle-ear pressures.The low-frequency vibration magnitudes at negative middle-ear pressures on the pars tensa were higher than those on the manubrium. R1 was not visible for large negative middle-ear pressures on the pars tensa. R2 appeared as a multi-peak feature on the pars tensa as well, and a higher-frequency branch on the posterior pars tensa appeared as a trough on the anterior pars tensa. The magnitude dip was not present on the pars tensa. The largest overall magnitude was recorded at the R2 peak on the posterior pars tensa.The results of this study expand on the findings of the step-wise pressurization experiments and provide further insight into the evolution of the vibration response of the eardrum under quasi-static pressures.

Purpose: To compare intra- and postoperative outcomes between the standard linear incision with tissue preservation and the Minimally Invasive Ponto Surgery (MIPS). Study Design: A non-randomized retrospective cohort series. Methods: Medical files were reviewed of adult and pediatric bone anchored hearing implant recipients. Extracted outcomes included patient characteristics, implant survival, operative time, anesthesia use, intra and postoperative complications, soft tissue tolerability assessed by the Holger’s classification, and implant stability assessed by the Resonance Frequency Analysis (RFA). Outcomes were compared between two surgeries. Results: A total of 59 implants were placed (21 MIPS; 38 linear). Conductive hearing loss was the most common etiology for implantation. Surgery was conducted under local anesthesia in 67% of MIPS patients and 16% of linear patients. No intraoperative complications were reported for both surgical approaches and no implants were lost. Patients undergoing implantation via the MIPS approach displayed less skin reaction postoperatively, however this was not significant ( P = .2848). The most common Holgers score for both groups was grade 1. The median and mean surgical duration for the MIPS group was statistically lower than the linear group ( P = .0001). Implant stability measured by the RFA implant stability quotient was greater in the MIPS cohort. Conclusion: The MIPS approach seems either similar or superior to the linear approach in all perioperative outcomes evaluated. Outcomes such as surgical duration, anesthesia choice and implant stability measurements support implantation through the MIPS approach for patients meeting eligibility criteria.

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

A wide variety of pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children; however, its use in tonsillar evaluation has not been widely explored. The objective of this study was to measure 3-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex vivo dimensions on pathology specimens.We performed a prospective cohort study.The study was set in a tertiary care children's hospital.Children undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasonography (HFU) was performed prior to surgery to obtain 3-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex vivo tonsil measurements and correlations were obtained.Seventy-five consecutive children underwent a transcervical HFU, with a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were -0.08 cm and -0.24 cm for the right and left craniocaudal axes, -0.19 cm and -0.18 cm for the right and left mediolateral axes, and 0.05 cm and 0.03 cm for the right and left anteroposterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5.HFU can accurately measure the size of pediatric tonsils in 3 dimensions.

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

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

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

Tympanometry is a relatively simple non-invasive test of the status of the middle ear. An important step towards understanding the mechanics of the middle ear during tympanometry is to make vibration measurements on the eardrum under tympanometric pressures. In this study, we measured in vivo vibration responses in 11 gerbils while varying the middle-ear pressure quasi-statically, with the ear canal at ambient pressure. Vibrations were recorded using a single-point laser Doppler vibrometer with five glass-coated reflective beads (diameter ~ 40 μm) as targets. The locations were the umbo, mid-manubrium, posterior pars tensa, anterior pars tensa and pars flaccida. As described in earlier studies, the unpressurized vibration magnitude was flat at low frequencies, increased until a resonance frequency at around 1.8–2.5 kHz, and became complex at higher frequencies. At both the umbo and mid-manubrium points, when the static pressure was decreased to the most negative middle-ear pressure (− 2500 Pa), the low-frequency vibration magnitude (measured at 1.0 kHz) showed a monotonic decrease, except for an unexpected dip at around − 500 to − 1000 Pa. This dip was not present for the pars-tensa and pars-flaccida points. The resonance frequency shifted to higher frequencies, to around 7–8 kHz at − 2500 Pa. For positive middle-ear pressures, the low-frequency vibration magnitude decreased monotonically, with no dip, and the resonance frequency shifted to around 5–6 kHz at + 2500 Pa. There was more inter-specimen variability on the positive-pressure side than on the negative-pressure side. The low-frequency vibration magnitudes on the negative-pressure side were higher for the pars-tensa points than for the umbo and mid-manubrium points, while the magnitudes were similar at all four locations on the positive-pressure side. Most gerbils showed repeatability within less than 10 dB for consecutive cycles. The results of this study provide insight into the mechanics of the gerbil middle ear under tympanometric pressures.

Objectives: Cochlear implants are known to significantly improve the quality of life (QoL) of implanted children. However, variability exists between self-reported outcomes and parental-reported QoL questionnaires. We evaluated the QoL agreement between children and their parents following cochlear implantation and determined which factors lead to increased agreement. Methods: A cross-sectional study was performed including pediatric cochlear implant recipients and their parents. We evaluated postoperative QoL using The Pediatric Quality of Life Inventory (PedsQL). To assess agreement between pediatric and parental QoL perception, PedsQL intra-class correlations (ICCs) were calculated. Results: Thirty-five children and their parents completed QoL questionnaires. Children who were evaluated between 8-12 years of age reported highest absolute total and subscale PedsQL scores. Highest agreement was found amongst parents and children when: (1) children were between 8-12 years at QoL assessment (ICC: between 0.917[95%CI: 0.676-0.981] and 0.972[95%CI: 0.882-0.994]), and (2) when evaluating the physical health QoL domain (ICC: 0.964[95%CI: 0.849-0.992]). Conclusions: This study demonstrates high agreement (ICC > 0.8) between pediatric and parental QoL report in children aged between 8-12 years at QoL assessment. Therefore, results confirm that: (1) QoL agreement between pediatric self-report and parent proxy-report is high in chronically ill children and (2) children using cochlear implants can reliably report QoL between 8-12 years.

To investigate factors associated with percutaneous bone anchored hearing implant (BAHI) loss.Africa-Wide, Biosis, Cochrane, Embase, Global Health, LILACs, Medline, Pubmed, and Web of Science electronic databases.All studies reporting on adult and/or pediatric patients with a BAHI loss were identified. Retrieved articles were screened using predefined inclusion criteria. Eligible studies underwent critical appraisal for directness of evidence and risk of bias. Studies that successfully passed critical appraisal were included for data extraction.Extracted data included study characteristics (study design, number of total implants and implant losses, follow-up), patient characteristics (sex, age, comorbidities, previous therapies), and information regarding BAHI loss (etiology of loss, timing of occurrence).From the 5,151 articles identified at the initial search, 847 remained after title and abstract screening. After full text review, 96 articles were eligible. Fifty-one articles passed quality assessment, however, due to overlapping study population, 48 articles reporting on 34 separate populations were chosen for data extraction. Three hundred one implant losses occurred out of 4,116 implants placed, resulting in an overall implant loss occurrence rate of 7.3%. Failed osseointegration was responsible for most implant losses (74.2%), followed by fixture trauma (25.7%). Most losses due to failed osseointegration occurred within 6 months of the implantation. BAHI implant loss occurred more frequently in pediatric patients (p 0.005).The current systematic review identified factors associated with BAHI loss. These factors should be considered when assessing patients' candidacy and when investigating reasons for impeded implant stability and loss.

Esophageal atresia (EA) is the most common congenital esophageal malformation. Airway pathology, in particular, tracheomalacia and laryngotracheal anomalies is a major cause of morbidity and mortalilty in patients with EA. The aim of this study was to report the incidence and type of laryngotracheal anomalies seen in a large series of patients with EA, and to evaluate their impact on the management of children with EA. Retrospective study. Retrospective cohort including all patients referred to the EA National Reference Center from January 2002 to December 2014. Airway assessment was based on endoscopy performed before, during and/or after esophageal surgery. One-hundred and fifty-eight patients were included in the study. Endoscopy revealed tracheomalacia in 141 cases (89.2%) and other laryngotracheal anomalies in 43 patients (27.2%). Ninety-six patients (60.7%) presented with persistent respiratory symptoms, including acute life-threatening events in 21 cases, leading to death in 6 cases. A correlation was observed between degree of tracheal collapse and presence of acute life-threatening events. Laryngotracheal surgery was required in 35 cases (22%). Laryngotracheal anomalies are frequently associated with EA and represent an important etiology of morbidity and mortality that can be prevented by early and systematic diagnosis and aggressive management. An early systematic endoscopic evaluation is recommended to coordinate the airway management with the EA surgery.

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

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

Background Chronic suppurative otitis media can be recalcitrant and difficult to treat, particularly with the increasing occurrence of antibiotic resistance. Lactobacillus plantarum is a probiotic that has been shown to decrease S. aureus and P. aeruginosa growth in wounds, making it a good candidate for the treatment of chronic suppurative otitis media. However, before it can be applied in the ear, its ototoxicity potential must be evaluated. Methods A prospective controlled trial was conducted in a chinchilla animal model at the Animal care research facilities of the Montreal Children’s Hospital Research Institute to determine whether Lactobacillus plantarum is ototoxic when applied transtympanically. Ten chinchillas each had one ear randomly assigned to receive 109 CFU/mL of Lactobacillus plantarum solution, while the contralateral ear received saline. Auditory brainstem responses were measured bilaterally at 8, 20, 25 kHz before, at 7–10 days after application, and at 28 days after application of probiotic or saline. Facial nerve and vestibular function were assessed clinically. Results There were no statistically significant differences in hearing thresholds between control and experimental ears at 28 days after application. A difference of 11 dB was noted in the 25 kHz range at day 7–10, but resolved by day 28. No animals receiving probiotics developed vestibular nerve dysfunction. There was no histologic evidence of auditory hair cell damaged evidenced by scanning electron microscopy. Conclusion Our study suggests that a single application of Lactobacillus plantarum at 109 CFU/mL does not cause ototoxicity in a chinchilla animal model. These preliminary safety evaluations and the pathogen inhibitory effects of L. plantarum demonstrated by previous studies present this probiotic as a candidate of interest for further investigation. Electronic supplementary material The online version of this article (10.1186/s40463-017-0242-y) contains supplementary material, which is available to authorized users.

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

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

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

This study aims to review differences between acute otitis media (AOM) diagnosis and treatment guidelines from different countries, with regards to the aspects of diagnostic criteria and methods, supplementary tests, treatment options, recommended first-, second-, and third-line antibiotics, non-antibiotic treatment options, and preventive means and measures. Tympanic membrane (TM) bulging, opacity, and presence of middle ear fluid are the pillars for diagnosis, as marginal/uncertain cases are not accepted anymore. Guidelines from developed countries offer the use of pneumatic otoscopy and tympanometry to aid diagnosis. Withholding antibiotic therapy and a “watchful waiting” in mild-moderate cases are preferred in settings where follow-up visits are both possible and attainable, mostly in developed countries. While amoxicillin is mostly accepted as the first-line antibiotic therapy, options for second- and third-line antibiotics vary, according to local bacteriology and antimicrobial susceptibility data and costs. Other treatments, such as complementary and alternative medicine, steroids, or anti-histamines, are either rejected or ignored. Reduction of known risk factors and call for vaccinations (influenza, pneumococcal conjugate vaccine) are encouraged mostly in developed countries, where such immunizations have been implemented in National Immunization Programs. Despite regional differences, AOM guidelines worldwide share common grounds on various matters concerning diagnosis and management: diagnosis based on TM findings observed on otoscopy and/or pneumatic otoscopy or tympanometry, “watchful waiting” approach in appropriate cases, oral analgesic treatment using ibuprofen/paracetamol, reduction of risk factors, and preventive measures to reduce AOM.

Objectives/Hypothesis Children with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our preliminary experience with the anterior–posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI. Study Design Multicenter review. Methods A review of patients undergoing endoscopic APCS for BTVFI at four institutions was performed. Patients were evaluated for the ability to ventilate without the requirement for tracheostomy or reintubation. Additional data extracted included the duration of intubation following APCS, the requirement for additional procedures, and demographics. Surgical success was defined as the ability to avoid tracheostomy and to cap or decannulate without respiratory symptoms if a tracheostomy was present prior to APCS. Results Nineteen APCS procedures were performed between October 2010 and June 2016. There were 12 male patients, the mean age at APCS was 4.7 months. BTVFI was primarily idiopathic (58%) and associated with other comorbidities (74%). All patients were candidates for tracheostomy prior to APCS. Fourteen patients (74%) were considered surgical successes. Of the unsuccessful patients, three (66%) required tracheostomy following APCS, and one was treated with a posterior cartilage graft. There was one nonsurgical mortality greater than 2 months after APCS and thought to be unrelated to the airway. Conclusions Endoscopic APCS appears to be a safe and effective intervention for pediatric BTVFI. Under the correct circumstances, this can be performed as a single procedure, obviating tracheostomy. Further study is warranted. Level of Evidence 4. Laryngoscope, 128:257–263, 2018

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

Objective 1) To assess the feasibility of reconstructing 2-cm-long circumferential tracheal defects with a 3D printed polycaprolactone (PCL) implant in rabbits. 2) To evaluate endoscopic, histologic, and functional characteristics of a PCL tracheal implant over time. Methods Ten New Zealand rabbits were included in this study. A 2-cm-long 3D printed PCL tracheal implant was created. All rabbits underwent surgical excision of a 2-cm-long cm segment of cervical trachea, which was reconstructed with the implant. Rabbits were sacrificed at the following time points: 0, 4, 5, 6, and 7 weeks postoperatively. At these time points, a rigid bronchoscopy was performed, and blinded evaluators calculated the percentage of airway stenosis. The tracheas were then harvested and prepared for histologic analysis. Results All rabbits survived to their date of sacrifice except for one. Rabbits were euthanized between 0 to 54 days postoperatively with a median of 30 days. All rabbits developed significant granulation tissue with an average percentage stenosis of 92.3% ± 6.1%. On histology, granulation was present with extensive neovascularization and mixed inflammatory cells. There was re-epithelialization present on the luminal surface of the PCL implant near the anastomoses but absent at the center of the implant. Conclusion This study demonstrates that our 2-cm-long 3D printed PCL tracheal implant can be used to reconstruct a tracheal defect of equivalent size in a New Zealand rabbit model in the short term. However, significant granulation tissue formation limits long-term survival. Further research is warranted to limit the granulation tissue overgrowth. Level of evidence NA Laryngoscope, 2019.

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

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

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

We hereby present the first-reported pediatric case of a hard palate neurovascular hamartoma in a male newborn, in which the diagnosis was established following an initial nondiagnostic biopsy, extensive radiological investigations, and eventual wide local excision. These benign lesions can easily be mistaken for malignant diagnoses, leading to increased parental and child anxiety as well as avoidable diagnostic and therapeutic interventions.

Cisplatin is a commonly used chemotherapeutic agent and causes serious side effects, including progressive and irreversible hearing loss. No treatment is currently available for cisplatin-induced ototoxicity. We have previously demonstrated that erdosteine, a potent antioxidant, partially protected the cochlea against cisplatin toxicity in vivo. The aims of this study were to (1) evaluate the protein profiles of the cochlea following cisplatin administration and (2) evaluate the impact of erdosteine on the protein profile using a proteomics-based approach. Thirty Sprague-Dawley rats were injected intraperitoneally with saline (n = 10), cisplatin (n = 10) or with cisplatin and erdosteine (n = 10). The cisplatin dosage was 14 mg/kg and for erdosteine, 500 mg/kg. Following euthanasia, protein lysates were obtained from fresh-frozen cochleae and were processed for mass spectrometry and western blotting. We detected 445 proteins that exhibited a twofold change or greater in the cisplatin group as compared to the control group. Of these, 18 proteins showed a fourfold or greater change in expression associated with cisplatin administration, including ras-related protein Rab-2A, Rab-6A, cd81, ribosomal protein S5, and myelin basic protein, which were downregulated, while Ba1-647 and fibrinogen (alpha chain), amongst others, were upregulated. Co-administration of erdosteine revealed a reversal of these changes in the expression of ras-related protein Rab-2A, ribosomal protein S5, myelin basic protein, and fibrinogen (alpha chain); erdosteine also upregulated glutathione reductase. In this study, we identified various proteins that may play a role in cisplatin-induced ototoxicity. We also observed the changes resulting from co-treatment with an antioxidant.

Objective Systemic dexamethasone has demonstrated conclusive benefits in reversing sudden sensorineural hearing loss (SSNHL) despite considerable number of potential side effects. In contrast, the intratympanic route of steroid administration averts several possible complications. This study aims to examine the literature to delineate the efficacy and side effect of intratympanic dexamethasone (ITD) injection for the treatment of SSNHL. Data Source Cochrane, Embase, and MEDLINE electronic databases from January 1950 to August 2014, with an update performed on November 10, 2014. Review Methods Systematic review and meta-analysis of randomized controlled clinical trials (RCCTs), using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram and guidelines. Quality assessment was performed using The Cochrane Collaboration Tool for Assessing Risk of Bias. Results Eight RCCTs on SSNHL were included Three of the eight studies had high risk of bias. Substantial heterogeneity was found. The meta-analysis failed to detect statistically significant difference between ITD and alternative treatment (odds ratio = 0.39, 95% credible intervals = 0.11–1.27). The side-effects profile was favorable for ITD. No serious adverse events were recorded. Conclusion There is no sufficient scientific evidence to support a difference between ITD and alternative therapy for SSNHL. We recommend larger RCCTs to determine the effectiveness of ITD compared to oral steroid therapy. We encourage a shift in study design selection toward noninferiority or superiority studies. Avoiding systemic corticotherapy, especially in vulnerable populations, should be the rationale for future research in the field. Laryngoscope, 127:1897–1908, 2017

The authors describe the conservative management of 2 rare patients of uncomplicated pneumosinus dilatans of the frontal sinus with minimal bossing of the forehead. Regular nasal hygiene in combination with topical corticosteroids was administered with following complete resolution symptoms.

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

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

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

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

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

Objectives: To report a case of two BAHI extrusions occurring in a heavy smoker and to review the literature to investigate the underlying biomechanisms leading to implant losses in smokers. Methods: Case report and literature review. Results: A 35-year-old man experienced delayed healing and increased pain around the abutment site despite an uneventful BAHI surgery. The implant extruded 2 days after sound processor coupling. A second implant was placed and extruded 1 week after post-operatively. The literature review identified 2 other cases of implant loss in heavy smokers; one undergoing 6 surgeries. Smoking is thought to adversely affect hormones and enzymes involved in bone regulation, and to have an inhibitory effect on osteogenesis and on angiogenesis. At the cellular level, nicotine reduces the proliferation of red blood cells, macrophages, and fibroblasts and increases micro clot formation in blood vessels through increased platelet adhesiveness. Conclusion: We highlight possible risks associated with bone anchored hearing implant loss and smoking. These risks should be discussed with patients who are BAHI candidates and heavy smokers. Keywords: Bone anchored hearing implant, BAHA, Smoking, Implant loss, Extrusion, Osseointegration

Introduction: Familial hemophagocytic lymphohistiocytosis (FHL) is an autosomal recessive disease affecting the cytotoxic pathway. Due to the recent advances in molecular diagnosis, immuno-chemo therapy, and hematopoietic stem cell transplantation treatment, FHL survival rates have drastically increased. Case Presentation: Herein, we describe a case of FHL type 5 presenting with low-frequency sensorineural hearing loss. Alongside our reported case, 6 additional patients were identified in the literature. Management and Outcome: The progressive nature of FHL disorder may cause bilateral, low-frequency, irreversible sensorineural hearing loss. This type of hearing loss should be considered among the long-term sequelea presenting with FHL5. Discussion: We recommend audiological evaluation at initial FHL5 diagnosis to assess for hearing functions. Follow-up in audiology should be part of the long-term monitoring of patients with FHL5 as hearing loss could develop long after diagnosis.

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

Sialolithiasis should be considered in the differential diagnosis of any patient with persitent or recurring salivary gland swelling or inflammation. It occurs most frequently in the Wharton duct followed by the Stensen duct, and rarely in the sublingual glands. Sialolithiasis typically presents with pain and swelling of the involved gland and is aggravated by eating. In the acute setting, patients with sialadenitis secondary to calculi are treated conservatively with antibiotics, and stones less than 2 mm may pass spontaneously. Sialendoscopy is now well established as a novel minimally invasive diagnostic and therapeutic modality for salivary gland stones. Sialoendoscopes can also be used in combination with several open surgical approaches to guide the extraction of large calculi. This article highlights the open surgical interventions that are frequently used in sialolithiasis management, when sialoendoscopy is not the most appropriate option, has failed, or is not available. They range from minimally invasive to open techniques. Mastering the anatomy of the salivary ducts and surrounding structures is of exquisite importance. The management of sialolithiasis should aim for gland-sparing procedures before considering gland excision.

The present study reviewed all cases reported of isolated Langerhans cell histiocytosis bone lesions in the head and neck of pediatric patients. The objective was to create a treatment algorithm to facilitate the diagnosis and management of these lesions.Eligible articles were identified through a comprehensive search of the following electronic databases: PubMed, Ovid Medline, Embase, and Cochrane Library.Two authors independently reviewed the titles and abstracts retrieved by the electronic search concordant with the criteria for study eligibility. The lists of articles from each author were jointly reviewed and a common list created. All relevant articles were reviewed in hard copies and as full texts to justify inclusion.A total of 201 patients (67% male, mean age: 8.1 ± 4.3 years) were included from 45 studies. Clinical presentations included swelling (64%), pain (9%), or both (18%). The skull (61%) and the orbit (24%) were the most common location for isolated bone lesions in the head and neck. The most frequently documented management option was resection, followed by observation, chemotherapy, and intralesional steroid injection.Due to its rarity and variability in presentation and severity, treatment of these lesions has yet to be standardized. Based on the review, a diagnosis and treatment algorithm was created for head and neck surgeons when encountering these types of lesions.

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

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