Search

Background The purpose of this study was to evaluate the efficacy of sleep endoscopy-directed simultaneous lingual tonsillectomy and epiglottopexy in patients with sleep disordered breathing (SDB), including polysomnography (PSG) and swallowing outcomes. Methods A retrospective review was performed of all patients undergoing simultaneous lingual tonsillectomy and epiglottopexy over the study period. PSG objective measures were recorded pre- and postoperatively, along with demographic data, comorbidities, and descriptive data of swallowing dysfunction in the postoperative setting. Results A total of 24 patients met inclusion criteria for consideration, with 13 having valid pre- and postoperative PSG data. Successful surgery was achieved in 84.6% of patients, with no difference based on presence of medical comorbidities including Trisomy 21. Median reduction in obstructive apnea–hypopnea index (oAHI) with the procedure was 69.9%. Four patients (16.7%) had postoperative concern for dysphagia, but all objective swallowing evaluations were normal and no dietary modifications were necessary. Conclusion Combination lingual tonsillectomy and epiglottopexy in indicated patients has a high rate of success in this single-institutional study without new dysphagia in this population. These procedures are amenable to a combination surgery in appropriately selected patients determined by sleep state endoscopy in the setting of SDB evaluated with drug-induced sleep endoscopy. Graphical abstract

Surgical management of the airway in children with Pierre Robin Sequence (PRS) includes tongue lip adhesion and mandibular distraction. Herein, the authors report the first case of an alternative surgical approach, the tongue base suspension (TBS).A full-term 5-week-old male with PRS with difficulty managing his airway through noninvasive mechanisms. A polysomnogram revealed severe obstructive sleep apnea (OSA) despite support. Parents desired the least invasive surgical approach, and therefore TBS was offered. Child underwent TBS without complications and weaned from 15L high flow to room air over 48 hours. Post-procedure polysomnogram revealed complete resolution of OSA. The child was discharged home without any supplemental support.The standard of surgical care for children with PRS has been either tongue lip adhesion or mandibular distraction. While their success is well-established, no alternatives have been considered. The authors demonstrate TBS can provide a less invasive, equally viable, and improved alternative in children with PRS.

Objective To identify an age at which initiation of whole nut into the pediatric diet could be considered safe, by evaluating the age distribution of children undergoing bronchoscopy with removal of nut or seed material from the airway. Method A retrospective chart review over a ten-year period identifying children age 0–18 that have undergone bronchoscopy with retrieval of airway foreign bodies. A statistical analysis of demographic data was carried out to identify age distribution of aspiration events. Results Sixty-four cases of foreign body aspiration were identified, of which 43 (67%) were of organic origin, specifically nuts. A Fisher’s exact test was carried out on the cumulative percentage of organic foreign body aspirations to identify the age distribution of nut aspiration events. A statistically significant decrease in organic foreign body aspirations occurred at approximately 36 months of age (p = 0.004). Conclusion Foreign body aspiration is a leading cause of accidental injury or death in children. Nut and other small organic foreign bodies account for a significant portion of accidental aspiration events, however, no guidelines exist regarding appropriate age of whole nut introduction into the diet. Our study suggests that 90% of pediatric nut aspiration events occur under the age of 36 months. We suggest supervised introduction of whole nuts between the ages of 3 and 4 years. Official guidelines regarding this should be considered by professional pediatric societies. Level of evidence 4

The outbreak of COVID-19 has affected the globe in previously unimaginable ways, with far-reaching economic and social implications. It has also led to an outpouring of daily, ever-changing information. To assess the amount of data that were emerging, a PubMed search related to COVID-19 was performed. Nearly 8000 articles have been published since the virus was defined 4 months ago. This number has grown exponentially every month, potentially hindering our ability to discern what is scientifically important. Unlike previous global pandemics, we exist in a world of instantaneous access. Information, accurate or otherwise, is flowing from one side of the world to the other via word of mouth, social media, news, and medical journals. Changes in practice guidelines should be based on high-quality, well-powered research. Our job as health care providers is to mitigate misinformation and provide reassurance to prevent a second pandemic of misinformation.

To provide evolving information on active protocols regarding inpatient, outpatient, procedural, and surgical case management taking place in otolaryngology practices in response to COVID-19.Cross-sectional multi-institutional survey.An online survey of 55 otolaryngology departments across North America.As of March 25, 2020, almost all (n = 53 of 55, 96.3%) otolaryngology departments had canceled elective cases and were performing only urgent consults. Most residents continued to participate in operative cases (n = 45 of 49, 91.8%) and take call (n = 48 of 50, 96.0%). Of the respondents, 27 of 29 (93.1%) stated that they were deferring nonemergent tracheostomy procedures for the time being. The use of personal protective equipment followed a general trend of an increasing level of protection with an increased risk of the procedure; most (n = 49 of 54, 90.7%) incorporated N95 mask usage for bedside/clinic examinations with flexible laryngoscopy. Powered air-purifying respirators and N95 masks were used mainly for procedures involving the mucosal surfaces.Due to the high viral density in the nasal cavity and nasopharynx of patients with COVID-19, basic examinations and common otolaryngology procedures place practitioners at high risk of exposure. Although there is variability in practice among otolaryngologists across North America in managing the COVID-19 outbreak, most are primarily seeing urgent ambulatory and inpatient consultations. Most are also incorporating personal protective equipment appropriate to the level of transmission across mucous membranes.In these rapidly evolving times, it is helpful to find solidarity and assurance among health care providers. Current data aimed to provide (1) perceived methods regarding the safe care of otolaryngology patients and (2) updated practice patterns at a national level.

The COVID-19 pandemic has created a situation unparalleled in our lifetime. As the medical community has attempted to navigate a sea of ever-changing information and policies, this uncertainty has instead bred creativity, community, and evolution. Necessity is the mother of invention, and one of the by-products of our rapidly changing environment is the increased reliance on telemedicine. Here, we discuss our experience with incorporating telemedicine into an urban academic pediatric otolaryngology practice, the challenges that we have encountered, and the principles unique to this population.

Peritonsillar (PT), parapharyngeal (PP), and retropharyngeal (RP) abscesses are common pediatric deep neck space infections (DNSI). Despite established literature on DNSI microbiology, obtaining intraoperative cultures remains commonplace. The objective was to evaluate the resource utilization of intraoperative cultures when draining PT, PP, and RP abscesses.Pediatric patients (age18.0 years) who underwent surgical drainage of a PT, PP, or RP abscess between January 2013 and June 2018 were retrospectively reviewed. Changes in antimicrobials based on intraoperative culture results were assessed by use of Fisher's exact tests or Wilcoxon rank-sum tests, as appropriate. Multivariable linear regression was used to model the association between factors of interest and number of cultures obtained.Eighty-eight patients underwent surgical drainage, of which 80 patients (median age 6.96 years) had intraoperative bacterial cultures (32 PT, 21 PP, and 27 RP). There were no positive fungal or acid-fast bacilli cultures. Seven patients had culture-directed changes in treatment; none of these patients had a PT abscess. Age was inversely associated with culture-directed changes (p = 0.006) while the use of blood cultures (p = 0.012) was positively associated with culture-directed treatment changes. Hospital length of stay (p 0.001) and history of prior DNSI (p = 0.001) were associated with number of cultures obtained.Younger children with PP and RP abscesses are most likely to benefit from intraoperative bacterial cultures. Cultures of PT abscesses are unlikely to change clinical management. Fungal and acid-fast bacilli cultures are unlikely to yield clinically useful information. Prudent use of intraoperative cultures may decrease the use of hospital resources and admission-related costs.

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits and surgical volumes. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. Our institution has had the unique opportunity to already return operations back to full capacity. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to patient care.

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to outpatient care.

Although there have been many advances in new tools and procedures for endonasal sinus surgery in children, the management and care for pediatric chronic rhinosinusitis has remained relatively unchanged. However, there have been advances in skull base surgery and tumor removal and new knowledge about perioperative concerns in children. This article discusses the role and risks of endoscopic sinus surgery, the use of balloon sinuplasty in children, management of complicated rhinosinusitis, and advances in skull base tumors and choanal atresia repair.

Objective This study aimed to describe complex tracheostoma reconstructions utilizing a pectoralis major myocutaneous flap. Results We present the case of two children who required extensive tracheostoma reconstructions. Both patients had chronic tracheostomies. The first child, aged 4, had underlying neuromuscular disorder. Her neck anatomy resulted in the formation of a keyhole stoma with erosion of the underlying cricoid cartilage. She underwent tracheostoma reconstruction using costal cartilage graft and use of a pectoralis major myocutaneous flap to recreate the superior aspect of the stoma. The second child, aged 5, had long-standing trach and underwent laryngotracheal reconstruction. In the postoperative setting, the patient developed a wound infection that resulted in breakdown of the overlying wound. A pectoralis major myocutaneous flap was required in the defect to recreate the wound bed. Both patients had successful wound bed creation and required no further procedures. Conclusion Chronic tracheostomies can result in superficial skin or tracheal breakdown, resulting in tracheostomy complications. Tracheostoma reconstruction is classically managed with debridement and local tissue flaps with use of either overlying skin or surrounding musculature. In patients with chronic wound breakdown, local tissue reconstruction can be challenging due to the fragility of the surrounding tissue. Use of virgin tissue outside the wound bed provides the best chance of recovery. The pectoralis major myocutaneous flap has the ability to be the ideal tissue source for extensive tracheostoma reconstruction. The flap is the workhorse of many head and neck oncologic procedures. The flap can provide adequate bulk from muscle and fat, overlying skin, and is within the surgical field to provide a robust blood supply. We advocate for the role of this flap in use with patients with chronic wound issues, poor wound healing, and failed prior stoma reconstructions.

Objective The objective of this study was to review the utilization of a standardized tracheostomy handoff sheet to reduce tracheostomy-related complications. Methods A retrospective chart review was carried out of patients who underwent tracheostomy and had a dedicated tracheostomy handoff sheet utilized in the postoperative period. The handoff sheet contains trach size, backup trach size, airway findings, suction depth, location of maturation suture, location of stay sutures, and photograph of the wound bed on postoperative day 0. An anonymous survey of healthcare providers participating in the patient's care was undertaken regarding the utility of the dedicated trach handoff sheet. Results There were a total of 18 completed questionnaires. The majority of respondents felt the trach handoff sheet was helpful and provided vital information (4.61, scale 1–5). Hundred percent of respondents referenced the handoff sheet at some point during the hospital stay; 83% of respondents (15/18) felt the handoff sheet was more productive than a verbal handoff and 67% of respondents (12/18) preferred the sheet be available bedside rather than a digital format for reference in the electronic medical record. 89% of respondents (16/18) utilized the handoff sheet for wound care. Conclusion There are numerous aspects to proper tracheostomy care. From the immediate postoperative time period to several years out, proper care can make the difference for quality of life, respiratory standpoint, and airway safety. With a daily nursing handoff that at times can become redundant, utilization of a standardized tracheostomy handoff can lead to improve outcomes. These handoff sheets provide information deemed essential to optimal patient care and are always available bedside for review. Standardization and utilization of these tracheostomy sheets have led to decreased airway complications in emergency situations, reduced wound breakdown, and increased safety and efficiency in handoffs.

Introduction Midline Cervical Cleft (MCC) is a midline cervical congenital anomaly that manifests as a vertical cutaneous/subcutaneous defect with abnormal dermal elements as well as an underlying fibrous cord that extends from the sternum to the mentum of the mandible, which can lead to "wry neck" and hypoplastic mandible. The goal of surgical correction of MCC is to provide adequate healthy tissue coverage, as well as restore contour of the anterior neck. The primary treatment modality for midline cervical cleft is surgical. We describe a technique involving complete excision of the fibrous cord, and use of double z-plasty flap in order to create a tension-free closure and restore contour to the anterior neck. Methods Using a database search method, children with the clinical diagnosis of midline cervical cleft treated between 2006 and 2016 were identified at a pediatric tertiary care center. Chart review was completed to assess for age at surgery, follow up, results, and complications. Results 12 patients were identified in the Lurie Children's Hospital (LCH) database. 8 patients underwent complete cord excision by the seniorauthor using the double z-plasty (DZ) technique for closure, with no recurrences. 4 patients underwent linear closure by another surgeon, had persistent contracture, and underwent revision using the DZ technique by the senior author, with no recurrence. Average age of surgery was 9.5 months. Most common post op complication was hypertrophic scar (3/12). Recurrence was only seen in the linear closure cases (4/12). Conclusions Midline Cervical Cleft is a rare entity with less than 200 cases in the literature. We believe the double z-plasty closure and complete excision of the fibrous cord results in reproducible restoration of neck contour and prevents cord recurrence, and should be considered the standard method for surgical excision of MCC.

Objective To identify the relationship of pediatric temporal fractures to the incidence and type of hearing loss present. To analyze the timing and utility of audiometric testing in children with temporal bone fractures. Methods Retrospective case series of 50 pediatric patients with temporal bone fractures who were treated at an urban, tertiary care children's hospital from 2008 to 2014. A statistical analysis of predictors of hearing loss after temporal bone fracture was performed. Results Fifty-three fractures (69.7%) in 50 patients involved the petrous portion of the temporal bone. The mean age of patients was 7.13 years, and 39 (73.6%) were male. A fall was the most common mechanism of injury in 28 (52.8%) patients, followed by crush injury (n = 14, 26.2%), and vehicular trauma (n = 10, 18.9%). All otic capsule violating fractures were associated with a sensorineural hearing loss (n = 4, 7.5%, p = 0.002). Three of four otic capsule sparing fractures were associated with ossicular dislocation, with a corresponding mixed or conductive hearing loss on follow up audiometric testing. The majority of otic capsule sparing fracture patients (n = 19/43, 44.2%) who had follow up audiograms had normal hearing, and those with otic capsule violating fractures were statistically more likely to have persistent hearing loss than those with otic capsule sparing fractures (p = 0.01). Conclusions Patients with otic capsule violating fractures or those with ossicular disruption are at higher risk for persistent hearing loss. Cost-saving may be accrued by selecting only those patients at high risk for persistent hearing loss for audiometric testing after temporal bone fractures.

Objectives: This retrospective chart review demonstrates that the prevalence of middle cranial fossa (MCF) dehiscence on computed tomography (CT) scans increases with age. Methods: High-resolution temporal bone CT scans, which had been obtained for any otologic complaint, were reviewed independent of all clinical history. Scans showing soft tissue, fluid, trauma, or previous operations were excluded. The CTs from 183 patients (296 ears) were reviewed, blinded for age and body mass index (BMI). The MCF floor was divided into 7 regions and systematically inspected. Ages and BMIs of the patients were subsequently extracted from the medical record. Results: Logistic regression analysis confirmed increasing MCF dehiscence with age ( P < .05, odds ratio [OR] = 1.07, R = .584). Over all ages (range, 1-88 years; average, 38.5), 32% of MCF floors were dehiscent at any 1 site. For age 60 and over, 55% were dehiscent. The most common sites of MCF dehisence were directly above the malleus head and above the additus ad antrum (35% and 28%, respectively). Superior canal dehiscence (SCD) was seen in 7% of all patients and only in the context of MCF dehiscence. The prevalence of MCF dehiscence increased with age when patients were analyzed by BMI 30 ( P < .003, P < .04, P = .03). Conclusion: The increase of middle cranial fossa dehiscence with respect to age is statistically significant. Over all ages, approximately 32% of ears show dehiscence. Over 60 years, approximately 55% show dehiscence. The odds of having dehiscence double with a 10-year difference in age. The most common sites along the MCF floor are in the epitympanum over the malleus head and the additus ad antrum. There was a statistically significant increase in MCF dehiscence with age when patients with equivalent BMIs are compared.