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Objectives/Hypothesis To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy. Study Design Prospective case control study. Methods A total of 70 screened patients (mean age 7.47 years) underwent polysomnography to confirm OSA, and then underwent MRI of the upper airway. Seventy-six matched controls (mean age 8.00 years) who already had an MRI underwent polysomnography. Volumetric analysis of lymphoid tissue volumes was carried out. Chi-square analysis and Student's t test were used to compare demographic data and lymph node volumes between cohorts. Fisher's Exact test and Chi-square analysis were used to compare sleep data. Results Patients and controls demonstrated no significant difference in mean age (7.47 vs. 8.00 yrs), weight (44.87 vs. 38.71 kg), height (124.68 vs. 127.65 cm), or body-mass index (23.63 vs. 20.87 kg/m2). OSA patients demonstrated poorer sleep measures than controls (P < 0.05) in all polysomnography categories (sleep efficiency, apnea index, apnea-hypopnea index, baseline SpO2, SpO2 nadir, baseline ETCO2, peak ETCO2, and arousal awakening index). Children with OSA had higher lymphoid tissue volumes than controls in the retropharyngeal region (3316 vs. 2403 mm3, P < 0.001), upper jugular region (22202 vs. 16819 mm3, P < 0.005), and adenotonsillar region (18994 vs. 12675 mm3, P < 0.0001). Conclusions Children with OSA have larger volumes of deep cervical lymph nodes and adenotonsillar tissue than controls. This finding suggests a new paradigm in the understanding of pediatric OSA, and has ramifications for future research and clinical care. Level of Evidence 3b. Laryngoscope, 123:2043–2049, 2013

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.Multicenter review.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.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.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.4. Laryngoscope, 128:257-263, 2018.

Importance Sinusitis is the most common otolaryngologic complaint in children with cystic fibrosis (CF). However, basic knowledge about the effect of sinusitis on these children is lacking. Objective To evaluate the incidence and quality-of-life impact of chronic rhinosinusitis (CRS) in an unbiased cohort of children with CF. Design, Setting, and Participants Survey study of consecutive pediatric patients with CF presenting for routine quarterly evaluation at a tertiary CF clinic at an academic pediatric hospital. Surveys were completed during the period from December 2012 to January 2013. Main Outcomes and Measures Surveys designed to assess major criteria for diagnosis of CRS and a validated pediatric sinonasal quality-of-life instrument, the Sinonasal-5 (SN-5). Statistical analysis was performed to evaluate association between demographic features and survey responses. Results Of the 102 consecutive eligible patients, 47 children (46%) aged 2 to 20 years (mean [SD] age, 12.9 [5.6] years; 24 [51%] female) completed the surveys. Depending on the exact diagnostic criteria used, 5 (11%) to 18 (38%) of children with CF had CRS. Mean domain (2.16; 95% CI, 2.02-2.30) and overall visual-analog scale (8.26; 95% CI, 8.01-8.51) scores on the SN-5 were consistent with minimal effect on quality of life and comparable to historical posttreatment scores. Mean scores on nasal obstruction (3.07; 95% CI, 2.80-3.34) and sinusitis (2.68;; 95% CI, 2.42-2.94) were the most affected domains, whereas allergy (1.83; 95% CI, 1.65-2.01), emotional disturbance (1.76; 95% CI, 1.56-1.96), and activity restriction (1.43; 95% CI, 1.31-1.57) were minimally affected. Children with a diagnosis of CRS had higher mean SN-5 scores (2.60; 95% CI, 2.31-2.89 vs 2.05; 95% CI, 1.90-2.20; difference of 0.55; 95% CI, 0.29-0.80). Twenty-five patients (53%) had undergone some treatment for sinusitis. There was no association between SN-5 score and CRS treatment history. Conclusions and Relevance In this study, the incidence of symptomatic CRS was high, but quality-of-life impact was relatively low among children with CF. Use of standardized assessment scales, including consensus diagnostic criteria and validated quality-of-life surveys, may be helpful to guide referral and management decisions.

Objective To study the efficacy of surgical management for obstructive sleep apnea (OSA) syndrome in children with hypotonia, and to identify common anatomic sites of airway obstruction. Methods Retrospective chart review of polysomnographic parameters and quality of life instrument scores for seventy eight children with hypotonia who underwent surgical intervention for sleep-disordered breathing at two tertiary children's hospitals, and analysis of drug-induced sleep endoscopy data using a previously validated scoring system. Results Children undergoing surgical intervention had baseline severe OSA with a statistically significant improvement in apnea-hypopnea index from 23.6 to 11.1 after surgery, but persistent severe OSA. OSA-18 sleep-related quality of life measurement and overall quality of life score showed statistically and clinically significant improvements, from 72.0 to 43.4 and from 5.3 to 7.6 respectively. Sleep endoscopy showed an average obstructive score of 7.2/15 (n = 39), with multi-level obstruction in 49% of children. Greater than 50% obstruction was observed at the tongue base in 64% of patients, velum in 46%, lateral pharyngeal wall in 38%, supraglottis in 38%, and adenoid in 23%. Conclusion OSA syndrome is challenging to treat in hypotonic children. Severe residual OSA is common after surgical intervention, but improvement in quality of life is clinically and statistically significant. The tongue base is the most common site of persistent airway obstruction. Drug-induced sleep endoscopy can identify sites of airway obstruction and may aid in surgical planning for high-risk patients.

Deep neck space infections are commonly seen and managed across various medical and surgical specialties. Common presentations permit straightforward management but still pose the risk of severe complications sometimes even with appropriate management. This article emphasizes the anatomic and physiologic process to heed when managing children with deep neck infections. The roles of radiography and medical versus surgical management are discussed.

Objective To compare suprastomal granulation tissue (SSGT) removal using the microdebrider with other common methods of excision. Methods Retrospective review (n = 21) of SSGT excision at a tertiary care pediatric hospital (2004–10). Outcome measures included intraoperative blood loss, operative time, decannulation rates, and complications. Results 10 children underwent excision of SSGT via powered SSGT debridement and 8 were decannulated (80% success rate). Of the other 11 patients who had manually non-powered techniques (kerrison rongeur, laryngeal microinstruments, or optical forceps), 7 were decannulated (63% success rate). Operative time was on average shorter than all other procedures, but not significantly (p = 0.101). There was no significant difference in blood loss when powered debridement was compared to other techniques (p = 0.872). There were no significant complications encountered in our patients who received SSGT powered debridement. Conclusions Endoscopic powered SSGT debridement is a simple and useful tool in the process of pediatric tracheotomy decannulation with superior decannulation rate, shorter operative time, and comparable blood loss to other techniques.

Treatment of sigmoid sinus thrombosis with long-term anticoagulation therapy remains controversial. We present the case of a 6-year-old boy with intraoperatively confirmed sigmoid sinus thrombosis secondary to acute otomastoiditis. Combined-modality treatment—including mastoidectomy, sigmoid sinus decompression, and antibiotic and anticoagulation therapy—resulted in a complete clinical resolution of the patient's signs and symptoms. However, a 19-month follow-up with magnetic resonance venography demonstrated that the sigmoid sinus thrombosis itself had not resolved. It is clear that occlusion of the sigmoid sinus may persist after the completion of surgical and medical therapy for sigmoid sinus thrombosis secondary to otomastoiditis. It remains unclear (1) whether anticoagulation treatment aids in recanalization of the affected sinus and (2) whether patient outcomes are affected if recanalization is achieved.

Objectives/Hypothesis: To compare gene expression in oropharyngeal mucosa of children with (ex+) and without (ex−) secondhand smoke exposure. Study Design: Prospective case-control. Methods: Forty-one age- and gender-matched children (2–6 years old) undergoing tonsillectomy for sleep disordered breathing at a tertiary care children's hospital were assessed for secondhand smoke exposure. Parental response to a validated questionnaire relating to secondhand smoke exposure governed inclusion. Sixteen samples were selected for microarray analysis (7 ex+, 9 ex−). Following tonsillectomy, ex vivo brushing of the mucosa isolated total RNA. Genome-wide expression profiles were generated by comparing sample RNA to a reference of all samples, assessing 27,323 cDNA clones. Microarray clones were ranked according to their ability to distinguish between the two groups using a Student t test. Results: A total of 318 cDNA clones distinguished the two groups (P < .01); 180 genes were overexpressed and 138 underexpressed in ex+ samples relative to the ex− group. Independent analysis of these two groups sorted genes into disease processes and molecular functional groups, including cancer (34 genes in the overexpressed group, 29 underexpressed, P < .05), cell cycle (14 and 10), and cell growth and proliferation (7 and 11). Two of the upregulated genes, LCN2 and IQGAP1, have been previously linked to inflammation in smokers and response/repair to cellular injury in bronchial epithelium. Conclusions: Findings in this pilot study support the hypothesis that secondhand smoke exposure seems to induce gene expression changes in the oropharyngeal mucosa of exposed children, which may have significant implications for current and future disease processes. Laryngoscope, 2010

Objectives We assessed the safety and efficacy of balloon dilation as treatment for recurrent stenosis after pediatric laryngotracheoplasty. Methods We studied a retrospective case series at an academic tertiary care children's hospital. We included all patients under the age of 18 years with subglottic or tracheal stenosis treated at our institution with balloon dilation between June 2007 and April 2009. The records were analyzed for patient demographics, presenting symptoms, surgical technique, and airway description. The outcome measures were airway diameter, postoperative symptoms, tracheotomy status, and complications. Results Ten patients (9 with subglottic stenosis and 1 with tracheal stenosis) underwent 20 balloon dilation procedures without complication. The average age at the time of the procedure was 17 months (range, 3 months to 9 years). The patient presenting symptoms were stridor in 7 cases and tracheotomy in 3 cases. Vascular balloons (diameter range, 6 to 12 mm; length, 20 mm) were inflated to 10 to 12 cm H2O pressure for an average of 40 seconds (range, 10 to 120 seconds). Each procedure consisted of 1 to 3 dilation cycles. The immediate postdilation airway area increased by an average factor of 4.9 (range, 1.9 to 9). Six patients had repeat procedures with an average interval between dilations of 67 days (range, 6 to 337 days). Stridor was eliminated or greatly improved in all patients on the first postoperative day; 7 patients sustained this benefit, with an average follow-up time of 10 months (range, 4 to 23 months). Six of the 10 patients had undergone previous laryngeal reconstruction (age range, 3 months to 4 years). Of these 6, 3 have no tracheotomy, with a mean follow-up of 12.5 months. The 3 children who benefited the least from dilation were noted to have more diffuse and chronic inflammation of the larynx in comparison to the responders. Conclusions This case series suggests that balloon dilation is a relatively safe and effective procedure. It may be particularly well suited to recent stenosis after laryngotracheal reconstruction.

Objective Obstructive sleep apnea syndrome (OSAS) is commonly associated with adenotonsillar hypertrophy. We hypothesized that respiratory perturbations extend to other regions of the upper respiratory tract in such children, particularly to rhino-sinus regions. Study Design A prospective case control study using Magnetic Resonance Imaging (MRI) of the upper airway and surrounding tissues of OSAS and controls. Magnetic resonance imaging was used to evaluate radiographic changes within the: paranasal sinuses, middle ear and mastoid air cells, and the nasal passages. Results We studied 54 OSAS (age 5.7 ± 3.0 years) and 54 controls (age 6.2 ± 2.0 years, P = NS). Children with OSAS had significantly more opacification of: maxillary sinuses (P

Objective The purpose of the study is to determine whether Caribbean Hispanic and African admixture populations have a paucity of mutations in GJB2 , encoding connexin 26. Methods We reported the paucity of mutations in GJB2 and deletions in GJB6 in Caribbean Hispanic and African admixture populations in the Bronx, NY, in 2007 [1] . We have now collected 102 additional probands with non-syndromic sensorineural hearing impairment (NSHI), for a total of 209. We describe here a presentation of the combined data. Results Of the 209 probands, 36% have affected family members with NSHI and the rest have sporadic occurrence. Of the familial cases, 43% had a first-degree relative affected, and the remainder a more distant relative. The hearing impairment ranged from unilateral mild to bilateral profound, with 76% exhibiting bilateral NSHI (BLNSHI). The single coding exon of the GJB2 gene was sequenced in 209 probands, PCR screening for del(GJB6-D13S1830) and sequencing of the non-coding exon of GJB2 to look for the known splice site mutation was performed in 32 NSHI patients with a heterozygous variation in GJB2 , and multiplex ligation-dependent probe amplification (MLPA) testing of GJB2 and GJB6 exon deletions or amplifications (P163 GJB-WFS1 kit) was done in 70 probands. Eight unrelated individuals had biallelic GJB2 mutations, representing 4% of our entire cohort, or 5% of our probands with BLNSHI. Of 127 probands of Hispanic or African descent with BLNSHI, six (4.7%) had biallelic pathogenic mutations, three (2.3%) had monoallelic mutations and 118 (93%) had no disease-causing mutations in GJB2 . At the same time, no major deletions were identified either by PCR screening (del(GJB6-D13S1830)) or by MLPA analysis ( GJB2 or GJB6 ), and no subjects had the known splice site mutation in GJB2 . Conclusion These results demonstrate that GJB2 is not the major contributor to the genetic basis of NSHI for the Bronx minority admixture populations.

Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device.Prospective, multi-institutional controlled trial.Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs.Twelve ES3-trained novice residents were compared with 13 control novice residents.Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation.Completion time was significantly shorter in the experimental group (injection P = 0.003, dissection P0.001), which, according to the rater panel, also demonstrated higher confidence (P = 0.009), demonstrated skill during instrument manipulation (P = 0.011), and made fewer technical mistakes during the injection task (P = 0.048) compared with the control group. The raters' post hoc internal consistency was deemed adequate (r0.5 between serial measurements).The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is one of the few virtual reality simulators with a comprehensive validation record. Advanced simulation technologies need more rapid implementation in otolaryngology training, as they present noteworthy potential for high-quality surgical education while meeting the necessity of patient safety.

Aortic arch thrombosis (AAT) is a potentially life threatening condition in neonates. We report 3 neonates with AAT and complete occlusion of a unilateral internal carotid artery with multiple cerebral infarcts. Multidisciplinary input led to deferral of thrombolytic therapy and surgical thrombectomy owing to the potential risk of hemorrhage within the infarcts. All the neonates were treated with low-molecular weight heparin treatment alone without any complications. Thrombus resolution was complete in 2 neonates, whereas it was near complete in one neonate. All the infants showed normal growth and development during follow-up. The rewarding outcome in these cases suggests that treatment with low-molecular weight heparin could be considered an option to treat AAT in selected patients.

Summary Objective Demonstrate the benefits of a multidisciplinary pediatric airway team prepared to evaluate and treat otolaryngology patients with flexible bronchoscopy. Design Case series. Setting Tertiary, academic children’s hospital. Patients 10 children (5 male, 5 female age range 2 months–16 years) presenting with complex symptoms potentially referable to large airways. Intervention Flexible bronchoscopy for diagnostic (bronchoalveolar lavage, ciliary biopsy, assess ongoing surgical intervention, and rule in or rule out foreign body; N = 6) or therapeutic (evacuate bronchial mucus plug, laser subglottis when patient has fused cervical spine, and distal instillation [fibrin glue for bronchopleural fistula and dornase alpha for plastic bronchitis]; N = 4). Main outcome measure Retrospectively ask if flexible bronchoscopy and interdisciplinary management improved patient care in these select otolaryngology cases. Results 10/10 patients benefited from interdisciplinary management including flexible bronchoscopy. Conclusion Our experience illustrates many uses for flexible bronchoscopy in otolaryngology patients, and suggests that an airway team prepared to use flexible bronchoscopy will create opportunities for improved patient care.

Summary A plunging or cervical ranula is a mucous extravasation pseudocyst which arises from the sublingual gland and crosses the mylohyoid line into the neck. The definitive surgical treatment for plunging ranula is transoral excision of the ipsilateral sublingual gland. Plunging ranula is a rare entity in the pediatric population. To our knowledge, there are no reported cases of pediatric plunging ranula extending to the skull base. We present a rare case of a pediatric plunging ranula with extension to the parapharyngeal space and skull base as well as a review of the literature.

Objectives: To review the literature comparing operative techniques in tonsillectomy and postoperative pain. Methods: Randomized controlled trials comparing operative techniques and pain outcomes over a 10-year period were reviewed. Results: 44 trials met inclusion criteria for analysis. A total of nine different techniques for complete or partial tonsillectomy were compared. There were several studies with contradictory results. Many of the studies were performed under different parameters. Conclusions: Future studies comparing tonsillectomy technique and pain outcomes should be conducted using a standard protocol to allow for accurate comparisons between numerous techniques.

To determine if standardized intraoperative scoring of anatomic obstruction in children with obstructive sleep apnea correlates with the apnea-hypopnea index (AHI) and lowest oxygen saturation on preprocedural polysomnogram (PSG). A secondary objective was to determine if age, presence of a syndrome, or previous adenotonsillectomy affect this correlation.Case series with chart review.Two tertiary care children's hospitals.Patients with a preprocedural PSG who underwent drug-induced sleep endoscopy (DISE) over a 4-year period.All DISEs were graded in a systematic manner with the Chan-Parikh (C-P) scoring system. AHI and nadir oxygen saturations were extracted from preprocedural PSG. Data were analyzed with a multivariate linear regression model that controlled for age at time of sleep endoscopy, syndrome diagnosis, and previous adenotonsillectomy.A total of 127 children underwent PSG prior to DISE: 56 were syndromic, and 21 had a previous adenotonsillectomy. Mean AHI was 13.6 ± 19.6 (± SD), and mean oxygen nadir was 85.4% ± 9.4%. Mean C-P score was 5.9 ± 2.7. DISE score positively correlated with preoperative AHI (r = 0.36, P.0001) and negatively correlated with oxygen nadir (r = -0.26, P = .004). The multivariate linear regression models estimated that for every 1-point increase in C-P score, there is a 2.6-point increase in AHI (95% confidence interval: 1.4-3.8, P.001) and a 1.1% decrease in the lowest oxygen saturation (95% confidence interval: -1.7 to -0.6, P.001).The C-P scoring system for pediatric DISE correlates with both AHI and lowest oxygen saturation on preprocedural PSG.

The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS).Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus.The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS.As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.

Objective To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients. Design Retrospective chart review. Setting Pediatric tertiary hospital. Patients Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis. Interventions Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures. Main outcomes measures Vocal cord recovery and decannulation. Results With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%). Conclusion In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.

Surgical management of frontal sinus disease in children is often a challenge, given the wide variation in frontal sinus development. A thorough understanding of the embryology and anatomy of the frontal sinus is essential to safe surgical intervention. With current advances in technology including endoscopy and image guidance, new operative techniques are evolving to safely instrument the pediatric frontal sinus. Here, we review the embryology, anatomy, surgical indications, and contemporary surgical techniques of the frontal sinus in children.

Aspirin sensitivity syndrome is an underdiagnosed entity in pediatric otolaryngology. The diagnosis must be considered in a pediatric non-cystic fibrosis patient with florid nasal polyposis. In this small case series, we will describe 2 patient's presentation, work up, allergic and surgical therapies and their postoperative course. In doing so, we hope to increase awareness and to illustrate the details that are involved in its diagnosis and treatment.

Common modalities of aural rehabilitation include external hearing aids, cochlear implantation, and bone anchored hearing aids. In recent years, there has been research, development, and application of implantable and semi-implantable hearing aids. These devices act by vibration of the ossicular chain by piezoelectric or electromagnetic energy. Although only recently approved by the U.S. Food and Drug Administration, implantable hearing aids are evolving as a plausable option for patients with sensorineural or conductive hearing loss. Here, we review all current devices and surgical techniques for implantation.

The purpose of this review article is to discuss the differences between ventricular repolarization in males and females in terms of morphology, possible mechanism, and practical significance. The interest in the subject increased when it became known that in comparison to men, women have a higher incidence of torsade de pointes (tdp) and a greater lengthening of QT‐interval after administration of class III antiarrhythmic drugs. Before puberty, the QT intervals and the patterns of ventricular repolarization in boys and girls are similar. At puberty, in boys the QT interval shortens, and a typical male pattern of ventricular repolarization develops. This pattern is characterized by a higher amplitude of the J‐point, a shorter and steeper ST segment course, a steeper ascent, and a higher amplitude of the T wave. This pattern is prevalent in >90% of young males. With increasing age the prevalence of the male pattern in males declines gradually and drops to 14% in the oldest age group. The rise and fall of the prevalence of the male pattern appears to parallel the rise and decline of testosterone in males. The female pattern of ventricular repolarization is prevalent in about 80% of females in all age groups. The hormonal effects on ventricular repolarization have been studied in normal and castrated rabbits of both sexes. The available evidence indicates that the females have greater divergence of L calcium current among different layers of the myocardium and a lower density of the repolarizing Kr and Ks currents. The clinical significance of the repolarization differences among genders remains to be determined. Of particular interest is the question whether the males with female pattern are at the same risk of tdp as the females or whether the females with male pattern are at lower risk of tdp than the females with female pattern.

To evaluate the polysomnographic outcomes of supraglottoplasty (SGP) performed for sleep endoscopy diagnosed sleep dependent laryngomalacia as treatment for obstructive sleep apnea syndrome (OSAS).Nine subjects aged 6-55 months underwent supraglottoplasty for sleep dependent laryngomalacia. All subjects underwent both pre- and post-procedural polysomnograms.Supraglottoplasty for sleep dependent laryngomalacia resulted in improvement of OSAS as measured by collective improvements in 8 different primary polysomnogram parameters: apnea-hypopnea index (AHI), minimum (nadir) and mean oxygen saturation, mean and maximum carbon dioxide, total sleep time, sleep efficiency, arousal index, as well as improvement in weight for length percentiles. Subjects had a significant 80% decrease in percentage change in AHI (p0.005), with decrease in mean AHI from 23.4 to 4.8 following supraglottoplasty. Seven of 9 subjects demonstrated improvement in nadir saturations, 6 of 9 subjects had improvement in sleep efficiency, and 7 of 8 subjects under 4 years of age had improvement in weight for length percentile.Supraglottoplasty for sleep dependent laryngomalacia is an effective treatment of OSAS, and can be readily diagnosed using sleep endoscopy. Further investigation is warranted to increase awareness and outcomes related to sleep dependent laryngomalacia.

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Program Description:On the hinge of health care reform, the Board of Governors’ (BOG’s) 2014 hot topic is: will fee for service survive? Expert panelists, consisting of American Academy of Otolaryngology—Head and Neck Surgery presidents, BOG chairs, and physician payment and policy workgroup members, will discuss if fee for service will be superseded by payments based on work relative value units, quality measures, hospital employment, and bundled payments. Presentations will be made on current and past payment structures, bundled payments, quality metrics, and the sustainability of private practice. Time for interaction between the audience and panelists will be ensured through a final round table discussion.Educational Objectives:(1) Describe the history of fee for service and how it has changed in the past 10 years. (2) Relate the impact of health care reform on current and future payment systems. (3) Recognize the challenges private practice will have with new reimbursement models.

Objectives:Computed tomography (CT) measurements were used to investigate the feasibility of performing vascularized nasoseptal flap reconstruction of sellar defects in children.Methods:Ten CT scans from children of each year of age from birth to 18 were obtained for 190 total subjects. Patients with incomplete pneumatization were excluded from analysis. Measurements of nasoseptal flap and sellar defect length were obtained for each subject using OSIRIX radiology software. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1.Results:Of the 190 CT studies, 125 displayed complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting feasibility of flap reconstruction. Mean ratio of nasoseptal flap length to sellar defect length for all subjects was 1.47 (SD = 0.33) with 95% CI [1.41, 1.53]. Only 5 patients (4%) had inadequate nasoseptal flaps; mean age for...

Objective: This study aimed to investigate the role of interarytenoid injection laryngoplasty (IL) for the management of pediatric aspiration. Methods: Medical records of 30 patients, 9 female, with radiographically confirmed chronic aspiration who underwent intraoperative IL were retrospectively reviewed. Clinical improvement was defined as successful advancement of feeds to thinner consistencies. Results: Clinical improvement was observed in 57% of patients. Six children with type 1 posterior laryngeal cleft (PLC-1) were not significantly more likely to show improvement compared to the children without PLC-1. Type 1 posterior laryngeal cleft was associated with older age and higher prevalence of neurodevelopmental risk factors relative to absence of PLC-1. Patients with PLC-1 were more likely than noncleft patients to show recurrence of symptoms after initial improvement with IL. Five patients underwent endoscopic repair. Repair was successful in 3 patients who improved after IL but not in 2 patients who did not improve after IL. Conclusion: Chronic aspiration can improve after IL even in patients with normal anatomy. Injection laryngoplasty can be performed to improve selection of PLC-1 patients for definitive endoscopic repair. Further prospective research, with a randomized control group, is needed to understand whether interarytenoid incompetence plays a role in some patients with chronic aspiration, who do not have a PLC-1.

Congenital tracheal stenosis is an uncommonly associated malformation in children with congenital heart defects. Airway symptomatology should prompt immediate work-up to prevent a delay in diagnosis. Although results to date show acceptable mortality and morbidity for simultaneous repair of tracheal stenosis and cardiac anomalies there are cases where the severity of the lesion in association with other anomalies increases the mortality significantly. We report about a newborn diagnosed with transposition of the great vessels and several other anomalies who developed progressively worsening respiratory distress. Imaging revealed long-segment tracheal stenosis. The family was offered the option of slide tracheoplasty but decided not to pursue any further surgical intervention. The patient soon thereafter died.

Although rigid bronchoscopy is the procedure of choice for interventional procedures of the proximal airway, flexible bronchoscopy can be used when lesions are not accessible by rigid equipment. We present an adolescent patient with tracheal stenosis whose airway was inaccessible through rigid bronchoscopy and thus required flexible bronchoscopy for all therapeutic procedures, including a stent placement. In addition, we describe our use of impulse oscillometry to monitor stent patency.

Fine-needle aspiration biopsy (FNAB) is a well-recognized minimally invasive tool in the diagnosis of neoplasia of various organ systems. Several reports in the literature suggest that FNAB can be an accurate method for the preoperative diagnosis and treatment planning. We describe a case to caution the interpretation from a FNAB that contains suboptimal contents (basaloid cells only) and highlight a clinical-pathologic-based algorithm that can provide the appropriate management for the patient when the cytopathologic diagnosis does not fit the clinical impression.

Several techniques have been developed to retrieve catheter and guide wire fragments that have embolized to the heart and pulmonary vasculature. In most instances, retrieval of the embolized fragments is performed soon after the event has occurred. In this report, we summarize our experience with the removal of these fragments in 3 children after a significant amount of time had elapsed since the time of embolization. The embolized catheter and guide wire fragments were removed without any complications. We also describe the techniques used for their removal, and the problems encountered during the removal of these "old" foreign bodies.

Importance Propranolol therapy is changing the treatment paradigm for infantile hemangioma. This study addresses the effect of propranolol therapy on the treatment of nasal infantile hemangioma (NIH), an area that often does not respond to medical therapy. Objective To determine if propranolol treatment is associated with fewer invasive treatments for NIH. Design, Setting, and Participants Retrospective cohort study conducted within a single pediatric institution’s multidisciplinary vascular anomaly program for patients with NIH treated between January 1, 2003, and December 31, 2011. Three NIH cohorts were compared: prepropranolol (20 in group 1; 2003-2009), propranolol (25 in group 2; 2009-2011), and nonpropranolol (13 in group 3; 2009-2011) treatment. Interventions Analysis of systemic medical, laser, or surgical therapies for NIH. Main Outcomes and Measures The study plan was created to detect a change in invasive therapy for NIH. Data collected included presenting age, sex, affected nasal subunits, infantile hemangioma morphologic characteristics, treatment type and number, and primary treating service. An NIH grading system, based on nasal subunit involvement, helped quantify treatment change. Descriptive statistics summarized data, and a Cox proportional hazards regression model evaluated propranolol use and the likelihood of invasive treatments (surgical excision or laser). Results Of the 95 patients identified, 58 met inclusion criteria: 20 in group 1 (mean age, 4.8 months), 25 in group 2 (mean age, 4.9 months), and 13 in group 3 (mean age, 4.9 months). Nasal infantile hemangiomas involved the nasal tip subunit in 33 of 58 patients (56.9%). Eight of 13 patients (61.5%) in group 3 frequently had small NIH (grade 1). Patients in group 2 were less likely to undergo any invasive treatments (relative risk, 0.44; 95% CI, 0.27-0.73), have surgical excision only (0.45; 0.15-1.38), or undergo laser treatment only (0.44; 0.27-0.78) compared with those in group 1. Patients with higher-grade NIH had more medical or invasive therapy, but invasive procedures were carried out in each subgroup defined by grade. Conclusions and Relevance Patients with isolated propranolol-treated NIH were less likely to undergo invasive treatment, but despite its implementation, the need for invasive treatment was not totally supplanted by its use.

Objectives/Hypothesis To evaluate the risk of post-tonsillectomy hemorrhage associated with perioperative ketorolac use. Study Design Systematic review and meta-analysis of primary articles reporting individual-level post-tonsillectomy hemorrhage rates in subjects receiving perioperative ketorolac and matched controls. Retrospective and prospective studies were both included. Methods PubMed search was performed for “[ketorolac OR toradol] AND tonsillectomy.” Articles fulfilling inclusion criteria were subjected to meta-analysis to determine summary relative risk (RR). Results Adults are at five times increased risk for post-tonsillectomy hemorrhage with ketorolac use (RR: 5.64; 95% confidence interval [CI]: 2.08–15.27; P

Program Description:This video-based forum will provide audience members with state of the art concepts in pediatric otolaryngology. The speakers consist of: Carlton Zdanski: Transoral Robotic Surgery in Children: Indications and Results; Christopher Hartnick: Bevacizumab (Avastin) injection for pediatric RRP; Craig Derkay: Modifications of the Seldinger technique to secure the difficult pediatric airway; David White: Endoscopic division of the sternocleidomastoid muscle for treatment of torticollis; Ken Kazahaya: Endoscopic assisted otologic surgery; Michael Rutter: Tracheotomy tube fenestration; Sanjay Parikh: Diagnosis of sleep induced laryngomalacia; Soham Roy: Radiofrequency ablation of pediatric oral cavity lesions; Steven Goudy: Video-assisted pharyngeal surgery.Educational Objectives:1) Consider contemporary airway management ideas for tracheotomy tubes, recurrent papillomatosis, and laryngomalacia. 2) Describe novel endoscopic laryngopharyngeal techniques with robotics, radiofrequency, and video-...

The reasons why adenotonsillectomy (AT) is less effective treating obese children with obstructive sleep apnea syndrome (OSAS) are not understood. Thus, the aim of the study was to evaluate how anatomical factors contributing to airway obstruction are affected by AT in these children.Twenty-seven obese children with OSAS (age 13.0 ± 2.3 y, body mass index Z-score 2.5 ± 0.3) underwent polysomnography and magnetic resonance imaging of the head during wakefulness before and after AT. Volumetric analysis of the upper airway and surrounding tissues was performed using commercial software (AMIRA®).Patients were followed for 6.1 ± 3.6 mo after AT. AT improved mean obstructive apnea-hypopnea index (AHI) from 23.7 ± 21.4 to 5.6 ± 8.7 (P0.001). Resolution of OSAS was noted in 44% (12 of 27), but only in 22% (4 of 18) of those with severe OSAS (AHI10). AT increased the volume of the nasopharynx and oropharynx (2.9 ± 1.3 versus 4.4 ± 0.9 cm(3), P0.001, and 3.2 ± 1.2 versus 4.3 ± 2.0 cm(3), P0.01, respectively), reduced tonsils (11.3 ± 4.3 versus 1.3 ± 1.4 cm(3), P0.001), but had no effect on the adenoid, lingual tonsil, or retropharyngeal nodes. A small significant increase in the volume of the soft palate and tongue was also noted (7.3 ± 2.5 versus 8.0 ± 1.9 cm(3), P = 0.02, and 88.2 ± 18.3 versus 89.3 ± 24.4 cm(3), P = 0.005, respectively).This is the first report to quantify volumetric changes in the upper airway in obese children with OSAS after adenotonsillectomy showing significant residual adenoid tissue and an increase in the volume of the tongue and soft palate. These findings could explain the low success rate of AT reported in obese children with OSAS and are important considerations for clinicians treating these children.

The initial optimal assessment of the neonate born with unilateral facial paralysis should be performed as soon after birth as possible by a multidisciplinary team with the goal being to distinguish between a traumatic or developmental etiology. Electrophysiologic studies, particularly ENOG testing, are essential for this differentiation; radiologic and audiologic studies are of potential diagnostic benefit. In children determined to have a unilateral facial paralysis of developmental origin, subsequent clinical exams complemented by electrophysiologic testing facilitate prognosis. Unfortunately, in the majority of developmental etiology cases, the likelihood of spontaneous improvement is negligible. In these children, reanimation procedures will need to be considered with limited information in the current literature to dictate the optimal age of such surgical intervention.