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This case report describes the gradual deterioration of a healthy, highly functioning man who initially presented with a draining right ear. The patient's indolent neurologic decline and referral to an otologist ultimately led to the diagnosis and treatment of an otogenic cerebellar abscess, an increasingly rare intracranial complication of otitis media. We report this case to illustrate that severe complications of chronic otitis media still occur in the United States, to stress the importance of clinical suspicion in the postantibiotic era, and to review the literature regarding the most appropriate time to perform the otologic portion of the surgery.

Objective: To evaluate the effect of vascular endothelial growth factor (VEGF) on full-thickness skin graft (FTSG) survival on irradiated tissue as a model of wound healing in ischemic conditions., Design: Twenty-four Sprague-Dawley rats underwent 30 Gy of irradiation to their left dorsum (10 Gy/d). After 4 weeks of recovery, 3-cm FTSGs were harvested from the healthy contralateral dorsum and placed onto irradiated recipient beds. Before grafting, recipient beds were delivered subfascial injections of either VEGF protein (5 microg) or physiologic saline. Graft failure (more than 10% necrosis) and graft microvascular density were compared between groups., Results: Seven of the 11 FTSGs from saline-treated irradiated beds (64%) failed, whereas the failure rate for grafts treated with VEGF was 23% (3 of 13) (P = .048). Mean microvascular density was not different between groups., Conclusion: Exogenously administered VEGF may improve the outcome of FTSGs on irradiated tissue beds.

Objectives: Previous reports suggest that patients with Turner syndrome have a predisposition for acute and chronic otitis media. However, the role of early or aggressive surgical management of otologic disease has not been explored in the pediatric population. With respect to otitis media in pediatric Turner syndrome patients, we examined (1) the impact of timing and (2) the type of surgical intervention in the treatment of disease., Methods: Retrospective 10-year review of patients with Turner syndrome and chronic otitis and its surgical management at a single pediatric tertiary institution., Results: One hundred and seventy-eight patients with Turner syndrome were evaluated at our institution from 1997 to 2007. Thirty-two (18.0%) were diagnosed with middle ear disease. Eighteen (10.1%) were referred to otolaryngology for evaluation. Average age at presentation was 4.7 years (range: 1 month to 12 years). The 18 patients referred to otolaryngology required a mean of 16 clinic visits each for otologic symptoms. A mean of 6.7 pressure equalization tubes (PET) were required per patient (range: 0-25). Middle ear effusions (n=14, 78%) along with tympanic membrane retractions and/or perforations (n=10, 55.6%) were the most common otoscopic findings. Patients with tympanic membrane retractions (8/18) required a higher average number of PET (9.1) and cumulatively underwent a total of five tympanoplasty-type procedures. Six ears had evidence of cholesteatoma. Two patients underwent myringoplasty, 6 patients underwent tympanoplasty (33.3%, mean age 11.6 years), and 3 patients (16.7%, mean age 9.4 years) underwent tympanomastoidectomy. Revision procedures were common. Older age at first PET placement was significantly correlated with the need for later tympanoplasty and/or tympanomastoidectomy operations (p<0.036). Tympanoplasty or tympanomastoidectomy patients had their first PET placed on average at 5.2 years as compared to 2.6 years in those not requiring tympanoplasty or tympanomastoidectomy operations., Conclusions: Recurrent and chronic otitis media is common in patients with Turner syndrome. Once established, disease is recalcitrant and leads to multiple surgical procedures. Early PET insertion is advocated to offset the future necessity of more extensive tympanic procedures.

Objective: To develop a novel mouse model of acquired subglottic stenosis (SGS) using heterotopic transplanted laryngotracheal complexes (LTCs)., Design: Pilot randomized controlled animal study., Subjects: Forty-eight C57BL/6 mice., Interventions: Twenty-four donor C57BL/6 mice underwent LTC harvesting. The LTCs were then implanted deep to a cutaneous dorsal flap in 24 allogenic recipients. Sixteen LTCs underwent direct subglottic injury before transplantation, while 8 control LTCs were transplanted without injury. Transplanted LTCs were harvested 1, 2, 3, and 4 weeks after surgery. Tissues were fixed and cut transversely in 6-microm sections from the larynx to the second tracheal ring. Movat pentachrome staining was performed for connective tissue and morphometric analysis. Digital images of the subglottis were captured at x 20 magnification. The thicknesses of the lamina propria and the epithelium were measured at 5 random and equally spaced locations within the subglottic lumen. Vascular endothelial growth factor 164 (VEGF 164) and transforming growth factor beta1 (TGF-beta1) immunohistochemistry was performed on representative sections., Results: Lamina propria thickness was significantly greater in transplanted LTCs 3 and 4 weeks after injury compared with controls (P = .03, P = .01, respectively). Combined results (groups harvested at 1-4 weeks) revealed a significant difference between all 8 control animals and all 16 experimental animals (P < .001). Epithelial thickness was also greater in the transplanted LTCs 2, 3, and 4 weeks after injury to the subglottis compared with controls (P = .04 for weeks 2 through 4). Movat pentachrome staining showed random distributions and high concentrations of connective tissue within the lamina propria of the subglottis. The VEGF 164 and TGF-beta1 staining patterns were consistent with previous in vivo models of SGS., Conclusion: Heterotopic transplanted LTCs in mice can provide an inexpensive and flexible model for experimental investigation of acquired SGS.

Background: Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature., Methods: FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries., Results: Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices., Conclusions: Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.

Objective: To identify and describe the features of laryngomalacia (LM) in a cohort of older children, with the goal of providing an approach to diagnosis and management of these patients. Laryngomalacia is a common congenital disorder characterized by decreased laryngeal tone, supraglottic collapse, and stridor during inspiration and is rarely seen in older children. However, the presence of LM in this population may be obscured by related but uncommon clinical features., Design: Prospective collection and retrospective evaluation of older children with evidence of LM from 1998 to 2005., Setting: Two tertiary pediatric institutions., Patients: Prospective data collection of 239 patients with LM, including 222 with congenital LM and 17 diagnosed as having LM when they were older than 2 years and without a medical history of prior disease or symptoms-late-onset LM (mean age at onset, 6.6 years)., Intervention: Supraglottoplasty., Main Outcome Measure: Symptom improvement., Results: Patients with late-onset LM were classified into 3 categories according to their symptom complex; those presenting with feeding-disordered LM (n = 7; mean age at onset, 3.3 years), sleep-disordered LM (n = 7; mean age at onset, 6.3 years), and exercise-induced LM (n = 3; mean age at onset, 15 years). Stridor was rarely present except in patients with exercise-induced LM during strenuous activity. Profound arytenoid redundancy and prolapse was discovered in all patients during nasolaryngeal endoscopy. Typical anatomic features of congenital LM (shortened aryepiglottic folds or retroflexed epiglottis) were not discovered. No patient had a history of neuromuscular disease. Supra-arytenoid reduction (supraglottoplasty) led to clinical cure in all patients (mean duration of follow-up, 7.4 months). Prior adenotonsillectomies were performed in 5 patients with sleep-disordered LM. This did not improve symptoms, and these patients displayed evidence of LM as the source of obstruction., Conclusions: Physicians should consider late-onset LM as a potential cause of feeding difficulties in toddlers, sleep apnea in children, and exercise intolerance in teenagers. As in infants with LM, supraglottoplasty improves late-onset disease.

Objectives: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials., Study Design: In vivo, rat model., Methods: Subcutaneous implantation of 1-mm thick, 1 cm x 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively., Results: AlloDerm showed significantly greater soft tissue ingrowth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks (P < 0.001)., Conclusions: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model.

Objective: To examine the effect of exogenous vascular endothelial growth factor (VEGF) on skin graft survival in Sprague-Dawley rats., Design: Dorsal full-thickness skin grafts were harvested from 18 Sprague-Dawley rats. To simulate human full-thickness skin grafts, the panniculus carnosus muscle was removed from the undersurface of each graft. The recipient beds were delivered subfascial injections of recombinant human VEGF or isotonic sodium chloride solution in 12 animals before replacement of the grafts (6 in each group). Grafts were replaced without injections in 6 sham control animals. Using planimetry, grafts were analyzed for necrosis along epidermal and dermal surfaces on postoperative day 7. Results were compared between groups. To determine the role of the panniculus carnosus muscle in graft survival, 12 Sprague-Dawley rats underwent the same procedure with an intact panniculus carnosus muscle and with subfascial injections of VEGF or physiologic isotonic sodium chloride solution (6 in each group). Analyses were performed on postoperative day 14. The mean microvascular density was determined in each graft after staining with anti-factor VIII antibody., Results: The mean percentage of dermal necrosis in VEGF-treated skin grafts (10.0%) was significantly lower than that in saline-treated grafts (26.7%) or in control grafts (18.9%). Reduced, but not significant, epidermal necrosis was found in VEGF-treated rats vs saline-treated rats. No difference was found in VEGF-treated grafts vs saline-treated grafts when the panniculus carnosus muscle was left intact. Increased microvascular density was observed in VEGF-treated grafts vs saline-treated grafts, which did not reach statistical significance (P = .17)., Conclusion: Exogenously administered VEGF may improve the outcome of full-thickness skin grafts by decreasing dermal necrosis.