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Introduction Diagnosis and treatment of obstructive sleep apnea (OSA) in children is often delayed due to the high prevalence and limited physician and sleep testing resources. As a result, children may be referred to multiple specialties, such as pediatric sleep medicine and pediatric otolaryngology, resulting in long waitlists. Method We used data from our pediatric OSA clinic to identify predictors of tonsillectomy and/or adenoidectomy (AT). Before being seen in the clinic, parents completed the Pediatric Sleep Questionnaire (PSQ) and screening questionnaires for restless leg syndrome (RLS), nasal rhinitis, and gastroesophageal reflux disease (GERD). Tonsil size data were obtained from patient charts and graded using the Brodsky-five grade scale. Children completed an overnight oximetry study before being seen in the clinic, and a McGill oximetry score (MOS) was assigned based on the number and depth of oxygen desaturations. Logistic regression, controlling for otolaryngology physician, was used to identify significant predictors of AT. Three triage algorithms were subsequently generated based on the univariate and multivariate results to predict AT. Results From the OSA cohort, there were 469 eligible children (47% female, mean age = 8.19 years, SD = 3.59), with 89% of children reported snoring. Significant predictors of AT in univariate analysis included tonsil size and four PSQ questions, (1) struggles to breathe at night, (2) apneas, (3) daytime mouth breathing, and (4) AM dry mouth. The first triage algorithm, only using the four PSQ questions, had an odds ratio (OR) of 4.02 for predicting AT (sensitivity = 0.28, specificity = 0.91). Using only tonsil size, the second algorithm had an OR to predict AT of 9.11 (sensitivity = 0.72, specificity = 0.78). The third algorithm, where MOS was used to stratify risk for AT among those children with 2+ tonsils, had the same OR, sensitivity, and specificity as the tonsil-only algorithm. Conclusion Tonsil size was the strongest predictor of AT, while oximetry helped stratify individual risk for AT. We recommend that referral letters for snoring children include graded tonsil size to aid in the triage based on our findings. Children with 2+ tonsil sizes should be triaged to otolaryngology, while the remainder should be referred to a pediatric sleep specialist. Graphical abstract

Objectives To describe and investigate facial nerve displacement in deep lobe parotid lesions in children and to determine clinical and radiographic predictors of abnormal facial nerve position. Methods Retrospective case review of children who underwent total parotidectomy for deep lobe parotid lesions at a tertiary care center between January 2014 and December 2017. Aberrant facial nerve trajectory was defined as ascension of the nerve at an angle of 45° or greater. Elongation was defined as the main trunk >2 cm in length. Patient demographics, radiographic, pathologic results, postoperative nerve weakness, and intraoperative nerve findings were collected. Wilcoxon rank‐sum test and Fisher's exact test were used to assess the associations between variables of interest and facial nerve position. Results A total of 20 patients were included. The mean age was 7.7 ± 5 years. The most common pathologies were lymphatic malformation, pleomorphic adenoma, and first branchial cleft cyst. Twelve out of twenty (60.0%) patients had abnormal intraoperative facial nerve position. There was no significant difference in distribution of pathologies between those with or without an abnormal intraoperative nerve position (P = .41). Neither radiographic lesion size nor distance between the lesion and proximal portion of the facial nerve (mastoid tip) were associated with abnormal facial nerve position intraoperatively. Conclusion Pediatric deep lobe parotid lesions can displace the facial nerve and distort its anatomy in a posterior lateral direction, in approximately 60% of patients. Statistical analysis of increased numbers of patients to further define predictors of aberrant nerve course is warranted. Level of Evidence 4.

Karakterisasi adalah kegiatan mengidentifikasi dan mengelompokkan sifat-sifat yang bernilai ekonomis atau yang merupakan penciri dari suatu varietas. Karakterisasi dilakukan untuk menjaga kekayaan plasma nutfah padi gogo lokal dan untuk mengetahui potensi keunggulan dari genotipe lokal padi gogo Sumatera Barat. Penelitian ini bertujuan untuk (1) mengetahui tingkat keragaman karakter agro-morfologi, dan (2) mengetahui nilai korelasi antar karakter agro-morfologi beberapa genotipe lokal padi gogo asal Sumatera Barat. Penelitian dilaksanakan di Kebun Percobaan Fakultas Pertanian Universitas Andalas dari November 2018 hingga April 2019. Penelitian ini menggunakan metode deskriptif. Data diperoleh dari kegiatan menanam dan mengkarakterisasi karakter morfologi dan agronomis 15 genotipe padi gogo lokal Sumatera Barat. Data dianalisis menggunakan statistika deskriptif. Tingkat keeratan hubungan antar karakter dianalisis menggunakan analisis korelasi sederhana. Hasil penelitian menunjukkan bahwa seluruh genotipe lokal padi gogo memiliki variabilitas yang luas pada karakter agro-morfologi. Terdapat korelasi positif antara komponen hasil seperti bobot gabah 100 butir terhadap karakter panjang malai dan panjang gabah. Ditemukan karakteristik yang diharapkan pada 15 genotipe lokal padi gogo Sumatera Barat yaitu karakter tinggi tanaman yang pendek pada genotipe Alin, Sirah kualo, dan Siranting. Karakter tanaman berumur genjah terdapat pada genotipe Siopat, Simaritik, dan Merah silayang. Karakter tanaman dengan jumlah anakan banyak terdapat pada genotipe Siopat, Merah silayang, dan Kititiran. Karakter tanaman dengan jumlah gabah yang banyak terlihat pada genotipe Sirah Gadang, Pucuk pisang, dan Silampung. Karakter tanaman dengan bobot gabah yang berat terdapat pada genotipe Bolah Suri, Simarus, dan Tandan.

Background Drug induced sleep endoscopy (DISE) is hoped to identify reasons of failure of adenotonsillectomy (AT) in treating pediatric sleep disordered breathing (SDB). Maxillomandibular disproportion has been studied as another association which may explain alternative pathogenesis of SDB. We aimed to explore the relation between the size of the gonial angle and inclination of the epiglottis measured from cone beam CT (CBCT) and tongue base collapse based on DISE in children with SDB. Method A retrospective chart review was conducted at a tertiary pediatric center. Children (6-17 years old) assessed at a multi-disciplinary Upper Airway Clinic, diagnosed with SDB and maxillo-mandibular disproportion (MMD), and who underwent DISE were eligible. Variables obtained from the electronic medical records of the clinic and prospective database included demographics, comorbidities, surgeries performed, investigations, DISE findings and CBCT findings. The gonial angle of subjects with and without tongue base collapse (TBC) on SNP were compared. Results In total 29 patients (13 male, 8 female) age 6-17 (median= 9) were eligible for the study from January 2009 – July 2016. We included 11 subjects, and 10 comparators. The mean gonial angle of the TBC group was 139.3°± 7.6°, while that of the comparison group was 129.4°±3.5 (mean difference -9.937, 95% CI of -15.454 to - 4.421, P = 0.001, power of test 0.95). Additionally, the mean inclination of the epiglottis had a mild positive correlation (r=0.32, p

Introduction Injection laryngoplasty (IL) is a brief, minimally invasive procedure involving injection of agents to augment the interarytenoid space. It was initially described as a diagnostic and temporizing measure for management of type one laryngeal clefts (LC1) and associated swallowing dysfunction (SwD), but more gradually it is being proposed as a definitive treatment modality. However, the morbidity of this treatment for LC1 remains under-investigated. This study sought to determine the morbidities associated with IL as a treatment modality for LC1 and associated SwD. Method Single centre retrospective review of a prospective surgical database of one Pediatric Otolaryngologist at a tertiary care center. Participants included pediatric patients with an endoscopic diagnosis of LC1, treated with IL between 2000 and 2018—excluding those with concurrent upper airway anomalies. Patient charts were reviewed for demographic information, immediate post-op complications (within the first 14 days following IL), and subsequent management. Results Out of 85 consecutive, eligible patients, 12 were excluded (5 subglottic stenosis, 6 laryngomalacia, and one tracheomalacia). Of the 73 included patients, 42 were male and 31 females. The median age at IL was 29 months (range 1–132, interquartile range of 38 months). All IL procedures in this study utilized hyaluronic acid derivatives. From this series, 13 patients experienced post-operative complications. The complications encountered were respiratory distress (N = 5), croup-like cough (N = 6), and stridor (N = 6). These complications were either self-limiting (N=9), managed by systemic or inhaled steroids (N = 4), or admitted to hospital for monitoring (N=3). One case (augmented with dextranomer and hyaluronic acid) required intubation, repeat endoscopy, and drainage of seroma. Conclusion IL was followed by respiratory morbidity in nearly two in ten of this series of consecutive patients. All the morbidities occurred in association with one injection product. Parents should be counselled appropriately about potential morbidities associated with this procedure.

ObjectiveTo evaluate the effect, on birth weight and birth weight centile, of use of the PrenaBelt, a maternal positional therapy device, during sleep in the home setting throughout the third trimester of pregnancy.DesignA double-blind, sham-controlled, randomised clinical trial.SettingConducted from September 2015 to May 2016, at a single, tertiary-level centre in Accra, Ghana.ParticipantsTwo-hundred participants entered the study. One-hundred-eighty-one participants completed the study. Participants were women, 18 to 35 years of age, with low-risk, singleton, pregnancies in their third-trimester, with body mass index 2at the first antenatal appointment for the index pregnancy and without known foetal abnormalities, pregnancy complications or medical conditions complicating sleep.InterventionsParticipants were randomised by computer-generated, one-to-one, simple randomisation to receive either the PrenaBelt or sham-PrenaBelt. Participants were instructed to wear their assigned device to sleep every night for the remainder of their pregnancy (approximately 12 weeks in total) and were provided a sleep diary to track their use. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants and the outcomes assessor were blinded to allocation.Primary and secondary outcome measuresThe primary outcomes were birth weight and birth weight centile. Secondary outcomes included adherence to using the assigned device nightly, sleeping position, pregnancy outcomes and feedback from participants and maternity personnel.ResultsOne-hundred-sixty-seven participants were included in the primary analysis. The adherence to using the assigned device nightly was 56%. The mean ±SD birth weight in the PrenaBelt group (n=83) was 3191g±483 and in the sham-PrenaBelt group (n=84) was 3081g±484 (difference 110 g, 95% CI −38 to 258, p=0.14). The median (IQR) customised birth weight centile in the PrenaBelt group was 43% (18 to 67) and in the sham-PrenaBelt group was 31% (14 to 58) (difference 7%, 95% CI −2 to 17, p=0.11).ConclusionsThe PrenaBelt did not have a statistically significant effect on birth weight or birth weight centile in comparison to the sham-PrenaBelt.Trial registration numberNCT02379728.

Objectives Laryngomalacia (LM) is commonly diagnosed in infants and children with upper aerodigestive symptoms. In the literature, the focus has been on the respiratory impairment, with fewer studies addressing swallowing dysfunction (SwD). The objective of this study is to systematically review the literature for evidence on the prevalence of SwD in children diagnosed with LM. Methods A search was conducted on the following databases: OVID Medline, Ovid EMBASE, EBSCO CINAHL, PROSPERO, and Cochrane Library. We included all the studies that reported on children with LM and documented objective swallowing assessment using fiberoptic endoscopic evaluation of swallowing (FEES) or videofluoroscopic swallowing study (VFSS). Two authors independently screened all the studies, assessed the level of evidence in the included studies, and extracted data. Risk of bias assessment and pooled data analysis were performed. Results The search yielded 512 abstracts. Four studies met the selection criteria representing 425 children. Three studies were retrospective uncontrolled case series and one was a prospective cohort study. In all studies but one, an instrumental assessment of swallowing was selectively performed in patients with clinical indicators of SwD. The pooled estimate (range) of prevalence of SwD was 49% (13.9–90.6%). Conclusion The literature suggests a high prevalence of SwD in children with LM, however the level of evidence is low and generalizability is poor. The wide range of prevalence figures suggests a significant variability in the threshold and indications to assess swallowing in children with LM.

Laryngomalacia (LM) is the most common cause of congenital stridor. Tradition holds that the majority of patients resolve spontaneously by 12-18 months of age. The objective of this study was to systematically review the literature on the spontaneous resolution of LM and/or its presenting symptoms, in otherwise healthy infants.Data sources included Medline/PubMed, EMBASE, Scopus, CINAHL, Proquest, Cochrane database, Cochrane Methodology Register, Web of Science Conference Proceedings Citation Index, and ACP Journal Club. Study inclusion criteria included participants with an endoscopic diagnosis of LM, and symptoms of stridor, swallowing dysfunction, and/or snoring/sleep-disordered breathing, that documented subjective or objective resolution endpoints. Surgical series, case reports, and narrative reviews were excluded. Studies with insufficient follow-up (3 months), and patients with comorbidities without subgroup analysis were excluded. Two independent reviewers extracted follow-up duration, rate of retention, time to resolution of LM, and method of documentation of resolution.Of the 1146 articles identified, three met inclusion/exclusion criteria (n=411 patients). All were retrospective and used stridor resolution as the only endpoint. Resolution rate was 89%, with time to resolution ranging from 4 to 42 months. Level of evidence was low, and studies suffered from lack of follow-up, and no objective endpoints. Meta-analysis was not possible.Endoscopic evidence of the natural history of laryngomalacia and its resolution is lacking. Low level of evidence supports that stridor and respiratory distress resolve, but the range of the time to resolution and rate of resolution is wide. Other clinical manifestations have not been studied. Prospective longitudinal trials are required to better understand the natural history.

BACKGROUND The incidence of oropharyngeal squamous cell carcinoma caused by oncogenic HPV (HPV-OPSCC) is rising worldwide. HPV-OPSCC is commonly diagnosed by RT-qPCR of HPV-16 E6 and E7 oncoproteins or by cyclin-dependent kinase inhibitor 2A, multiple tumor suppressor 1 (p16) immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as ultra-sensitive and highly precise method of nucleic acid quantification for biomarker analysis. We aimed to validate this method for the detection of HPV-16 E6 and E7 in HPV-OPSCC. METHODS Participants were recruited from January 2015-November 2015 at initial presentation to the University of Alberta Head and Neck Oncology Clinic. RNA was extracted, purified and quantified from prospectively collected participant tissues, and ddPCR was performed with fluorescent probes detecting HPV-16 E6 and E7. Results from ddPCR were compared with p16 IHC performed by clinical pathology as standard of care. RESULTS Head and neck tissues were prospectively obtained from 68 participants including 29 patients with OPSCC, 29 patients with non-OPSCC and 10 patients without carcinoma. 79.2% of patients with OPSCC were p16 positive. The sensitivity and specificity of ddPCR HPV E6/E7 compared with p16 IHC in OPSCC was 91.3 and 100%, respectively. The amount of target RNA used was ≤1 ng, 20-50 times lower than reported by other for RT-qPCR HPV E6/E7. CONCLUSIONS The ddPCR of HPV E6/E7 is a novel and highly specific method of detecting HPV-16 in OPSCC. Cancer 2016. © 2016 American Cancer Society.

Laryngomalacia (LM) is a commonly encountered entity in infants and children with stridor and other upper aerodigestive symptoms [1]. Although the presentation and functional deficits encompass stridor, cyanotic spells, failure to thrive, and feeding and swallowing disorders (FSD), traditionally, the main focus had been on the respiratory impairment. The earlier and majority of the literature has been concerned mainly with the most severe cases whose life or thriving was at risk and the assessment of surgical success to relieve them [2]. Later research examined the association of LM with sleep-disordered breathing (SDB) [3], and only relatively recently has interest been directed toward the impact of FSD.

Background Human papillomavirus (HPV) has recently been implicated as a causative agent in a rapidly growing number of oropharyngeal cancers. Emerging literature supports the hypothesis that HPV vaccination may protect against HPV-related head and neck cancer (HNC) in addition to HPV-related cervical and anogenital disease. While the association between HPV infection and cervical cancer is widely understood, its relation to HNC is less well known. The purpose of this study was to better understand HPV counseling practices for infection and vaccination in relation to HNC of primary care physicians (PCPs), Obstetricians/Gynecologists (OBGYNs), and Otolaryngology - Head and Neck Surgeons (OHNSs) in Canada. Methods A Canada-wide electronic questionnaire regarding counseling practices on HPV infection, transmission, and vaccination was designed and distributed to PCPs, OBGYNs, and OHNSs across Canada through electronic and paper-based methods. Basic Descriptive statistics were used to analyze responses. Results In total, 337 physicians responded (239 family physicians, 51 OHNSs, 30 OBGYNs, and 17 pediatricians). Three out of four PCPs reported routine counseling of their patients regarding HPV infection, transmission, and vaccination. Among this group, 68% reported “never” or “rarely” counseling patients that HPV can cause HNC. The most commonly reported reason that PCPs cited for not counseling was a lack of knowledge. The majority of OHNSs (81%) and OBGYNs (97%) counseled patients regarding HPV infection, transmission, and vaccination. However, very few OHNSs (10%) regularly counseled patients with HPV-related HNC about HPV-related anogenital cancer. Similarly, very few OBGYNs (18%) regularly counseled patients with HPV related cervical/anogenital cancer about HPV related HNC. Conclusions The rate of counseling on HPV infection, transmission, and vaccination in relation to HNC among PCPs is low. The most common reason is a lack of knowledge. Specialists rarely counsel patients with confirmed HPV-related cancer about other HPV-related malignancies. More research is needed on the relationship between different HPV-related cancers in order to better inform counseling practices.

Background Adenotonsillectomy (AT) is the most commonly performed procedure for sleep disordered breathing (SDB) in pediatrics. However, 20-40% of patients will have persistent signs and symptoms of SDB after AT. Drug-induced sleep endoscopy (DISE) has the potential to individualize surgical treatments and avoid unnecessary or unsuccessful surgeries. The objective of this study was to determine the predictors of failure of DISE-directed adenoidectomy and/or tonsillectomy in otherwise healthy children with SDB. Methods We retrospectively reviewed a prospective database of children who presented with SDB. All patients underwent preoperative pulse oximetry (PO), followed by DISE with T ± A, The variables documented included demographics, ethnicity, co-morbidities, family history, McGill Oximetry Score (MOS) on PO, as well as findings of collapse and or obstruction on DISE and symptom resolution based on modified Pediatric Sleep Questionnaire (PSQ). The primary outcome was the independent predictors of treatment failure based on multivariate binary logistic regression. Results Three hundred eighty-two patients satisfied the inclusion criteria. Based on post-operative modified PSQ, SDB resolved in 259 patients (68%), whereas 123 (32%) had persistent symptoms. On bivariate analysis, neuropsychiatric diagnosis (r = 0.286, p = 0.042), history of sleepwalking or enuresis (r = 0.103, p = 0.044), MOS (r = 0.123, p = 0.033), presence of DNS (r = 0.107, p = 0.036), and presence of laryngomalacia (r = 0.122, p = 0.017) all positively correlated with treatment failure. Small tonsil size on DISE correlated with treatment failure (r = −0.180, p

Background The incidence of oropharyngeal squamous cell carcinoma (OPSCC) caused by oncogenic human papillomavirus (HPV) is rising worldwide. HPV-OPSCC is commonly diagnosed by RT-qPCR of HPV E6 and E7 oncoproteins or by p16 immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as an ultra-sensitive and highly precise method of nucleic acid quantification for biomarker analysis. To validate the use of a minimally invasive assay for detection of oncogenic HPV based on oropharyngeal swabs using ddPCR. Secondary objectives were to compare the accuracy of ddPCR swabs to fresh tissue p16 IHC and RT-qPCR, and to compare the cost of ddPCR with p16 IHC. Methods We prospectively included patients with p16+ oral cavity/oropharyngeal cancer (OC/OPSCC), and two control groups: p16− OC/OPSCC patients, and healthy controls undergoing tonsillectomy. All underwent an oropharyngeal swab with ddPCR for quantitative detection of E6 and E7 mRNA. Surgical specimens had p16 IHC performed. Agreement between ddPCR and p16 IHC was determined for patients with p16 positive and negative OC/OPSCC as well as for healthy control patients. The sensitivity and specificity of ddPCR of oropharyngeal swabs were calculated against p16 IHC for OPSCC. Results 122 patients were included: 36 patients with p16+OPSCC, 16 patients with p16−OPSCC, 4 patients with p16+OCSCC, 41 patients with p16−OCSCC, and 25 healthy controls. The sensitivity and specificity of ddPCR of oropharyngeal swabs against p16 IHC were 92 and 98% respectively, using 20–50 times less RNA than that required for conventional RT-qPCR. Overall agreement between ddPCR of tissue swabs and p16 of tumor tissue was high at ĸ = 0.826 [0.662-0.989]. Conclusion Oropharyngeal swabs analyzed by ddPCR is a quantitative, rapid, and effective method for minimally invasive oncogenic HPV detection. This assay represents the most sensitive and accurate mode of HPV detection in OPSCC without a tissue biopsy in the available literature. Electronic supplementary material The online version of this article (doi:10.1186/s40463-016-0177-8) contains supplementary material, which is available to authorized users.

Sand aspiration is rare in children. It is a potentially lethal injury, with outcomes ranging from full recovery to global cerebral asphyxia and death. The medical literature was searched for cases of sand aspiration in children, including mechanisms of injury and treatment methods. We found only ten reports of pediatric sand aspiration. The majority were treated with bronchoscopy and lavage. We present a unique case of sand aspiration in a ten-year-old boy caused by an accidental burial, which was successfully treated with bronchoscopy and extra-corporeal membrane oxygenation (ECMO) as a rescue therapy. This is the first ever case of the use of ECMO in the management of sand aspiration. We argue that ECMO is an effective and potentially life-saving measure in severe cases of sand aspiration requiring high ventilatory pressures allowing repeated bronchoscopies while resting the lungs.

Importance No guidelines at present describe when fludeoxyglucose F 18–labeled positron emission tomography and computed tomography (FDG PET-CT) should be used in the initial posttreatment period for evaluation of oropharyngeal squamous cell carcinoma treatment outcome and recurrence. Objective To compare accuracies of the initial posttreatment PET-CT between primary treatment groups and to define indicators of false-positive findings. Design, Setting, and Participants This retrospective cohort study identified adults with a new diagnosis of oropharyngeal squamous cell carcinoma who received treatment with curative intent from October 1, 2006, through November 30, 2016, using the Alberta Cancer Registry (n = 380). Patients who underwent PET-CT within 1 year of treatment completion were included (n = 190). Of these, 103 patients (54.2%) had PET-CT findings positive for residual or recurrent disease, and 61 (32.1%) had false-positive findings. Among the 61 patients, 42 (68.9%) had received chemoradiotherapy (CRT) and 19 (31.1%) had primary surgery. Forty-two patients had true-positive findings, indicating a prevalence rate of disease of 22.1%. Data were analyzed from July through October 2017. Exposures One of 2 primary treatment modalities (surgery with or without adjuvant therapy vs CRT). All patients had posttreatment FDG PET-CT. Main Outcomes and Measures Primary outcome measures included the diagnostic odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for detecting residual and/or recurrent disease. A multivariate analysis determined indicators of false-positive findings. Discriminative ability was assessed using receiver operating characteristic curve analysis of maximum standardized uptake value (SUVmax) metabolic data. Results Of the 190 participants, 77.9% were men, with a mean (SD) age at diagnosis of 58.5 (8.5) years. The diagnostic odds ratio was 19.3 (95% CI, 5.7-65.1); pooled sensitivity, 93.3% (95% CI, 80.7%-98.3%); and pooled specificity, 57.9% (95% CI, 49.4%-66.0%). The PPV of detecting disease was 54.7% (95% CI, 38.8%-69.8%) for primary surgery and 31.1% (95% CI, 20.2%-44.4%) for CRT. The NPV was 100% (95% CI, 94.7%-100%) for primary surgery and 96.6% (95% CI, 89.5%-99.1%) for CRT. Multivariate analysis identified treatment type, p16 disease, and smoking status as indicative of false-positive findings. In the receiver operating characteristic curve analysis for primary tumors, the optimal cutoff SUVmax for indicating true- vs false-positive results was 5.1 for surgically treated patients (area under the curve, 0.729; 95% CI, 0.570-0.888) and 5.3 for patients treated with CRT (area under the curve, 0.844; 95% CI, 0.700-0.989). Conclusions and Relevance The results indicate a higher specificity for FDG PET-CT for initial posttreatment surveillance imaging among patients treated with primary surgery compared with nonsurgical management. Both sets of patients with posttreatment FDG PET–CT findings with an SUVmax greater than 5.0 should undergo close evaluation for possible residual or recurrent disease.

ObjectiveTo evaluate whether the percentage of time spent supine during sleep in the third trimester of pregnancy could be reduced using a positional therapy device (PrenaBelt) compared with a sham device.DesignA double-blind, randomised, sham-controlled, cross-over pilot trial.SettingConducted between March 2016 and January 2017, at a single, tertiary-level centre in Canada.Participants23 participants entered the study. 20 participants completed the study. Participants were low-risk, singleton, third-trimester pregnant women aged 18 years and older with body mass index 2at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep.InterventionsA two-night, polysomnography study in a sleep laboratory. Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either a PrenaBelt or a sham-PrenaBelt on the first night and were crossed over to the alternate device on the second night. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants, the recruiter and personnel involved in setting up, conducting, scoring and interpreting the polysomnogram were blinded to allocation.Primary and secondary outcome measuresThe primary outcome was the percentage of time spent supine during sleep. Secondary outcomes included maternal sleep architecture, respiration, self-reported sleep position and feedback.ResultsThe median percentage of sleep time supine was reduced from 16.4% on the sham night to 3.5% on the PrenaBelt night (pseudomedian=5.8, p=0.03). We were unable to demonstrate differences in sleep architecture or respiration. Participants underestimated the time they spent sleeping supine by 7.0%, and six (30%) participants indicated they would make changes to the PrenaBelt. There were no harms in this study.ConclusionsThis study demonstrates that the percentage of sleep time supine during late pregnancy can be significantly reduced via positional therapy.Trial registration numberNCT02377817; Results.

The incidence of oropharyngeal squamous cell carcinoma caused by oncogenic HPV (HPV-OPSCC) is rising worldwide. HPV-OPSCC is commonly diagnosed by RT-qPCR of HPV-16 E6 and E7 oncoproteins or by cyclin-dependent kinase inhibitor 2A, multiple tumor suppressor 1 (p16) immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as ultra-sensitive and highly precise method of nucleic acid quantification for biomarker analysis. We aimed to validate this method for the detection of HPV-16 E6 and E7 in HPV-OPSCC.Participants were recruited from January 2015-November 2015 at initial presentation to the University of Alberta Head and Neck Oncology Clinic. RNA was extracted, purified and quantified from prospectively collected participant tissues, and ddPCR was performed with fluorescent probes detecting HPV-16 E6 and E7. Results from ddPCR were compared with p16 IHC performed by clinical pathology as standard of care.Head and neck tissues were prospectively obtained from 68 participants including 29 patients with OPSCC, 29 patients with non-OPSCC and 10 patients without carcinoma. 79.2% of patients with OPSCC were p16 positive. The sensitivity and specificity of ddPCR HPV E6/E7 compared with p16 IHC in OPSCC was 91.3 and 100%, respectively. The amount of target RNA used was ≤1 ng, 20-50 times lower than reported by other for RT-qPCR HPV E6/E7.The ddPCR of HPV E6/E7 is a novel and highly specific method of detecting HPV-16 in OPSCC. Cancer 2016;122:1544-51. © 2016 American Cancer Society.

Objectives:(1) List the factors that are predictive of non-diagnostic cytology in surgeon-performed ultrasound-guided fine-needle aspiration (FNA) of thyroid nodules. (2) Describe a patient cohort that may benefit from early referral to other clinicians.Methods:Retrospective chart review. Patients included all adults who underwent thyroid nodule FNA by a staff, fellow, or resident otolaryngologist at our center between January 2011 and June 2013. Cytology was interpreted by a staff cytopathologist according to the Bethesda classification system. The predictive factors analyzed were patient age, sex, body mass index (BMI), thyroid gland size, thyroid function, presence of multinodular goiter, presence of Graves’ disease or thyroiditis, nodule size, location, vascularity, echogenicity, calcifications, cystic component, level of performer training, and level of FNA experience. Results were analyzed using chi-squared, Fisher exact test, or unpaired t test.Results:A total of 190 patients were reviewed, for a t...

Background Fine needle aspiration (FNA) is the standard of care for the diagnostic work-up of thyroid nodules but despite its proven utility, the non-diagnostic rate for thyroid FNA ranges from 6-36%. A non-diagnostic FNA is problematic for the clinician and patient because it can result in repeated procedures, multiple physician visits, and a delay in definitive treatment. Surgeon-performed FNA has been shown to be safe, cost-effective, as accurate as those performed by other clinicians, and has the added benefit of decreasing wait times to surgery. Several studies have examined rates and factors that may be predictive of a non-diagnostic cytology in non-surgeon FNA, but none have evaluated this in surgeon-performed thyroid FNA. If these factors are unique in surgeon-performed vs. non-surgeon performed thyroid FNA, then patients may be more appropriately triaged to FNA by alternate clinicians. Objectives The purpose of this study was to determine the rate and factors predictive of a non-diagnostic FNA in surgeon performed ultrasound-guided FNA of thyroid nodules. Methods We conducted a retrospective review of all adult patients who underwent thyroid FNA by a staff, fellow, or resident Otolaryngologist at the University of Alberta between January 2011 and June 2013. Factors analyzed included patient factors, thyroid characteristics, nodule characteristics, and surgeon level of training and experience. Univariate and multivariate binary logistic regression analysis were performed. Results 131 patients (180 nodules) were reviewed. The non-diagnostic rate was 23%. Nodules with predominant cystic component, those less than 1 cm, and resident-performed FNA were associated with non-diagnostic cytology (p = 0.001, p = 0.02, p = 0.04 respectively). A cystic nodule was the only independent predictor of non-diagnostic FNA on multivariate analysis (OR = 4.441, 95% CI [1.785-11.045], p = 0.001). Conclusions The rate of non-diagnostic thyroid FNA performed by a surgeon with ultrasound guidance is similar to other clinicians. A cystic nodule is a strong independent predictor of non-diagnostic cytology. Non-cystic nodules may particularly benefit from surgeon-performed thyroid FNA due to the high diagnostic rate and potential for earlier definitive management.

OBJECTIVES: The primary objectives were to evaluate the quality of development and reporting of American Academy of Pediatrics (AAP) guidelines and to determine the level of evidence underlying the recommendations. METHODS: Two reviewers scored each guideline by using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument and determined the level of evidence for each recommendation in each guideline. Subgroup analyses compared AAP guidelines published before and after key changes in AAP guideline development policy and compared internal with endorsed guidelines. RESULTS: For the 28 current guidelines, the highest average scores on AGREE-II were in scope and purpose (75%) and clarity of presentation (73%). The lowest average scores were in editorial independence (17%) and applicability (30%). The only domain that improved after AAP policy updates was editorial independence (P = .01). Of the 190 treatment recommendations, 43% were based on experimental studies, 30% on observational studies, and 27% on expert opinion or no reference. Compared with early guidelines, late guidelines included a higher proportion of treatment recommendations based on experimental studies (P = .05). CONCLUSIONS: There was no clear improvement in the quality of development and reporting of AAP clinical practice guidelines over time. Routine application of AGREE-II to guideline development could enhance guideline quality. The proportion of guideline recommendations based on experimental evidence has increased slightly over time. Pediatric research agendas should be matched to vital gaps in the evidence underlying pediatric guidelines.

IMPORTANCE Nasal obstruction is common in children and difficult to quantify objectively. Symptom quantification is paramount for surgical and medical decision making. Acoustic rhinometry is a relatively new technique aimed at the objective assessment of nasal obstruction. There is no standardized method for the objective assessment of the pediatric nasal airway. OBJECTIVE To explore the correlations between acoustic rhinometry (AR), subjective symptoms, and endoscopic findings in children presenting with nasal obstruction. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, exploratory, diagnostic study of prospectively collected data from a multidisciplinary airway clinic (pulmonology, orthodontics, and otolaryngology) database at a tertiary academic referral center. Data were collected over a 2-year period (2010-2012) from 65 nonsyndromic children (38 boys) 7 years and older (mean [SD] age, 10.3 [2.5] years [range, 7-14 years]), presenting with persistent nasal obstructive symptoms for at least 1 year, without signs and symptoms of sinus disease. INTERVENTIONS We collected patient demographics and medical history information including allergy, asthma, and sleep-disordered breathing. Subjective nasal obstruction was scored using a visual analog scale (VAS). Sleep-disordered breathing was assessed using overnight pulse oximetry. The adenoid size, septal position, and visual severity of chronic rhinitis (endoscopic rhinitis score [ERS]) were rated on nasal endoscopy by 2 independent reviewers and validated by agreement. Acoustic rhinometry (AR) was undertaken before and after use of a decongestant. MAIN OUTCOMES AND MEASURES Correlation and multiple regression analyses were performed to explore interrelationships between subjective nasal obstruction VAS, AR, and nasal endoscopy. RESULTS Among the 65 patients, 28 (43%) had symptoms of sleep-disordered breathing, 14 (22%) had allergic rhinitis, 10 (15%) had asthma, 27 (41%) had grade 3 or 4 adenoidal obstruction, 28 (43%) had an ERS of 2, 6 (9%) had an ERS of 3, and 19 (29%) had septal deviation. Significant correlations were found between subjective nasal obstruction VAS score and ERS (r = -0.364, P = .003), ERS and minimal cross-sectional area before decongestion (r = -0.278, P = .03), and adenoid size and calculated nasal resistance after decongestion (r = 0.430, P

Importance Diprosopus is a medical condition that refers to full or partial craniofacial duplication. A particular subset of this condition, duplication of the mouth, is an exceedingly rare condition, with 7 reported cases in the medical literature. The embryogenesis and mechanism of disease are not well understood. The objective of this report was to describe a case of partial facial duplication with a discussion of the previous literature, leading to a proposed theory of embryogenesis for this rare anomaly. Observations We present a rare case of duplication of the mouth associated with an intraoral dysontogenic cyst, which presented with upper airway obstruction. The diagnostic and management strategies are discussed, as well as the histopathological features and theories of embryogenesis. Conclusions and Relevance On the basis of our findings, we propose the mechanism of origin for duplication of the mouth to be duplication of the first branchial arch. This case offers a deeper understanding of the mechanism of this disease than previously reported. Additional basic science and clinical research is needed to corroborate this theory.

Background Adenotonsillectomy is the most commonly performed operation for pediatric snoring/sleep disordered breathing (S/SDB). However, 20–40% of patients will fail to improve. Drug-induced sleep endoscopy (DISE) may provide a more individualized surgical plan and limit unsuccessful surgeries. The aim of this study was to assess the impact of DISE on surgical decision-making in surgically naïve children with S/SDB. Methods A retrospective observational cohort study was undertaken at the Stollery Children’s Hospital. Patients 3–17 years of age who underwent DISE-directed surgery for S/SDB between January 2009 and December 2015 were eligible. We excluded other indications for tonsillectomy and syndromic children. The primary outcome was the level of agreement between a DISE-based surgical decision and the reference standard based on the American Academy of Pediatrics (AAP) guidelines via un-weighted Cohen’s kappa. Secondary outcomes included the frequency and type of alternate surgical targets identified by DISE. The agreement on tonsil size between in-office physical assessment and DISE was also calculated. The effectiveness of DISE-directed surgery on postoperative S/SDB was not investigated. Results Five hundred fifty-eight patients were included. DISE changed the surgical plan in 35% of patients. Agreement between DISE-based and AAP clinical practice guidelines-based management was low (κ = 0.354 +/- 0.021 [95% CI 0.312–0.395]). An alternate diagnosis or surgical target was identified by DISE in 54% of patients. There was moderate agreement on tonsil size (κ = 0.44 [0.33–0.55]) between DISE and in-office clinical assessment. Conclusions This is a first phase diagnostic study, which demonstrates that DISE affects decision-making in surgically naïve children with S/SDB in up to 35% of patients. It has utility in individualizing first stage surgical treatments as well as identifying alternate targets for further surgical or medical therapy, while potentially limiting unsuccessful surgeries. Further studies to examine the effect of DISE on surgical outcomes are required.

Background Otolaryngology-Head and Neck surgery resident physicians (OHNSR) have a high prevalence of burnout, job dissatisfaction and stress as shown within the literature. Formal mentorship programs (FMP) have a proven track record of enhancing professional development and academic success. More importantly FMP have an overall positive impact on residents and assist in improving job satisfaction. The purpose of the study is to determine the effects of a FMP on the well-being of OHNSR. Methods A FMP was established and all OHNSR participation was voluntary. Eight OHNSR participated in the program. Perceived Stress Survey (PSS) and the Maslach Burnout Inventory (MBI) were administered at baseline and then at 3, 6, 9, and 12 month intervals. World Health Quality of Life-Bref Questionnaire (WH-QOL) was administered at baseline and at 12 months. Results Baseline statistics found a significant burden of stress and burnout with an average PSS of 18.5 with a high MBI of 47.6, 50.6, and 16.5 for the emotional, depersonalization, and personal achievement domains respectively. Quality of life was also found to be low with a WH-QOL score of 71.9. After implementation of the FMP, PSS was reduced to 14.5 at 3 months (p = 0.174) and a statistically significant lower value of 7.9 at 12 months (p = 0.001). Participants were also found to have lower emotional scores (14.9, p