Search

In accordance with ACCME regulations, the American College of Surgeons, as the accredited provider of this journal CME, must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. The editor and author(s) of this article were required to complete disclosures and any reported conflicts have been managed to our satisfaction. However, if you perceive a bias within the article, please advise us of the circumstances on the evaluation form. The requirement for disclosure is not intended to imply any impropriety of such relationships, but simply to identify such relationships through full disclosure, and to allow readers to form their own judgments regarding the material.

A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of "production pressure," such as the requirement to see a high volume of patients.

Creating a culture of respect is the essential first step in a health care organization’s journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organization’s leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment. When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station. Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

Objectives: Studies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services. Methods: We retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a “zero-defect” paradigm, recording any error or adverse event—from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency. Results: A total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant. Conclusions: Multiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a “zero-defect” standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity. Laryngoscope, 2009

Objectives: The objectives of this study were to describe otolaryngologists' emotional reactions to errors and adverse events, their efforts to take responsibility, and their attempts to implement improvements. Study Design and Methods: A retrospective, anonymous survey of 2,500 U.S. otolaryngologists who were members of the American Academy of Otolaryngology–Head and Neck Surgery about errors in their practice was conducted. Respondents were asked whether an error had occurred in their practice in the past 6 months and, if so, to describe the error, its consequences, and any corrective actions taken. Two aspects of these reports stood out, which were beyond the scope of the original study: the respondents' emotional responses and their corrective actions. Results: The response rate was 18.6%. Two hundred ten (45%) respondents reported a total of 212 analyzable error reports and 230 corrective actions. Corrective actions included disclosure to the patient (20 [9%]), ameliorating the consequences of the event to the patient (107 [50%]), personal practice changes (14 [7%]), improvements in the respondent's practice or department (60 [28%]), and hospitalwide or broader corrective actions (19 [9%]). Emotional reactions to errors and adverse events were reported by 22 (10%) otolaryngologists, including regret, embarrassment, guilt, anxiety, loss of temper, and irritation. Legal action was mentioned by five physicians (2%). Conclusions: Otolaryngologists took actions not only to treat their patients, but also to improve patient care in their practice, department, hospital, or community. Emotional reactions to errors and adverse events are common and need to be addressed in medical training and practice.

Vascular endothelial growth factor–A (VEGF-A) is known to play an important role in the angiogenic response essential for tumor growth in a variety of human and experimental tumors. This study was designed to investigate whether VEGF-A may play a role in the pathogenesis of recurrent respiratory papillomatosis (RRP). A retrospective study with institutional review board approval was performed at a tertiary care medical center on 12 patients with a history of laryngeal RRP. Their ages at the time of initial diagnosis ranged from 19 to 96 months (mean, 56 months). All patients had involvement of right and left true vocal cords. All patients required multiple endoscopic procedures (range, 4 to 66; mean, 12). Normal pediatric larynx samples from 5 autopsy patients were used as controls. Formalin-fixed, paraffin-embedded sections of laryngeal squamous papillomas from the 12 patients with a diagnosis of RRP and the 5 control patients were examined by in situ hybridization for the presence of messenger RNA (mRNA) for VEGF-A and vascular endothelial growth factor receptor 1 (VEGFR-1) and vascular endothelial growth factor receptor 2 (VEGFR-2). The biopsy specimens were from the true vocal cord (N = 10) or subglottis (N = 2) in the patients with RRP and consisted of large sections of larynx including the true vocal cord in the control patients (N = 5). Strong expression of VEGF-A mRNA was noted in the squamous epithelium of papillomas of all 12 patients. Strong expression of VEGFR-1 and VEGFR-2 was noted in the endothelial cells of the underlying vessels in all 12 patients. Neither strong labeling of VEGF-A mRNA nor labeling of its receptors was noted in the control patients. We conclude that the angiogenic growth factor VEGF-A is strongly expressed in the epithelium of squamous papillomas in RRP. Also, VEGFR-1 and VEGFR-2 mRNAs are strongly expressed by underlying vascular endothelial cells, suggesting an important role in the pathogenesis of RRP.

Objective: Simulation is a tool that has been used successfully in many high performance fields to permit training in rare and hazardous events. Our goal was to develop and evaluate a program to teach airway crisis management to otolaryngology trainees using medical simulation. Methods: A full-day curriculum in the management of airway emergencies was developed. The program consists of three airway emergency scenarios, developed in collaboration between attending otolaryngologists and faculty from the Center for Medical Simulation. Following each scenario, the participants are led in a structured, video-assisted debriefing by a trained debriefer. Didactic material on team leadership and crisis management is built into the debriefings. Pediatric otolaryngology fellows, residents, and medical students have participated in the four courses that have been held to date. Participants evaluated the program on a five-point Likert scale. Results: A total of 17 trainees participated in four pilot training courses. The survey data are as follows: overall program, 5.0 (SD, 0.00); course goals, 4.79 (SD, 0.43); realism, 4.36 (SD, 0.63); value of lecture, 4.71 (SD, 0.47); and quality of debriefings, 4.92 (SD, 0.28). Sample comments include: “This is a valuable tool for students and residents since true emergencies in ORL are often life-threatening and infrequent,” and “This is a great course—really all physicians should experience it.” Overall evaluation was extremely positive and both residents and fellows described the course as filling an important void in their education. Conclusion: Medical simulation can be an extremely effective method for teaching airway crisis management and teamwork skills to otolaryngology trainees at all levels.

Objectives were 1) to review the presentation, natural history, and management of subglottic hemangioma; 2) to assess the affect of five variables (age, gender, degree of subglottic narrowing, location and extent of subglottic hemangioma, and lack or presence of other hemangioma) and the outcome of six different treatment modalities (conservative monitoring, corticosteroid, laser surgery, tracheotomy, laryngotracheoplasty, and interferon) in the management of subglottic hemangioma; and 3) to present specific guidelines to help determine the best possible treatment modality at the time of initial presentation.Retrospective review in the setting of three tertiary care pediatric medical centers.Methods included 1) extensive review of the literature; 2) a systematic review with respect to age, gender, presentation, associated medical problems, location and degree of subglottic narrowing, initial treatment, need for subsequent treatments, outcome, complications, and prognosis; and 3) statistical analysis to determine the effect of five variables (age, gender, degree of subglottic narrowing, location and extent of subglottic hemangioma, and lack or presence of other hemangioma) and the outcome of six different treatment modalities (conservative monitoring, corticosteroid, laser surgery, tracheotomy, laryngotracheoplasty, and interferon).In all, 116 patients with a mean age of 4.7 months were treated. The most common location of subglottic hemangioma was the left side. The range of subglottic narrowing was 10% to 99% (mean percentage, 65%). Twenty-six patients (22%) were managed with a single treatment modality, which included conservative monitoring (n = 13), corticosteroid (n = 11), and tracheotomy (n = 2). Ninety patients (78%) required multimodality treatments. Overall, the treatments included conservative monitoring (n = 13), corticosteroid (n = 100), tracheotomy (n = 32), CO2 laser (n = 66), interferon (n = 5), and laryngotracheoplasty (n = 25). Complication rates included the following: conservative monitoring (none), corticosteroid (18%), tracheotomy (none), CO2 laser (12%), interferon (20%), and laryngotracheoplasty (20%). The following variables showed statistical significance in the outcome of different treatment modality: 1) degree of subglottic narrowing (P.001), 2) location of subglottic hemangioma (P.01), and 3) presence of hemangioma in other areas (P.005). Gender (P.05) and age at the time of presentation (P.06) did not show any statistical significance on the outcome of the treatments.Each patient should be assessed comprehensively, and treatment should be individualized based on symptoms, clinical findings, and experience of the surgeon. The authors presented treatment guidelines in an attempt to rationalize the management of subglottic hemangioma and to help determine the best possible treatment modality at the time of initial presentation.

Almost all modern medical care is delivered in the setting of many overlapping systems. Each system may consist of multiple providers and in most cases electronic and mechanical components. Even “simple” outpatient care is delivered by teams of providers, administrators, and devices. Critically ill inpatients are cared for in extraordinarily complex systems with hundreds of human and non-human elements. The science of complex systems has exploded in recent decades, and there is a large body of knowledge about how such systems function effectively or ineffectively. Many principles of systems science are simple to understand and apply, but few Otolaryngologists are well educated about them. A basic knowledge of systems science will greatly improve the Otolaryngologist’s ability to function in complex health care systems and to provide the best care for his or her patients. Laryngoscope, 114:1810–1814, 2004

Objective To further evaluate the role of chromosomal translocation (15;19) in the presentation of the carcinoma (CA) of the upper aerodigestive tract. Study design and setting A retrospective study at a tertiary care pediatric medical center. Results Seven patients with a mean age of 12 years presented with CA of nasopharynx (N = 2), sinonasal region (N = I), parotid gland (N = 2), or larynx (N = 2). Treatments included combinations of surgery (N = 5), chemotherapy (N = 5), and radiation therapy (N = 4). One patient with sinonasal CA and one patient with laryngeal CA had chromosomal translocation (15;19); these patients both died of their disease with a mean survival of 6 months. The 5 patients without translocation (15;19) responded well to treatment and are disease-free with a mean follow-up of 47 months. Conclusion The preliminary results appear to indicate poor prognosis associated with the presentation of chromosomal translocation (15;19) despite aggressive multi-modality treatment. Further investigation is needed to better understand the cause and relationship of the translocation (15;19) and aggressive behavior of these tumors.

Objective: To review the biology of nasal glioma and encephalocele and to present an algorithm for preoperative evaluation and surgical management. Design: Retrospective review and analysis. Setting: Tertiary care medical center: 1970 to 2002. Patient: Sixteen patients with glioma (n = 10) and encephalocele (n = 6). Outcome: Age at the time of presentation, sex, signs and symptoms, imaging findings, surgical approach, pathology, complications, rate of recurrence, and follow-up were recorded. Results: Ten patients presented with nasal glioma with a mean age of 9 months. All patients underwent surgical excision. No complication was encountered with a mean follow-up of 3.5 years. Six patients presented with encephaloceles with a mean age of 15.5 months. All patients underwent surgical excision. Complications included cerebrospinal fluid leak (n = 1) and epiphora (n = 1). Follow-up was 1 to 14 years (mean, 4 years). Conclusion: Nasal glioma and encephalocele are rare, benign, congenital lesions with a potential for intracranial extension. Evaluation should include a complete rhinologic and neurologic examination. Preoperative imaging with a thin-cut axial and coronal computed tomography scan andlor multiplanar magnetic resonance imaging is essential. Surgical intervention should be performed soon after diagnosis to alleviate the increased risk of meningitis. A frontal craniotomy approach is recommended if intracranial extension is identified based on preoperative evaluation, followed by an extracranial resection. If there is no evidence of intracranial extension, a conservative extracranial approach is recommended.

A normal voice is a necessity for effectiveness at work, as well as for psychosocial health. Vocal difficulties are generally obvious during normal conversation, and all physicians should be prepared to initiate proper evaluation and treatment for patients with laryngeal dysfunction or disease. This review of laryngology and phonosurgery considers current advances in the detection and management of conditions that affect the voice.

Lymphatic malformations (LMs) are uncommon congenital lesions that may occur throughout the body, although the head and neck region is the most common site. Most LMs are seen at birth. However, they may present in adolescence or adulthood, mainly as a result of trauma or infection. We report the case of a 7-year-old boy who presented with an LM of the cervicofacial region causing airway compression. We discuss the causes of delayed presentation of these congenital lesions. An overview of the causation, natural history, diagnosis, and treatment options is presented.

A retrospective chart review of children who had airway foreign body removed via direct laryngoscopy and bronchoscopy (DLB) from 1987-1997 was conducted in Children's Hospital, Boston. Patient characteristics noted included age, sex, and clinical presentation. Pre-operative radiographic findings, reason for delay in evaluation, DLB findings, length of procedure, reason for repeat DLB, and types of foreign body etc. were recorded. Serious complications from aspirated foreign bodies such as severe airway obstruction and death tend to occur in infants and younger children because of their small airway size. A history compatible with foreign body aspiration dictates diagnostic endoscopy with or without radiologic confirmation. Chest and airway radiographs supplemented by fluoroscopy can increase the ratio of correct and early diagnosis. Fluoroscopy should be universally accepted as an initial diagnostic technique in airway foreign body evaluation. Fluoroscopy is not a worthwhile investigation if a preceeding chest radiograph suggests the presence of a foreign body. Long-standing airway foreign bodies are associated with considerable morbidity, and early diagnosis remains the key to successful and uncomplicated management of foreign body aspiration. Education aimed at increasing diagnostic acumen of the physicians and heightening of public awareness are the most important steps needed to reduce the morbidity and mortality. Parents should be instructed to abstain from feeding nuts and seeds to young children and to keep small, potentially ingestible objects out of their reach.

Allow me to take you on a journey through what in my opinion will form the legacy of the 21st-century surgeon. Many years from now the young surgeons of today will look back on their careers and examine their legacy. That legacy will be shaped during a career that will have embraced three distinct areas: competence, safety and quality.

Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The authors report on seven patients who required total esophageal replacement from the pharynx to the stomach. Injury occurred from alkali in six and acid in one. Age at injury ranged from 14 months to 14 years (mean, 4.5 years.) in five boys and two girls. Time from injury to esophageal replacement was 6 months to 10 years (mean, 3.5 years). Two required pharyngeal reconstruction before and one after esophageal replacement. Six patients had an isoperistaltic right or transverse colon interposition. One who had gastric necrosis had an ileo-right colonic substernal interposition with creation of a jejunal reservoir. Results of barium swallows showed intact anastomoses in all patients. There were no leaks. Most had some degree of mild to moderate aspiration, and one who had left vocal cord paralysis had initially massive aspiration. Three patients currently eat regular diets; four eat but still require supplemental tube feeds. The authors conclude that children who have hypopharyngeal scarring and obliterated esophageal inlet can undergo a successful colonic esophageal replacement with high proximal pharyngocolic anastomosis.

The multi-cytokine inducer OK-432 is a pulverized preparation of the low-virulence SU strain of Streptococcus pyogenes of human origin. A reduction of the tumour mass in the OK-432-injected areas was observed in 11 out of 13 patients with metastatic and/or recurrent head and neck cancer. Complete response (CR), partial response (PR) and minor response (MR) were noted in six, three and two cases respectively. OK-432 local administration therapy could create a new strategy for cancer therapy.

Creating a culture of respect is the essential first step in a health care organization's journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organization's leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment.When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station.Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

Objective: To ascertain changes in laryngeal anatomy and function associated with poor voice outcome after laryngotracheal reconstruction (LTR) and to specifically describe dysphonia in pediatric patients treated for subglottic stenosis. Design: A survey was undertaken of patients having undergone LTR for subglottic stenosis. Twelve patients were recruited during the year 1990-1991. Nine patients were able to complete the endoscopic portion of the protocol that included fiberoptic and direct laryngoscopy. Speech samples were qualitatively evaluable in only six of nine patients (vocal quality, loudness, and intelligibility) and objectively in five of nine patients (fundamental frequency and pitch perturbation). Patients: All patients in this consecutive sample had undergone LTR for congenital or acquired subglottic stenosis. The average age was 6 years. Each patient had previously undergone an average of two prior open laryngeal procedures and five endoscopic procedures. Outcome Measures: Correlation between anatomic and functional changes in the post-LTR larynx and voice outcome. Results: Endoscopic evaluation of the post-LTR larynx showed a 78% incidence of altered anatomy and 44% incidence of altered function. Speech sample analysis showed the following: 100% decreased vocal quality, 50% decreased intelligibility, 100% decreased volume, and 80% low fundamental frequency and increased jitter. Conclusions: Children with high-grade subglottic stenosis and multiple prior surgeries are at high risk for poor voice outcome after LTR. Future prospective studies will allow substantiation of this observation and clarification of which changes in laryngeal structure and function arise from surgery per se. (Arch Otolaryngol Head Neck Surg. 1994;120:641-647)

The management of nasal deformities in children often presents the clinician with a challenging dilemma. In the younger child, emphasis should be placed on correction of the nasal airway whereas, in older children, external cosmetic deformity can be considered with safety. Appropriate surgical techniques will ensure an appropriate outcome. Careful planning, as well as sensitivity to growth and development of the nasal structures should be considered when such a procedure is to be undertaken. Older children and adolescents present no unique difficulties in septorhinoplasty and the usual principles commonly applied to adults may be followed. A safe and effective technique can be designed for each child and adolescent afflicted with both internal and external nasal deformities.

Hemangioma is a well-recognized cause of airway obstruction in the infant with stridor. Corticosteroid and laser therapy are effective in stabilizing the airway in most cases. There are, however, some extensive airway lesions that are not adequately managed by these modalities. This report describes the use of recombinant interferon alfa-2a in 15 patients with life-threatening airway hemangiomas. All patients had failed corticosteroid and/or laser therapy. Multiple upper airway sites were involved, including the base of the tongue, supraglottis, subglottis, trachea, and mediastinum. Eleven patients have completed therapy and are doing well. Four patients have resolving lesions on the drug regimen. Life-threatening airway lesions unresponsive to conventional treatment should be considered for a trial of interferon alfa-2a.

Dr John J. Conley was an integral part of the house of surgery in the latter part of the 20th century. Conley placed the ethical values of practice at the forefront of his teachings and transcribed many valuable lessons in his writings. In 1993, he wrote his version of the Hippocratic Oath outlining 12 important principles. Those principles are revisited here as a way to celebrate the joy of the calling that is medical practice. In addition, 7 new elements are added as a way to enhance that joy in the light of 21st-century medicine. The uplifting experience found in a career filled with ethical conduct is the legacy we should all strive to achieve.

Our present training models date back almost 100 years. It is very apparent that trying to reshape an ageing system to meet the demands of today's patients and their physicians is just not going to be effective or efficient. In the past educators cared little about the working conditions for trainees such as the living and learning environment, social support and compensation models. You were just fortunate to be "chosen". Surgical educators in the 21st Century must reexamine their roles and consider what message they are sending to future generations on these and other critical issues that impact on safe patient care.

Objective To identify and quantify errors and adverse events on an inpatient academic tertiary-care pediatric otolaryngology service, a trigger tool was developed and validated as part of a quality improvement initiative. Study Design Retrospective record review. Setting Children's Hospital Boston quality improvement initiative. Subjects and Methods Fifty inpatient admissions were reviewed. The gold standard for errors and adverse events identification was a detailed chart review by two board-certified otolaryngologists blinded to trigger tool findings. Results Trigger tool interrater reliability ranged from poor to high for admission triggers (kappa = 0.35, 95% confidence interval [95% CI] −0.07 to 0.76), discharge triggers (kappa = 0.63, 95% CI 0.27-0.99), medical records triggers (kappa = 0.61, 95% CI 0.11-1.00), and medication triggers (kappa = 0.90, 95% CI 0.71-1.00). Errors and adverse events were found in all admissions: three percent were potentially harmful, and 93 percent were documentation-related. Conclusion The trigger tool was successful in identifying clerical and administrative errors and adverse events but failed to identify complex errors and adverse events. A hybrid approach for chart review may be cost-effective in pediatric otolaryngology.

Cerebrospinal fluid leaks can be difficult management problems. Little information has been published about handling these cases in the pediatric population. A review of cases over the past 10 years at Boston Children's Hospital was undertaken to identify any prognostic factors and therapeutic recommendations. Twenty-seven patients were identified. While most patients responded to conservative therapy, those with leaks that persisted longer than 8 days required some type of operative closure. Severity of injury had little correlation with the occurrence of a leak. The findings in this study indicate that most pediatric cases can be managed on a conservative basis.

Rhabdomyosarcoma (RMS), the most common malignant soft-tissue tumor in the pediatric population, occurs most often in the head and neck region. Major advancements in the management of these aggressive tumors have been achieved in the last 20 years on three fronts: chemotherapy, radiation therapy, and surgery. Surgery, with the advent of skull-base, craniofacial, and free-tissue-transfer reconstructive techniques, has once again become part of the primary management of these tumors. Prior to 1960, RMS was uniformly fatal; now, with the introduction of multimodality treatment regimens, two thirds of patients can expect long-term survival.

Studies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services.We retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a "zero-defect" paradigm, recording any error or adverse event-from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency.A total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant.Multiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a "zero-defect" standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity.

The consultants agree that an open biopsy is generally necessary to establish the histology of a pediatric head and neck neoplasm. Although a frozen section may be useful to ascertain whether tumor tissue has been sampled, definitive therapy should be based only on the histopathologic interpretation of the permanent specimen. The consultants also agree that certain studies should be obtained prior to a biopsy. Dr. Grundfast recommends a chest x-ray, liver function tests, complete blood count, and an magnetic resonance scan. Dr. Healy would obtain additional CT cuts and an MRI scan. Dr. Richardson prefers coronal cuts on the CT scan and an MRI. The skull base is regarded as the area that might pose the greatest difficulty in obtaining a surgical margin. In addition, Dr. Healy states that eustachian tube involvement would compromise the resection. Although all consultants agree that the facial nerve should be sacrificed, they disagree as to how to reconstruct this defect. Dr. Grundfast would restore the mandibular profile with a prosthesis and reconstruct the soft tissue defect with a myocutaneous flap. Dr. Healy would use an iliac bone graft for the skull base defect and would replace soft tissue with a rectus free flap or a myocutaneous flap. Dr. Richardson favors a latissimus dorsi free flap. Because the survival rates for poorly differentiated fibrosarcomas of the head and neck are so low, the experts recommend adjunctive chemotherapy. Drs. Grundfast and Richardson would also advise radiotherapy. Dr. Healy feels that the morbidity of radiotherapy is too high and would use it only in cases of positive margins, parameningeal involvement, or perineural invasion.

Objective:To provide an up to date review of the literature on aneurysmal bone cysts, including their diagnosis, pathology, pathophysiology, radiology and management.Method:Retrospective review of six cases over a 15-year period.Results:Six patients (age range, eight months to 17 years; mean, 9.6 years) presented with an aneurysmal bone cyst in the mandible (n = 3), maxilla (n = 2) or occipital soft tissue (n = 1). Each patient underwent primary excision, with one subsequent recurrence.Conclusion:Aneurysmal bone cysts are benign but locally destructive entities which may occasionally present to otolaryngologists, since they can involve the head and neck region, in particular the mandible.

Objectives/Hypothesis: To study the presentation, management, and long-time outcome of children presenting with lingual thymid. Study design: Institutional review board approved, retrospective study (1993-2004) Methods: The study was conducted at a tertiary care pediatric medical center. The main outcomes measured were initial presentation, radiographic finding, endocrine evaluation, surgical outcome, pathologic features, complications, need for hormonal replacement. Resuts: Four patients presented to the Department of Otolaryngology and Communications Enhance. ment. Children's Hospital Boston with liognal thyroid between 1993 and 2004. All patients were female, with an age range of 2 to 12 years (x=6). All patients presented with a mass (1.4-3.5 cm) and most with respiratory or feeding difficulty. Magnetic resonance imaging was obtained in three patients and revealed a mass unsistant with lingual thydoir. Thyroid seen confirmed the lingual thyroid as the only fonctioning thyroid in all four patients. None of the patients responded to hormonal replacemement, and all underwent surgical excision of the mass, Surgical approach included midline glossotomy (n = 2) and CO 2 laser excision (n = 3). Pathologie evaluation confirmed lingual thyroid in all four patients. No evidence of machignancy was sen in any patient. All four patients require lifelong hormonal replacement. Conclusions: Lingual thyroid is a race condition. with an incidence of 1.100.000. This infrequent congenital anormally is often asymptomatic until a pathologic stress such as systemic disease or physiologie stress such as puberty causes enlargement of the ecloptic tissue, leading to dysphagia, dysphonia, and dyspnea. The work-up should include routine blood wr*ork including thyroid function tests thyrotropin, thyroxine, and thyroid hormone binding ratio; iodine thyroid scintigraphy; and computerized tomography of magnetic resonance imaging. The majority of patients require surgical excision of the symptomatic mass and, in case of absence of arthotopic thyroid atic mass and, in case of absence of arthotopic thyroid tissue, long-term thyroid hormone replacement.

Objectives: Vascular endothelial growth factor A (VEGF-A) is important in the angiogenic response for wound healing. This study investigated whether VEGF-A may play a role in the pathogenesis of acquired airway stenosis. Methods: Eight lesions from 5 pediatric patients with subglottic stenosis after airway reconstruction (N = 4) or prolonged intubation (N = 1) and normal laryngeal tissue from 5 autopsy patients were included. Formalin-fixed sections of subglottic tissue from each patient were examined by in situ hybridization for the presence of messenger RNA (mRNA) for VEGF-A, vascular endothelial growth factor receptor 1 (VEGFR-1), and vascular endothelial growth factor receptor 2 (VEGFR-2). Results: Strong expression of VEGF-A mRNA was noted in hyperplastic squamous epithelium overlying granulation tissue. Strong expression of VEGFR-1 and VEGFR-2 was noted in the endothelial cells within granulation tissue. No strong labeling of VEGF-A mRNA or its receptors was noted in 2 specimens with mature scar tissue or in the control specimens. Conclusions: The angiogenic growth factor VEGF-A is strongly expressed in hyperplastic epithelium overlying granulation tissue in airway stenosis. Also, VEGFR-1 and VEGFR-2 mRNAs are strongly expressed in the endothelial cells of granulation tissue. This finding suggests an important role of VEGF-A in the pathogenesis of airway scar formation and stenosis.