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Penetrating transorbital injury with skull base involvement is a rare occurrence from a crayon. We report a case of a 2-year-old male who sustained a penetrating crayon injury through the right orbit and lamina papyracea into the posterior ethmoid sinus complicated by cerebrospinal fluid leak. There have been no other reported cases of this type of injury by a crayon.

Objectives: Recent technological advances have led to the capability of performing high resolution imaging of the tympanic membrane. Smartphone technologies and applications have provided the opportunity to capture digital images and easily share them. The smartphone otoscope device was developed as a simple system that can convert a smartphone into a digital otoscope. This device has the prospective ability to improve physician-patient communication and assist with the diagnosis and management of ear disease. Our objective was to evaluate the feasibility and physician/parental satisfaction using the Cellscope® smartphone attachment for at home tympanostomy tube monitoring. Methods: Children between 6 months and 15 years of age at an urban tertiary children’s hospital that were scheduled for bilateral tympanostomy tube insertion or underwent bilateral tympanostomy tube surgery were prospectively enrolled in the study. Comparisons were made between parental home-recorded videos and findings during in-office otoscopy. Two independent otolaryngologists reviewed the videos and concordance between inter-rater agreements was calculated. Acceptability and use questionnaires were administered to physicians and parents. Results: There was good intra-rater agreement between traditional otoscopy and video-otoscopy for tube extruding, tube blocked and tube extruded with at least 80% agreement ( P Conclusions: The CellScope® smartphone is feasible for use in tympanostomy tube surveillance. Use of the device may allow otolaryngologists to easily follow a child’s tympanostomy tube remotely over time and offer greater parental satisfaction.

BACKGROUND Coronavirus disease 2019 (COVID-19) is an ongoing viral pandemic that has affected modern medical practice and can complicate known pathology. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes symptoms that may mimic a viral pneumonia, with potential for serious sequelae, including acute respiratory distress syndrome, coagulopathy, multiorgan dysfunction, systemic vascular abnormalities, and secondary infection. OBSERVATIONS The authors describe a case of a 15-year-old boy who presented with a right subdural empyema and sinusitis while having active COVID-19 infection. The patient initially presented with left-sided weakness, frontal sinusitis, and subdural empyema. Emergent surgery was performed for evacuation of empyema and sinus debridement. Samples of purulent material within the subdural space were tested for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. The patient had a successful recovery and regained the use of his right side after combined treatment. To our knowledge, this is the first reported case of a bacterial subdural empyema associated with frontal sinusitis in a coinfected patient with COVID-19 without evidence of COVID-19 intracranial infection. LESSONS A subdural empyema, which is a surgical emergency, was likely a superinfection caused by COVID-19. This, along with the coagulopathy caused by the virus, introduced unique challenges to the treatment of a known pathology.

The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion.Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15.Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P .001, effect size = 3.1.This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing.2B Laryngoscope, 130:2256-2262, 2020.

Objective At our institution, cleft lip repair is performed at or before 8 weeks of age, and tympanostomy tubes (TT) have been inserted concurrently in some of these patients. Our objective was to determine the feasibility and present the preliminary results of TT placement at this early age. Methods A retrospective review was conducted of 22 patients born with cleft lip and/or palate who had TT placement in the first 8 weeks of life. Data collected included complications and audiologic function post TT placement. Results Subjects had a mean age of 3.9 weeks at the time of TT placement and cleft lip repair. Thirteen patients (59%) reported otorrhea during the follow-up period. Eighteen of 21 (86%) patients who underwent auditory evaluation had normal audiological function following TT placement. One patient had sensorineural hearing loss and 2 patients had mild conductive hearing loss due to bilateral extruded TT and OME at 15.9 and 39.2 months after surgery. Conclusion Exceptionally early TT is feasible. Placing TT at or before 8 weeks of age did not result in any major complications but demonstrated a high incidence of otorrhea. A randomized, prospective study with a larger sample size is necessary to determine the benefits of TT placement at this age.

OBJECTIVES Persistent or recurrent disease following excision of a thyroglossal duct cyst/sinus (TGDC) is often found in the suprahyoid region. Cadaver dissections were performed to identify and name important surgical landmarks in the suprahyoid area; a histopathologic analysis of surgical specimens was completed to determine the incidence and extent of microscopic disease; and clinical outcomes were compared to determine the efficacy of a specific anatomic dissection. STUDY DESIGN Retrospective case series. METHODS Standardized dissections of four adult cadavers were performed. Consecutive surgical specimens were examined for evidence of microscopic TDGC disease in the suprahyoid region, measuring the greatest width and length of disease. A retrospective review of all consecutive TGDC procedures was completed. RESULTS The important surgical landmarks in the suprahyoid area were identified in all cadavers. Microscopic disease in the suprahyoid area was found in 79% (37 of 47) of surgical specimens. The mean greatest length and width of microscopic disease was 12.4 mm and 1.4 mm, respectively. Following identification of these landmarks, the incidence of recurrent or persistent disease decreased (P = .02) from 5% (8 of 159) to 0% (0 of 112). CONCLUSION The majority of pediatric patients with a TGDC will have microscopic disease in the suprahyoid area. The surgical landmark of the fascial plane between the geniohyoid and genioglossus muscles demarcates the anterior and lateral borders of resection in the suprahyoid area. This approach can be used as a reliable and easily reproducible technique in TGDC surgery to increase confidence of achieving complete removal of disease in the suprahyoid area, avoiding persistent or recurrent disease and a revision procedure. LEVEL OF EVIDENCE 4 Laryngoscope, 131:553-558, 2021.

Approximately 130,000 adenoidectomies are performed each year in the United States. Few studies have examined adenoid regrowth and the incidence of revision surgery or have compared four different surgical instruments commonly used for adenoid surgery within the same institution. This study aimed to determine the incidence of revision adenoidectomy after the use of microdebrider, Coblation, suction cautery, and curette instruments over a 10-year period at a single major tertiary children's center in the United States. A retrospective chart review was performed for all patients who underwent primary and/or revision adenoidectomy at the Children's Hospital Los Angeles (CHLA) between August 2004 and August 2014. During the 10-year study period, a microdebrider was used in 212 cases, Coblation in 382, suction cautery in 1,926, and curette in 3,139 adenoidectomies. The percentages of revision adenoidectomy were 1.42% (3 patients) for microdebrider, 0.79% (3 patients) for Coblation, 0.36% (7 patients) for suction cautery, and 0.03% (1 patient) for curette. The cumulative incidence of revision adenoidectomy for initial surgeries performed at CHLA was 0.2% for the 10-year study period. Pearson chi-square analysis showed statistically significant differences between the surgical techniques (p < 0.0001). In conclusion, regrowth of adenoid tissue requiring revision surgery occurs very infrequently irrespective of the instrument used for the primary procedure, and the most common indication for revision adenoidectomy is to improve eustachian tube dysfunction rather than nasal obstruction due to adenoid hypertrophy.

Rosai-Dorfman disease is a rare histiocytic proliferative disorder of unknown etiology typically characterized by cervical lymphadenopathy. Extranodal involvement often manifests in the head and neck region. We present a 10-year-old male who presented to our hospital with left epiphora from an aggressive paranasal mass invading the left orbit with osseous destruction. The mass was surgically biopsied and debulked with histopathological examination revealing Rosai-Dorfman disease. Although rarely found in the sinuses, Rosai-Dorfman disease should be considered when evaluating sinonasal masses.

Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting.Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice.A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale.The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Sleep disordered breathing (SDB) is a spectrum of diseases ranging from primary snoring (PS) to obstructive sleep apnea (OSA). Although PS does not characteristically demonstrate gas exchange abnormalities on polysomnography and is usually considered a more benign condition, it still may be associated with significant neurocognitive and behavioral issues, such as hyperactivity, inattentive behavior, aggression and poor school performance.

Introduction A Sistrunk procedure is the standard operative management of patients with thyroglossal duct cysts. Drain placement is commonly employed with the goal of reducing postoperative complications. This study investigates the association between drain use and relevant postoperative complications following pediatric Sistrunk procedures. Methods Retrospective cohort study evaluating 295 pediatric patients treated between 2007 and 2016 at two tertiary care children’s hospitals. Results The mean age of the study population was 5.6 years (SD 4.0). A drain was utilized in 234 cases (79.3%). The mean procedural duration was 108 minutes (SD 48), and significantly longer in patients receiving a drain. Early postoperative complications included seroma (5.8%), secondary infection (3.4%), wound breakdown (2.0%) and hematoma (0.3%). The risk of such complications did not significantly differ between patients without drain placement (9.8%) versus those who underwent surgical drain placement (12.0%) after accounting for age and history of preoperative infection (adjusted RR = 0.86; 95% CI: 0.37, 1.98; p=0.72). In the subgroup analysis, findings were consistent across institutions, age category, history of infection, and primary versus secondary procedure. Conclusion This dual institutional study found drain placement during a Sistrunk procedure may not reduce rates of common postoperative complications, even in longer duration cases in which a drain is more frequently placed. This data suggests a Sistrunk procedure may be safely performed without drain placement in select cases.

Despite epistaxis occurring in up to 60% of the population, few studies have investigated health status disparities in the pediatric epistaxis population. The aim of this study was to evaluate sociodemographic risk factors associated with epistaxis visits for pediatric patients.Data were extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department from 2001 to 2010. Outpatient visits of children less than 18 years who received a primary, secondary, or tertiary diagnosis of epistaxis (ICD-9CM code 784.7X) were included. Bivariate and stepwise multivariate regressions were conducted to develop a final model for epistaxis visits described by sociodemographics.Epistaxis visits accounted for 5 ± 0.6 million visits in children less than 18 years. 51% and 33% of children presenting with epistaxis had private insurance and Medicaid, respectively (p = 0.001). 69% of epistaxis visits were evaluated at a pediatric clinic, 18% at an ENT/surgery clinic, and 13% at a general/family medicine clinic (p 0.0001). After multivariate adjustment, epistaxis visits were associated with older age (p = 0.006). Black children were more likely to present with epistaxis (95% CI 1.3-4.1, p = 0.005) compared to white children. Allergic rhinitis, present in 11% of epistaxis visits, was a significant comorbidity associated with visits (95%CI 1.3-4.6, p = 0.008). Patients were also more likely to present to an ENT/surgery clinic (95% CI 4.5-16.5, p 0.0001) compared to a general/family medicine clinic.Epistaxis visits by children are associated with age, race, and specialty. Targeted interventions to help reduce this common presentation should be developed.

Objective To determine the prevalence of an intact hyoid bone at the time of revision thyroglossal duct cyst (TGDC) surgery in a pediatric population. Methods The operative reports of 44 patients under 18 years of age who underwent a revision TGDC surgery from March 1997 to October 2015 at Children's Hospital Los Angeles were reviewed to determine finding of an intact hyoid bone at the time of the revision procedure. Results At the time of the revision surgery, 75% of the patients had an intact hyoid bone and 25% did not. Conclusion Patients who experience a recurrence of a TGDC are more likely than not to have an intact hyoid bone at revision surgery. These data indicate that some surgeons are not following the recommendation from Schlange and Sistrunk that removal of the mid-portion of the hyoid bone should be a routine part of any primary procedure for excision of a known or suspected TGDC in order to decrease the risk of recurrence. Despite the prevalent knowledge that the central portion of the hyoid bone be removed during a TGDC procedure, special attention should be given to the area of the midportion of the hyoid bone as a likely site of persistent disease in revision cases even if a previous operative report documents resection of a portion of the hyoid bone and/or cartilage.

Objective Despite the success of the Sistrunk procedure, persistence of a thyroglossal duct cyst (TGDC), sinus, or remnant following excision remains a clinical problem. This is most likely due to the presence of microscopic disease that was not excised at the time of surgery. The purpose of this study is to determine the incidence of microscopic disease superior to the hyoid bone in children who have had either a primary or revision procedure for a TGDC. Methods A prospective review of pathologic specimens was conducted of all consecutive patients undergoing TGDC excision by pediatric otolaryngologists at the Children's Hospital Los Angeles beginning March 2014 through July 2017 in both primary and revision procedures. Results Microscopic disease was present superior to the hyoid bone in 25 of the 34 (74%) specimens and in 100% (6) of the specimens from a revision procedure. Conclusion The majority of persons who have a TGDC will have microscopic disease superior to the hyoid bone. In order to minimize the incidence of persistence following a primary procedure, tissue superior to the hyoid bone should be removed routinely even if no gross disease is noted at the time of surgery. When performing a revision procedure, special attention should be given to the suprahyoid area as a likely site of persistent disease. Level of evidence 2b Laryngoscope, 129:1215-1217, 2019.

PURPOSE Otorrhea frequently follows tympanostomy tube (TT) placement. We evaluated otorrhea following single 6mg OTO-201 (OTIPRIO®, ciprofloxacin otic suspension 6%) intraoperative injection into each middle ear in a variety of effusion types and concurrent procedures in children undergoing TT placement. SECONDARY OBJECTIVE Efficacy based on Medicaid status and safety. BASIC PROCEDURES In this prospective, 8-week, multicenter, open-label study, 501 patients were enrolled: mean age 2.9years, male (56.9%), wet/wet ears (66.9%), wet/dry (16.8%), dry/dry (16.3%), and Medicaid-insured (32.9%). MAIN FINDINGS In per-protocol population (n=410), otorrhea rate through Day 15 were 8.8% (CI:5.7%-12.8%), 6.6% (CI:2.2%-14.7%), 3.3% (CI:0.4%-11.3%) in wet/wet, wet/dry, and dry/dry ears, respectively. For Medicaid patients through Day 15, Week 4 and Week 8, otorrhea rates were 8.1% (CI:4.1%-14.1%), 17.0% (CI:11.1%-24.5%), and 17.8% (CI:11.7%-25.3%) compared with those non-Medicaid insured: 7.3% (CI:4.5%-11.0%), 14.5% (CI:10.6%-19.3%), and 21.8% (CI:17.1%-27.2%), respectively. Safety was similar to previous Phase 3 trials. PRINCIPAL CONCLUSIONS OTO-201 demonstrated otorrhea rates consistent with Phase 3 trials in a broader, real-world, ENT practice-based pediatric population. Outcomes were similar in Medicaid- and non-Medicaid insured patients. OTO-201 was well-tolerated.

Foregut cysts are uncommon, mucosa-lined congenital lesions that may occur anywhere along the gastrointestinal or respiratory tract and typically present within the first year of life. Although infrequent, these cysts may generate feeding or respiratory difficulties depending on the size and location of the lesion. Foregut cysts of the oral cavity are rarely seen and of those cases localized to the tongue are even more uncommon. We describe a 4-month-old girl with a foregut cyst involving the floor of mouth and anterior tongue. Subsequent histologic analysis demonstrated a cyst lined with both gastric and respiratory epithelia. This case represents an extremely rare finding of both gastric and respiratory epithelia lined within a single cystic structure in the tongue. Although a very rare finding, a foregut cyst should be on the differential diagnosis of any lesion involving the floor of mouth or tongue in an infant or child.

Background First described in 1920 and later modified in 1928, the Sistrunk procedure substantially reduced the incidence of recurrence of midline neck cysts compared with a local excision or cystectomy. The purpose of this study was to determine if the rate of recurrence was influenced by performing either a ‘classic’ or a ‘modified’ Sistrunk procedure, if the recurrence rate was influenced by the physician's training, how successful we have been in managing patients with a recurrence? Finally, is outpatient surgery safe for Sistrunk procedures? Methods We performed a retrospective review of all patients with a thyroglossal duct remnant (TGDR) who were seen at the Children's Hospital Los Angeles (CHLA) from 1990 to 2010. The following data were collected: patient age, gender, presence or absence of a pre-operative infection, imaging studies, type of procedure performed, the attending surgeon's training background, inpatient or outpatient status, and complications. Results A total of 128 patients (61% male, 39% female) met the inclusion criteria. The age ranged from 2 months to 14 years (mean of 5.1 years). A total of 137 procedures were performed; 114 (83.2%) for primary and 23 (16.8%) for secondary disease. Complications included post-operative infection (10.9%), recurrence of disease (6.6%), undesirable scar (5.8%), and fistula (2.9%). Surgeons with fellowship-training in pediatric otolaryngology had a recurrence rate of 4.0% and surgeons with fellowship-training in pediatric surgery or pediatric plastic surgery had a recurrence rate of 30.1%. Twenty patients had a ‘classic’ Sistrunk (14.6%) and 117 (85%) had a ‘modified’ procedure. Patients were admitted after surgery in 78 cases (56.9%) and 59 patients (43.1%) had an outpatient (OPD) procedure. Conclusions There is no place for cystectomy in the treatment of TGDR. A ‘modified’ Sistrunk procedure is the procedure of choice in both primary and revision cases. Wide local excision of recurrences is required and a ‘classic’ Sistrunk should be considered. Specific training to gain an intimate knowledge of the anatomy in and around the larynx and experience with multiple cases reduces the incidence of recurrence. Outpatient surgery is safe and effective for selected patients who undergo a Sistrunk procedure.

Otorrhea after tympanostomy tube placement (TTP) in children is common. Although not approved by the US Food and Drug Administration, antibiotic ear drops are routinely used intraoperatively and prescribed for multidose, multiday postoperative administration by caregivers.To investigate the safety and efficacy of a single-dose intratympanic, intraoperative, thermosensitive, otic suspension of ciprofloxacin (OTO-201) in children requiring TTP.Two identically designed, prospective, double-blind, sham-controlled, multicenter phase 3 randomized clinical trials included 532 patients aged 6 months to 17 years with middle ear effusions. Patients with confirmed bilateral effusions on the day of TTP were randomized to TTP alone or to TTP with OTO-201 injection. Children underwent a 28-day observation period. Data were collected from November 14, 2013, to June 3, 2014. Final follow-up was completed on June 16, 2014, and intent-to-treat data were analyzed from June 10 to August 27, 2014.Efficacy was assessed as treatment failure, including the presence of otorrhea, use of otic or systemic antibiotics, loss to follow-up, or missed visits. Safety was assessed for serious adverse events and treatment-emergent adverse events using audiometry, otoscopy, and tympanometry.Among the 532 patients included in the trials, 175 were randomized to TTP only and 357 to OTO-201 treatment (304 boys [57.1%]; 228 girls [42.9%]; mean [SD] age, 2.4 [2.1]). At day 15, the cumulative proportion of treatment failures (primary end point) was 24.6% (44 of 179 patients) in trial 1 and 21.3% (38 of 178 patients) in trial 2 in the OTO-201 groups vs 44.8% (39 of 87 patients) in trial 1 and 45.5% (40 of 88 patients) in trial 2 in the TTP-alone groups. At day 15 otorrhea-only treatment failures in trial 1 included 21 of 179 (11.7%) in the OTO-201 group vs 22 of 87 (25.3%) in the TTP-only group; in trial 2, 17 of 178 (9.6%) in the OTO-201 group vs 29 of 88 (33.0%) in the TTP-only group. The odds of otorrhea-only failure were significantly reduced in the OTO-201 groups compared with the TTP-only groups in both trials (age-adjusted odds ratios, 0.38 [95% CI, 0.19-0.75] and 0.19 [95% CI, 0.09-0.38]; P .001 for both trials, post hoc analysis). No drug-related serious adverse events were seen, and most adverse events were mild or moderate. No evidence of increased tube occlusion and no negative effect on results of audiometry, tympanometry, or otoscopy were noted with OTO-201 administration.Two large phase 3 randomized clinical trials demonstrate the safety and efficacy of a single intraoperative administration of OTO-201 for middle ear effusion at the time of TTP.clinicaltrials.gov Identifiers: NCT01949142 and NCT01949155.

Objective. More than 25 million children in the United States are dependent on federal and state medical insurance programs for their health care needs. In California, 3.25 million children depend on Medi-Cal for their health insurance. In Southern California alone, the figure is as high as 1.81 million. However, 9.30 million children nationally and 1.55 million in California have no health insurance. Various public policies that would increase enrollment in these programs are being discussed to address this problem. However, before their implementation, it is important to understand what impact such policies would have on the actual delivery of health care to this patient population. In California, 2 predominant health care delivery models exist for Medi-Cal: a fee-for-service (so-called regular or straight Medi-Cal) and a managed care plan. One third of the children in Medi-Cal in the state are enrolled in the fee-for-service plan with the remainder in the managed care plan, whereas in Southern California, this figure is slightly lower at 28% in the fee-for-service plan. The objective of this study was to determine the number of otolaryngologists in Southern California who would offer a new patient appointment for an evaluation for tonsillectomy for a child with commercial insurance versus government-funded (Medi-Cal) insurance through direct contact with the physician and to determine whether the surgeon would offer to perform the procedure or refer the patient to another institution and to identify the specific reason(s) for any disparity in access to health care. Methods. A written questionnaire was sent via regular mail to 303 otolaryngologists in the Southern California area in 2003. Results. A total of 100 fully completed questionnaires were received. Ninety-seven surgeons would offer an office appointment to a child with commercial insurance as compared with only 27 for a child with Medi-Cal. Of those 27 surgeons, 8 would then refer the child to another physician to perform the surgery, and only 19 would actually offer to perform surgery, if indicated. Reasons provided for not offering an office appointment or surgery for the child with Medi-Cal include excessive paperwork and/or administrative burdens (96%), low monetary reimbursement for the surgery (92%), and low monetary reimbursement for the office visit (87%). Conclusions. There is a tremendous inequality of access to surgical specialty health care for children with government-funded insurance when compared with those with commercial insurance in Southern California. Physicians indicate that this disparity is related to excessive administrative burdens and low monetary reimbursement. The implications of our findings on public health care policies are discussed.

Objectives To identify the person or persons responsible for the conception and description of the operation that we know of today as tonsillectomy and to determine whether this was accomplished by an American otolaryngologist(s) before the description by George Waugh of London in 1909. Study design A review of the English language medical literature from 1879 to 1910. Methods Three hundred seventy-five articles relating to tonsil surgery or instrumentation for tonsil surgery were identified. It was possible to obtain and review only 67 articles. In addition, 20 textbooks relating to the tonsils and tonsil surgery (published between 1880 and 1966) were identified and reviewed. Results An attempt to remove the entire tonsil intact was described by Edwin Pynchon in 1890 with the use of galvanocautery. He recommended that only one tonsil be removed at one time with approximately 2 weeks between operations. In 1903, Charles Robertson advocated the removal of both tonsils at one operation using scissors but did not mention the capsule. J. Gordon Wilson published a description of the tonsillar capsule in 1906 but did not comment on tonsil surgery or the importance of any particular structure as a surgical landmark. In that same year, William Lincoln Ballenger of Chicago, Illinois, clearly recommended the complete removal of the tonsil with its capsule intact but commented that he usually used an ecraseur-tonsillotome to finally remove the tonsil. Also in 1906, Ovidus Arthur Griffin of Ann Arbor, Michigan, described the use of a knife and a specially designed pair of scissors to remove the tonsils in their entirety in one operation without the use of a guillotine or an automatic instrument. Conclusion The operation that we know of today as tonsillectomy, the removal of the entire tonsil with the capsule intact, and the term tonsillectomy itself were conceived, described, and published by American otolaryngologists before the description by George Waugh of London in 1909.

Concurrent Thyroglossal Duct Cyst and Dermoid Cyst in a Pediatric Patient Among the most frequently encountered congenital midline cervical masses in the pediatric population are thyroglossal duct cysts and dermoid cysts. While both of these entities should be considered in the differential diagnosis of an anterior midline neck mass, the two may occur simultaneously in rare instances. We present the case of a 4 year-old girl who presented with what appeared to be a single, anterior neck mass that extended into the floor of mouth on pre-operative imaging. During surgical excision, two completely separate cystic masses were identified; one in the floor of the mouth and another immediately superior to the hyoid bone. We present this case to increase awareness to the rare circumstance of a dual diagnosis in the evaluation of a pediatric neck mass and to illustrate the importance of preparing the patient and the parents for a Sistrunk procedure pre-operatively. We recommend that surgeons prepare for a Sistrunk operation when considering an excision of any mass in the midline, near midline, or floor of mouth in a pediatric patient.

To determine if recombinant human bone morphogenetic protein-2 (rhBMP-2) can be adsorbed onto porous ceramic hydroxyapatite (HA) and promote the integration of HA to host bone, 54 subperiosteal pockets were created on the skulls of 19 adult Pasteurella-free white rabbits. Fourteen HA implants were saturated with saline and placed in subperiosteal pockets (control), 22 HA implants were saturated with saline and placed into subperiosteal pockets after burring 1-2 mm of calvarium to expose bleeding cancellous bone, and 18 HA implants were saturated with rhBMP-2 and placed into subperiosteal pockets. The animals were sacrificed at 1 month with examination to determine implant mobility. Histology was used to determine the amount of bone growth into the implant. Of the 14 control sites, 10 implants were found to be freely mobile, five demonstrated host bone resorption, and only one exhibited bone growth into the implant. Of the 22 burred sites, eight were freely mobile and 10 demonstrated bone growth into the implant (p = 0.04). Of the 18 rhBMP-2 sites, only two were freely mobile, none demonstrated host bone resorption, and 16 exhibited bone growth into the implant (p = 0.00002). This study supports the use of porous ceramic HA as a biocompatible, osteoconductive implant material for use in craniomaxillofacial augmentation and reconstruction. It also provides evidence that rhBMP-2 enhances osseointegration, thereby fixing the implant in position against the host-bone interface. In the clinical setting, osseous fixation of the implant should aid in preventing displacement, minimizing host bone resorption, and decreasing the incidence of extrusion.

There is always concern for a malignancy or other serious disease when a child presents with a chief complaint of a neck mass. However, a neck mass in child is commonly inflammatory or congenital rather than neoplastic. A complete history and physical exam will often provide enough information to guide management and reassure the concerned parents. In some cases, laboratory tests, radiologic studies or a surgical procedure may be necessary to determine a specific diagnosis and treatment plan. An organized and systematic approach is recommended and detailed in this review.

We describe the rare case of a nine year-old girl with a several month history of mouth breathing and nasal obstruction due to a rudimentary tragus in the nasopharynx. We focus on the accessory tragus and its origins by describing the embryologic development of the external ear. Based on our review of the medical literature, this is the first report of a nasopharyngeal mass with a pathologic diagnosis of a rudimentary tragus.

Ear, nose, and throat problems comprise a significant portion of patient visits to the primary care physicians' offices, urgent care facilities, emergency rooms, and children's hospitals. Since its beginnings in the 1970s, the specialty of pediatric otolaryngology has developed significantly and even more so in the last five to ten years. The aim of this special issue is to offer our pediatrician colleagues an opportunity to learn about recent advances in both diagnostic methods and therapeutic procedures that are now available to assist in the care of children with ear, nose, and throat disorders. This special issue is comprised of both original clinical research and review articles from all areas of pediatric otolaryngology such as otologic disease and hearing loss, sinonasal disorders, airway issues, and head and neck masses. These papers emphasize how methods of diagnosis have improved for certain conditions, how existing surgical procedures have been modified to be less invasive and better tolerated, and finally, how new technology and operations allow clinicians to treat otolaryngologic disorders that were without treatment in the past. The paper “Troublesome tinnitus in children: epidemiology, audiological profile, and preliminary Results of Treatment” by G. Bartnik et al. offers a very readable and practical approach to a common otologic problem in children while most pediatric textbooks often have no information on this subject. This group offers their experience with a treatment called “Tinnitus Retraining Therapy.” A. Koravand, B. Jutras, and M. Lassonde present their original research using the diagnostic tools of cortical auditory evoked potentials and mismatch responses (MMRs) to identify patterns of neural activity in the central auditory system of children with hearing loss. The care of patients with nose and sinus complaints can be frustrating to the primary care physician. H. Ramadan's paper “Chronic rhinosinusitis in children” provides a simple, straightforward approach to the pediatric patient with these symptoms including the use of “real-life” examples to illustrate the important aspects of the history and physical exam that are necessary in the care of these patients. After reading this article, any health care practitioner will feel more confident about their decision-making in patients with sinus disease. Although juvenile angiofibroma is a rare clinical problem, P. Nicolai, A. Schreiber, and A. B. Villaret describe new, less invasive approaches to treatment of this sinonasal mass. This is in addition to a succinct review of the pathophysiology and recommended work-up including the relative advantages and disadvantages of various radiographic imaging techniques. The airway section of this special issue will be of great value to the primary care practitioner. Included are three papers on stridor in the infant, one dedicated entirely to laryngomalacia, and lastly, a paper on a new diagnostic tool called “sleep endoscopy.” M. Daniel and A. Cheng discuss the approach to an infant with noisy breathing or stridor; separating the material into three sections that allow for easy recall and use by the pediatrician. Novel approaches such as the EXIT procedure to treat disorders of the fetal airway are presented. A. M. Landry and D. M. Thompson's review article on laryngomalacia will be equally relevant. The reader will find it to be complete yet easily digestible. Finally, any health care practitioner will be familiar with the frustration of seeing patients for persistent difficulty breathing at night after adenotonsillectomy for upper airway obstruction or obstructive sleep apnea. Although polysomnography can determine the presence and severity of any degree of obstruction, it cannot identify the location of obstruction. The paper by A. C. Lin and P. J. Koltai describe a new diagnostic tool called “sleep endoscopy” that will allow otolaryngologists the opportunity to identify such areas of obstruction and perhaps offer treatment options which were not obvious in the past. The approach to a patient with a vascular malformation can be confusing. G. T. Richter's review article on this clinical entity will be very helpful to the primary care practitioner. Nomenclature, relevant parts of the history and physical exam, diagnostic tools including radiographic imaging studies, and medical and surgical therapies are discussed. D. Dzepina's paper on papillary thyroid carcinoma in children describes their approach and results with total thyroidectomy including neck dissection for lymphatic dissemination which is common in this type of thyroid cancer. The editors of this special issue have worked hard with the authors to provide primary care practitioners with information that is relevant to their practice and, at the same time, very easy to read and understand. We hope the papers in this special issue will be of great help to primary care practitioners as they see pediatric patients with ear, nose, and throat problems. Jeffrey A. Koempel Tomislav Baudoin Alan T. L. Cheng Debra M. Don Ajoy M. Varghese

Objective The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC. Method An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time. Results All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent. Conclusion Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction.

Objectives/Hypothesis: To determine the extent of thermal injury to the tonsillar tissue following the use of various types of instrumentation. To determine if tonsillectomy specimens routinely contain tissue other than lymphoid tissue. Study Design: Retrospective histologic analysis. Methods: A histologic analysis performed on 228 tonsillectomy specimens removed by use of an electrocautery in 132 specimens, harmonic scalpel in 46, coblation device in 24, and a tonsillotome in 26. The specimens were evaluated for presence and percentage of skeletal muscle and depth of thermal tissue injury. Results: The mean percentage of skeletal muscle present in the specimens was 0.79% for electrocautery, 1.74% for harmonic scalpel, 0.97% for coblation device, and 1.66% for the tonsillotome. Skeletal muscle was absent in only 8 of 228 specimens (3.5%). Electrocautery has a statistically significant (P < .05) lower percentage of muscle tissue compared to harmonic scalpel and the tonsillotome. There was no statistically significant difference in the mean depth of thermal injury among the harmonic scalpel (0.68 mm), electrocautery (0.58 mm), and coblation device (0.71 mm) specimens. The tonsillotome specimens had no thermal injury. Conclusions: Attempts to remove the entire tonsil results in a similar depth of thermal injury to tonsillectomy specimens when using the harmonic scalpel, electrocautery, and coblation device. Skeletal muscle is a nearly ubiquitous finding in routine tonsillectomy specimens. The use of an electrocautery with a needle point may allow for a more precise dissection as it results in tonsillectomy specimens with a smaller percentage of muscle present. Laryngoscope, 2009

In the early twentieth century, John Winslow wrote that there was no more difficulty in laryngology than treating chronic stenosis of the larynx and trachea. Winslow described cases as "excessively rebellious to treatment" and treatment requiring "patience, persistence, self-sacrifice and skill on the part of the surgeon" and "discomfort or even suffering by the patient." Three decades later, Chevalier Jackson wrote that curing patients required perseverance over a period of time rarely as short as 3 months and as long as 7 years. Significant strides in surgical technique have been made; this article chronicles the development of laryngotracheal reconstruction in children.

Some have suggested that younger children have a more severe form of obstructive sleep apnea than older children and therefore are at a higher risk for respiratory compromise after tonsillectomy and adenoidectomy. However, at present there are few studies that have identified any significant correlation between age and severity of obstructive sleep apnea.To determine if age specific differences in obstructive sleep apnea are present in children.Retrospective chart review.Tertiary care children's hospital.The records of children (1-18 years of age) with obstructive sleep apnea diagnosed by overnight polysomnography between January 1998 and January 2001 were reviewed. Children included in the study also had evidence of adenotonsillar hypertrophy and had no other co-existing medical problems.Overnight polysomnography was performed in all children. Apnea-hypopnea index (AHI), baseline and lowest O(2) saturation, baseline and peak end tidal CO(2), and total number of obstructive apneas, hypopneas, central apneas and mixed apneas were measured during each polysomnogram. Children were subdivided into the following age groups: 1-2, 3-5, 6-11 and 12-18 years. Polysomnograms were classified into normal, mild, moderate and severe categories.Three hundred and sixty-three children were studied; 45 children were ages 1-2 years, 159 children were ages 3-5 years, 137 children were 6-11 years and 22 children were 12-18 years. Although there appears to be a trend towards a greater mean number of obstructive apneas, hypopneas, central apneas, mixed apneas, a higher mean AHI, lower mean SaO(2) nadir, and a higher mean PETCO(2) in the younger age groups when compared to the older groups, a Student's t-test demonstrates that there is no statistical significance for most OSA parameters. An analysis of variance using the F-test reveals statistical significance (p0.01) when children ages 1-2 were compared to those 3-5, 6-11 or 12-18 years of age for the variables AHI, mean number of central apneas, hypopneas and mixed apneas. When comparing patients in the various severity categories, children ages 1-2 years show a distinct distribution with a larger percentage in the moderate to severe categories. Chi square analysis reveals a significant difference between the frequency distribution of children in age group 1-2 years and that of the other age groups (p0.01).There is a predilection for children less than 3 years of age to have more severe obstructive sleep apnea as documented by polysomnography. Central apnea also appears to be more common in this age group. These findings may be explained by anatomic and physiologic differences related to age and support a period of observation following adenotonsillectomy in younger children.

Within the last 10 to 15 years, a significant amount of research in tonsil surgery has focused on reduction of post-operative pain and recovery time. In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as ‘tonsillotomy’, specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy. More recently, surgeons have used terms such as partial tonsillectomy, partial intracapsular tonsillectomy or subtotal tonsillectomy to describe their procedure and have employed a variety of modern instrumentation. This return to a ‘partial’ procedure has generated a debate similar to that which occurred amongst tonsil surgeons about 100 years ago, when tonsillotomy was the most commonly performed procedure. Today, concerns about regrowth and problems with infection of the remaining tonsillar tissue have been raised. Such concerns, combined with an incomplete understanding of why the ‘partial’ procedure was abandoned in the early twentieth century, may explain why tonsil surgeons hesitate to change their approach to patients with OSDB due to adenotonsillar hypertrophy. These issues can be addressed in a meaningful way only through a detailed review of the evolution of tonsil surgery, which is presented here. This information, along with a summary of the last 10 years' experience with these techniques, supports the use of a ‘partial’ procedure in children with OSDB due to adenotonsillar hypertrophy. Future areas of research are also discussed.

To determine if temperature-controlled radiofrequency (TCRF) tonsil reduction and adenoidectomy (TCRFA) and conventional tonsillectomy and adenoidectomy (TA) are statistically similar in outcome and to compare morbidity between TCRFA and conventional TA.Randomized control trial.Tertiary care children's hospital.The study population comprised 23 patients aged 2.6 to 12.5 years with symptoms of obstructive sleep apnea, hypertrophic tonsils with no other areas of upper airway obstruction with the exception of hypertrophic adenoids, and a body mass index (calculated as weight in kilograms divided by the square of height in meters) of less than 30.Temperature-controlled radiofrequency tonsil reduction (mean +/- SD, 12.6 +/- 1.5 ablations per patient and 994.68 +/- 91.88 J per insertion) and adenoidectomy or traditional bovie TA.Primary outcomes were respiratory distress index and total volume reduction. Secondary outcomes include postoperative pain, daytime sleepiness, speech and swallowing problems, weight and diet, narcotic use, and analogue snoring scale.The respiratory distress index difference for TCRFA was 5.63 vs 6.56 for standard TA. On postoperative day 1 for the 13 patients who underwent TCRFA, 0 reported severe pain, 11 (85%) had mild to moderate pain, and 2 (15%) had no pain. In the 10 patients who underwent standard TA, 1 (10%) had severe pain and 9 (90%) had mild to moderate pain. By postoperative week 1, all TCRFA patients experienced mild or no pain, whereas 1 (10%) of the standard TA patients still had moderate pain. Mean visual analogue snore scores (0-10) 4 weeks after surgery were less than 1 for both groups. The mean +/- SD weight loss at postoperative week 1 for TCRF tonsil reduction patients was 1.0 +/- 3.5 lb (0.45 +/- 1.58 kg) vs 4.6 +/- 3.9 lb (2.07 +/- 1.76 kg) for standard TA patients. Return to normal diet at postoperative week 1 occurred in 11 TCRFA patients (85%) and 0 standard TA patients.The respiratory distress indexes were similar for TCRFA patients and standard TA patients. In addition, there were similar analog snoring scales, decreased pain, and weight loss.

The purpose of this study was to evaluate the effectiveness of regular otologic care on the long-term outcome in patients with cleft palates. We report the otoscopic and audiologic findings of 50 patients who were followed regularly at our center for an average of 15.4 years. All these patients had their cleft palates repaired by the same surgical team and all ears were examined by one of the authors under the microscope and a chart review completed. Thirty eight patients had at least one tube placement. The physical abnormalities noted were tympanosclerosis (36%), retraction of tympanic membrane (TM) (20%), atrophy of TM (15%), perforation (11%), PE tube in situ (11%), thick TM (6%) and PE tube in middle ear (1%). The examination was normal in 36%. A conductive loss was noted in 18% and sensorineural loss in 3%. The results of this study support the concept of regular otologic care for cleft palate patients even when they are overtly asymptomatic.

Foreign bodies of the upper aerodigestive tract in the pediatric population are a common occurrence. However, despite significant advances in prevention, first aid and endoscopic technology, they remain a diagnostic and therapeutic challenge. Early diagnosis is the key to successful and uncomplicated management of these accidents. An orderly and systematic approach to these patients including a careful history, physical exam and radiographic studies is detailed in this review.

In order to evaluate a new method for the direct application of a polypeptide growth factor to injured tracheal epithelium and to determine the effect of topical platelet-derived growth factor (PDGF) on tracheal wound healing, a controlled animal study was designed using six adult beagle dogs. Four 2×1 cm mucosal defects were created in the tracheal lumen of each dog for a total of 24 experimental sites. Twelve wounds were treated with PDGF in a collagen–fibrin composite tissue adhesive (CTA) carrier. Eight sites received CTA alone and four were left untreated. Healing was assessed by endoscopic exam on post-operative days 4, 7, 10, 14, 17 and 21. The animals were sacrificed on day 21 and the tracheas were harvested for histological examination of the experimental sites and adjacent unwounded trachea. By 21 days, complete healing of all sites was observed endoscopically. Wounds treated with CTA or PDGF-CTA healed at a faster rate than control sites. The PDGF-CTA treated wounds demonstrated excessive granulation tissue formation. Histological examination demonstrated a higher percentage of wound coverage with ciliated epithelium most similar to normal trachea in the PDGF treated wounds. CTA is effective as a carrier for the direct delivery of a growth factor to injured tracheal epithelium. The application of CTA or PDGF-CTA results in a more rapid rate of tracheal wound healing as compared with control wounds. PDGF-CTA led to increased acute local inflammatory changes but was associated with a structurally more normal respiratory epithelium after healing. Physiological studies are necessary to determine the functional significance of these findings.

The congenital absence of the epiglottis is a very rare anomaly. We present a patient who has a complete absence of the epiglottis, illustrated with an endoscopic photograph, review the literature and discuss the management of patients with this condition.

To the Editor .— Two articles in the October 2001 issue of Pediatrics have raised some important concerns regarding resident education today. Ng and Lawless1 provide statistics that coincide with my anecdotal experience with both pediatric and otolaryngology residents from 2 major university medical centers. That is, these young physicians receive little or no instruction in billing and compliance issues. In his commentary, Young2 correctly points out that there is more at stake than simply lost revenue when evaluation and management (E/M) coding does not correspond with a physician’s documentation in the patient’s medical record. Under the current federal law, a physician is fully responsible for each bill submitted to any payor—be it an insurance company or a state or federal agency. Under the False Claims Act, any discrepancies, upcoding, or undercoding are subject to monetary penalties that could total >$10 000 per incident. Unfortunately, lack of knowledge of proper coding is not considered an adequate defense by the federal government. Young further states that …