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Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA overall health impact. Integrative medicine brings conventional and complementary approaches together in a coordinated way. With rising obesity rates, weight loss and lifestyle programs seem to be the most favorable integrative methods to combine with conventional OSA therapies. Complementary and integrative approaches to OSA management are varied and, in conjunction with conventional methods, may offer some reduction in the apnea-hypopnea index.

Introduction: Transoral robotic surgery (TORS) in children is in its infancy and indications have been primarily limited to lingual tonsillar hypertrophy and superficial mucosal lesions. However, the relatively avascular channel of the midline posterior tongue, vallecula, and posterior hyoid space provides a safe plane of dissection for deep lesions of the tongue and access to structures in the anterior neck. As robotic surgeons gain experience, application of this technology will continue to grow. Methods: Retrospective case series Results: We present seven patients who had either a primary (n = 3) or recurrent (n = 4) lingual thyroglossal duct cyst (TGDC) and underwent TORS excision. Four of the seven patients also underwent transoral resection of the central portion of the hyoid bone, while 3 had central hyoid resection during prior surgery. Two minor complications occurred with no evidence of lesion recurrence after mean follow up of 19.7 mo. Discussion: The midline avascular channel of the tongue allows for relatively bloodless surgical access to pathologies of the midline base of tongue and anterior neck. Lingual thyroglossal duct cysts can safely be removed via TORS approaches with evidence of limited recurrence. Conclusion: Robotic technology can provide safe and effective surgical alternatives for children with a variety of pathologies, and we aim to promote the widespread adoption of TORS in pediatric head and neck surgery by sharing our knowledge and clinical experience. Further study and publication are needed to establish safety and efficacy.

Introduction: Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cervicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial. Objectives: This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges. Methods: A modified three-iterative Delphi method was used to establish expert recommendations on the diagnostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. Setting: Multinational, multi-institutional, tertiary pediatric hospitals. Results: Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. Conclusion: The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation. Keywords: Atypical mycobacteria; Cervical lymphadenitis; Consensus recommendations; Non-tuberculous mycobacteria.

To identify variables that are associated with poor compliance to thyroid hormone replacement therapy in children after total thyroidectomy.A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 1/2014 and 9/2021. Postoperative poor compliance was characterized by at least three separate measurements of high TSH levels not associated with radioactive iodine treatment.There were 100 patients, ages 3-20 years old who met inclusion criteria; 44 patients underwent thyroidectomy for cancer diagnosis, and 56 for Graves' disease. The mean follow-up time was 36.5 months (range 3.0-95.6 months). Overall, 42 patients (42%) were found to have at least three measurements of high TSH during follow-up, and 29 patients (29%) were diagnosed with clinical hypothyroidism. Sex, race, income, insurance type, and benign versus malignant etiology for thyroidectomy were not associated with adherence to therapy. Multivariate regression analysis identified patients with Graves' disease and hyperthyroidism at the time of surgery and Hispanic ethnicity to be associated with postoperative clinical hypothyroidism (OR 9.38, 95% CI 2.16-49.2, p = 0.004 and OR 6.15, 95% CI 1.21-36.0, p = 0.033, respectively).Preoperative hyperthyroidism in patients with Graves' disease and Hispanic ethnicity were predictors of postoperative TSH abnormalities. Preoperative counseling for patients and their families on the implications of total thyroidectomy and the need for life-long medications postoperatively is necessary. Efforts should be made to evaluate and improve adherence to therapy pre-and postoperatively in patients with Graves' disease.4 Laryngoscope, 2022.

Introduction Obstructive sleep apnea (OSA) can be associated with abnormal metabolic variables that may impact the overall health of the child into adulthood. Prior studies have focused on understanding the relationship of obesity, OSA, and metabolic alterations. Understanding the relationship of OSA and metabolic alterations in normal-weight children would improve understanding of the health impact of OSA in and of itself. The Objective of this study was to evaluate the association of OSA and metabolic variables, including lipid levels, blood glucose, and HbA1c in normal-weight children with OSA. Methods Prospective, case-control study performed at a tertiary care children’s hospital. Normal-weight children, aged 2-12 years, undergoing overnight polysomnography (PSG) for assessment of sleep disordered breathing were selected for participation in the study. Laboratory testing for lipid levels, fasting glucose, HbA1c were completed and analyzed relative to the PSG findings. Results A total of 61 patients with a mean age of 4.7±2.5 years were analyzed. Thirty-four (55.7%) patients were male, and 27 (44.3%) were female. The mean body mass index (BMI) z score was 0.5±1.2, and all patients were non-obese (BMI z score Conclusion Increasing severity of OSA in non-obese children was associated with worsening levels of cholesterol, blood glucose, and HbA1c. This points to the importance of addressing the issue of OSA in children given the potential impact of these elevated levels on the overall health of the child. Support (If Any) None

Hashimoto's thyroiditis (HT) affects 1-2 % of the pediatric population. In adults with HT, thyroidectomy is considered challenging and prone to postoperative complications due to the chronic inflammatory process. However, the complications of thyroidectomy among children with HT have not been established. The objective of our study was to evaluate whether children with HT undergoing total thyroidectomy for presumed thyroid cancer have higher complication rates than children without HT.A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 2014 and 2021.111 patients met inclusion criteria, 15 of these were diagnosed with HT preoperatively. Operative time and length of admission were similar among the groups. Postoperatively, patients with HT were more likely to have low levels of parathyroid hormone (60 % vs 26 %, p = 0.014) and transient hypocalcemia compared to non-HT patients, present with symptomatic hypocalcemia (67 % vs 27 %, p = 0.006), demonstrate EKG changes (20 % vs 6.3 %, p = 0.035) within 24 h of surgery, and to require both oral and intravenous calcium supplements (80 % vs 35 %, p = 0.001 and 60 % vs 22 % p = 0.004 respectively). Persistent hypocalcemia at 6 months follow-up, and recurrent laryngeal nerve paralysis rates were similar between groups. Parathyroid tissue was found in the thyroid specimen of 9 (60 %) HT patients vs 34 (35 %) non-HT patients (p = 0.069).The risk of permanent complications among children with HT following thyroidectomy is low. However, patients with HT are more likely to develop symptomatic transient hypocalcemia and to require oral and intravenous calcium supplements in the immediate post-operative period compared to non-HT patients. Tailoring a perioperative treatment protocol to optimize calcium levels may be considered for children with HT.

Objective: Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps. Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present. Methods: A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected. Results: A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases. Conclusion: A combination approach to fourth branchial apparatus lesions—including endoscopic cauterization, external excision, and hemithyroidectomy—is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.

Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism.Retrospective multi-institutional cohort study.Tertiary care pediatric hospital systems throughout North America.Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models.In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism.These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

Graves' disease (GD) is the most common cause of childhood hyperthyroidism. Surgery is often chosen as a treatment modality given the high relapse rates and side effects of antithyroid drugs and has shown to be safe and efficacious. The goal of our study was to evaluate whether hyperthyroidism at time of thyroidectomy is associated with higher intra and postoperative complication rates.A retrospective cohort study of children who underwent thyroidectomy for GD by high-volume pediatric otolaryngologists between 2014 and 2021.64 patients met inclusion criteria. Patients with hyperthyroidism (defined as free T4≥1.63 ng/dL) were more likely to be treated with beta-blocker preoperatively compared to the euthyroid group (20/24 patients (83%) vs 23/40 patients (58%) respectively, p = 0.035). Twenty (83%) patients with hyperthyroidism and 39 euthyroid patients (98%) were treated with methimazole prior to surgery. Intraoperative tachycardia was noted in 5% of euthyroid patients and 20.8% of patients with hyperthyroidism. The mean peak heart rate intra-operatively and the number of patients with heart rate ≥120bmp were significantly higher for patients with hyperthyroidism (96.5 ± 16.2 vs 87.6 ± 22.1bpm, p = 0.02). Two patients required administration of esmolol during surgery for heart rate control, both with hyperthyroidism. Intra-operative peak systolic blood pressure, operative time, estimated blood loss, persistent hypocalcemia, length of admission and recurrent laryngeal nerve paralysis rates were similar among groups.Hyperthyroidism at surgery is associated with increased heart rate intraoperatively, with no increased risk for other complications. While optimizing thyroid hormone levels before surgery should be pursued in all children, our data suggest that hyperthyroidism should not delay the surgery.

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

Introduction:Sleep disturbance, especially obstructive sleep apnea (OSA) and inadequate sleep, adversely affect various health-related quality of life (HR-QoL) domains in adults. Few studies have a...

Objective To describe a case of a complex neck mass with final pathology significant for two synchronous lesions, a type 1 branchial cleft cyst and an enteric duplication cyst, and to discuss its management given the unique presentation.

Introduction To identify the effect of Obstructive Sleep Apnea (OSA) and sleep duration on problems with health-related quality of life (HR-QoL) in children. Methods Children ages 8–18 years visiting sleep laboratory from 07/2019 to 01/2020 for overnight PSG participated in the study. Controls seen during 01/2020-02/2020 for issues other than sleep disturbance were recruited from the primary care pediatric clinics. HR-QoL was assessed by PROMIS V1.0 questionnaires. Statistical analysis was conducted using R 3.6.0. Results 122 children were studied: 64 males (52.4%).Twenty-nine(29.2%) had mild OSA, 8 (8.1%) moderate OSA, 17 (17.1%) severe OSA,46 (46.4%) were diagnosed with No-OSA and 22 (18.0%) were controls. Patients visiting the sleep laboratory had lower physical function mobility compared to controls (p=0.004). With increasing severity of OSA, there was a step wise decrease in physical function mobility (p=0.01). Correlation analysis suggested that physical function mobility was positively associated with total sleep duration (p=0.02) and negatively associated with apnea hypopnea index (p=0.01). Symptoms of anxiety in children was positively associated with number of arousals (p=0.04). Age was positively associated with fatigue (p=0.02) and negatively associated with deep sleep (p Conclusion We found interrupted sleep associated with symptoms of anxiety. OSA and reduced sleep duration are associated with problems with physical function mobility after adjusting for age, gender and number of arousals. Support (if any) None

Introduction To identify the status of health-related quality of life (HR-QoL) domains in children with sleep disturbance. Methods Patients ages 5–17 years visiting sleep laboratory from 09/2019 to 01/2020 for overnight PSG participated in the study. Age and sex matched control participants were seen in general pediatrics during 02/2020 for issues other than sleep disturbance. HR-QoL was assessed by PROMIS V1.0 questionnaires. Statistical analysis was conducted using R 3.6.0. Results 122 patients were included in the final analysis: 70 males (57.4%). Ninety nine (81.15%) patients were included from the sleep laboratory and 23 (18.85%) controls were recruited from the department of pediatrics. Among the patients visiting sleep laboratory, thirty one (25.4%) had mild OSA, 12 (9.8%) moderate OSA, 19 (15.6%) severe OSA, 37 (30.3%) were diagnosed with No-OSA. Twenty three (18.9%) controls were visiting to the hospital for their routine wellness examination requiring no PSG. Severity of OSA was not correlated with any HR-QoL domain. Patients visiting the sleep laboratory had lower life satisfaction (p=0.05) and higher physical stress experience (p=0.005). Age, BMI were negatively and N3 sleep was positively associated with family relations (p Conclusion Children visiting sleep laboratory had higher physical stress experience and lower life satisfaction as compared to controls. Deep sleep was associated with problems with family relations, life satisfaction and anger. Regression analysis suggested that age was negatively associated with family relations and life satisfaction. Support (if any) None

Objective First branchial cleft anomalies (FBCAs) are rare and often misdiagnosed, which can delay proper management and increase surgical risks. Complete excision often requires parotidectomy with facial nerve dissection. The literature reports that younger patients more often have lesions deep to the nerve with higher rates of nerve injury. We hypothesized that the rate of nerve injury and complications in children with FBCAs was not different in those ≤2 years of age compared to those >2 years of age. Methods Retrospective review of pediatric patients who underwent resection of histopathologically confirmed FBCAs between 2007 and 2017 at a tertiary care, pediatric hospital. Presenting symptoms, lesion classification, prior procedures, imaging techniques, extent of surgery performed, facial nerve position, and complications were reviewed and compared between patients ≤2 years of age and >2 years of age at time of surgery. Results 43 cases of FBCAs were included in the study: 12 in the younger group and 31 in the older group. There was no difference between groups regarding the presenting symptoms, gender breakdown, lesion classification, prior procedures performed, or extent of surgery. Lesions were more commonly deep to or running between branches of the facial nerve in the younger group (33.3% vs 9.7%, p = .0496). Rates of postoperative complications and facial nerve weakness were comparable between the younger and older groups (8.3% vs 25.8%, p = .206; 25.0% vs 16.1%, p = .503). In combining the age groups, FBCAs located deep to the facial nerve had increased risk of nerve weakness postoperatively (RR 7.2) and those with a history of prior incision and drainage or resection had increased risk of postoperative complications (RR 2.36). Imaging was obtained on all subjects with accuracy rates of 80–100%. Conclusion Presenting characteristics of FBCAs in patients ≤2 years of age and >2 years of age are comparable, but lesions in younger subjects had a greater likelihood of being deep to or coursing between branches of the facial nerve. However, the rates of facial nerve injury and postoperative complications are comparable in younger and older children, owing likely to accurate preoperative imaging and appropriate surgical planning.

Introduction Midline Cervical Cleft (MCC) is a midline cervical congenital anomaly that manifests as a vertical cutaneous/subcutaneous defect with abnormal dermal elements as well as an underlying fibrous cord that extends from the sternum to the mentum of the mandible, which can lead to "wry neck" and hypoplastic mandible. The goal of surgical correction of MCC is to provide adequate healthy tissue coverage, as well as restore contour of the anterior neck. The primary treatment modality for midline cervical cleft is surgical. We describe a technique involving complete excision of the fibrous cord, and use of double z-plasty flap in order to create a tension-free closure and restore contour to the anterior neck. Methods Using a database search method, children with the clinical diagnosis of midline cervical cleft treated between 2006 and 2016 were identified at a pediatric tertiary care center. Chart review was completed to assess for age at surgery, follow up, results, and complications. Results 12 patients were identified in the Lurie Children's Hospital (LCH) database. 8 patients underwent complete cord excision by the seniorauthor using the double z-plasty (DZ) technique for closure, with no recurrences. 4 patients underwent linear closure by another surgeon, had persistent contracture, and underwent revision using the DZ technique by the senior author, with no recurrence. Average age of surgery was 9.5 months. Most common post op complication was hypertrophic scar (3/12). Recurrence was only seen in the linear closure cases (4/12). Conclusions Midline Cervical Cleft is a rare entity with less than 200 cases in the literature. We believe the double z-plasty closure and complete excision of the fibrous cord results in reproducible restoration of neck contour and prevents cord recurrence, and should be considered the standard method for surgical excision of MCC.

Introduction Successful pediatric revision thyroid surgery depends primarily on effective localization of recurrent or persistent lesions. Secondary to fibrosis and scarring, blind regional dissection can fail to retrieve the tissues of concern. Conventionally, high resolution CT or ultrasound of the neck has been used to map lesions within the thyroid bed. The success rate of excising recurrent lesions using these mapping techniques is at best 80%. We present a small series of patients in which hook wire localization was used to help localize and excise recurrent and/or persistent neck disease during secondary operations. Methods The wire-localization technique was utilized for a prospective case series of four pediatric patients with history of previous thyroidectomy and recurrent or persistent malignant thyroid disease. Results All four patients had recurrence or persistence of their disease process in the central or lateral neck. Patients successfully underwent preoperative hook wire localization of their persistent or recurrent neck lesions with successful subsequent neck dissection. Each case involved a single wire localization for a unique mass, equally a total of 4 lesions accessed by the technique over the four cases. The ultrasound-guided wire-localization technique assisted in the localization and excision of non-palpable lesions. No complications were seen in our small series as a result of this technique. Conclusion Hook wire localization may be a useful tool to help the surgeon more efficiently localize and excise recurrent or persistent disease in a scarred/previously operated field.

The embryology, presentation, imaging, and treatment of the thyroglossal duct cyst will be reviewed. Anatomic features and surgical technique to prevent complications and recurrence will be discussed. Included in the discussion will be the management of thyroglossal duct cyst malignancy and ectopic thyroid.

Introduction Limited information exists regarding short-term morbidity in the resection of lymphatic malformations. In order to make informed collaborative medical decisions, clinicians and families would benefit from information on 30-day outcomes and the expected course associated with surgical excision of lymphatic malformations. Methods A retrospective chart review was conducted to develop a case series of patients who underwent resection of lymphatic malformation at a pediatric tertiary care center between June 1, 2007 and September 30, 2016. Demographic data, disease characteristics, operative details, post-operative care, and adverse events in the 30-day post-operative period were analyzed. Primary outcomes included facial nerve dysfunction, seroma formation, re-admission, and overall rate of any complications. Secondary outcomes included operative time, duration of stay, and duration of drain placement. Results Forty-nine excisions were performed in 46 patients (21 male, 25 female). Median age was 5 years. All but 7 cases were performed as the initial primary intervention. Median operative time was 96 min (range 22–224). Higher stage lesions (3-5) were associated with a longer operative time (p = .03). Median length of stay was 2 days (range 0–35). Higher stage lesions were associated with an increased length of stay (p = .0004). Median duration of drain placement was 2 days (range 0–14), and was longer in higher stage lesions (p = .0002). Higher stage lesions (p = .002) and cases ultimately found to have residual disease (p = .019) were associated with an increased overall rate of complications; there was no association between cyst type and rate of complications. Seroma formation (31%) and transient facial nerve weakness (26%) were the two most common complications observed. There was no association between stage or cyst type and likelihood of seroma formation. Seromas resolved after a median duration of 3 months and transient facial nerve weakness resolved after a median duration of 2 months. 3 patients required return to the OR and 1 patient was readmitted. Conclusion The overall rate of adverse events after surgical excision of cervical lymphatic malformations is relatively low. Increased rates of complications can be expected with higher stage. Similarly, for these higher stage lesions, a longer operative time, hospital stay, and duration of drain placement can be expected.

Swallowing disorders are associated with many disease processes and are associated with significant morbidity and mortality. This article provides information regarding the various causes of swallowing disorders as well as medical, surgical, and integrative approaches to their management.

Early posttransplant lymphoproliferative disorders (EPTLDs) represent the first changes in posttransplant lymphoproliferative disorders (PTLDs) morphologic spectrum. EPTLD data are available mostly from case reports and series that include other types of PTLD. Fifteen EPTLDs were reviewed retrospectively. Clinical data, histopathology, clonality, and Epstein- Barr virus (EBV) status were correlated with staining intensity to an antibody for phosphorylated S6 (pS6) ribosomal protein, a downstream effector of mammalian target of rapamycin (mTOR). Median time from transplantation to EPTLD was 50 months (range, 7-135 mo). EPTLDs involved tonsil and/or adenoids (n = 11) and lymph nodes (n = 4), all of which were nonclonal and EBV-encoded RNA–positive. Most (n = 11) were plasmacytic hyperplasia and florid follicular hyperplasia (n = 4). All regressed with reduced immunosuppression, and had increased pS6 staining compared with normal tonsil ( P = .002, F test). EPTLDs developed later than previously reported, involved mostly tonsils/adenoids, were EBV-encoded RNA (EBER) positive, showed increased pS6, and had excellent clinical outcome with reduction of immunosuppression.

Importance Limited information exists about the short-term morbidity of parotidectomy in children. This information is important when counseling parents and planning treatment for children with parotid masses. Objective To examine 30-day perioperative outcomes after parotidectomy in the pediatric population. Design, Setting, and Participants A prospective case series of 87 pediatric patients who underwent parotidectomy from January 1, 2008, to June 30, 2015, performed by 2 pediatric head and neck specialists in a tertiary care pediatric hospital. Main Outcomes and Measures Thirty-day perioperative complications, postoperative facial nerve function, reoperation rates, and readmission rates were the main outcome measures. Secondary outcome measures were operative time and length of stay. Results Ninety parotidectomies (71 superficial and 19 total) were performed in 87 patients (48 male and 39 female). Mean age at operation was 8.3 years. Eighty-five of the cases (94%) were performed for benign disease. Mean operative time was 4.09 hours (range, 1.58-10.43 hours) and mean length of stay was 2.24 days (range, 0.97-4.33 days). Immediate postoperative facial weakness was observed in 32 cases (36%); 10 of these cases (31%) involved the upper branch and 29 (90%) involved the lower branch. Immediate postoperative paresis occurred more often after total parotidectomy vs superficial parotidectomy (11 of 19 [58%] vs 21 of 71 [30%];P = .03) but was unrelated to the etiologic cause of the patients’ parotid disease. Thirty of 32 cases (94%) of facial nerve weakness were transient, and the mean time to resolution was 61 days. Eleven complications (12%) other than facial nerve weakness occurred during the 30-day postoperative period. Three patients (3%) required a return to the operating room for hematoma or wound dehiscence. One patient (1%) required readmission in the 30-day postoperative period for contralateral parotitis. Conclusions and Relevance We observed a low rate of 30-day perioperative complications as a result of superficial or total parotidectomy for pediatric parotid disease. Major adverse events included return to the operating room and 1 wound infection. Only 1 patient required readmission. Transient weakness of the facial nerve is relatively common, observed more often in the lower division, and can be expected to resolve in most patients by an average of 2 months.

Importance Closed reduction of a nasal fracture is a common and well established procedure in the pediatric literature. The Laryngeal mask airway is being used more frequently in recent years because it has been proven safe for select procedures. The goal of this article is to present a complication of using laryngeal mask airway for closed reduction nasal fractures and to examine the safety to prevent similar episodes. Observations We present a case of postoperative respiratory compromise secondary to pulmonary aspiration after a closed reduction nasal fracture in a child. The literature is reviewed, clinical characteristics, anesthesia techniques and surgical treatment are discussed. Conclusions and relevance To the best of our knowledge there is no such report in the literature. With this article and in conjunction with the above literature review, we suggest that the triad of nasal surgery, LMA and ‘deep’ extubation can lead to postoperative aspiration and respiratory compromise and should be avoided. Level of evidence Level 5, expert opinion or case report.

Objectives/Hypothesis: The anatomy of the anterior neck in the area of the hyoid, thyrohyoid membrane, and epiglottis is herein redescribed and compared to its classical depiction. The concept of the posterior hyoid space (PHS) is defined and substantiated through review of archived tissue and cadaver larynx dissection as well as by observation at many surgical dissections. The true anatomy of these relationships provides an insight into the effectiveness of the Sistrunk procedure. The author believes that recurrence of thyroglossal duct cysts (TGDC) occurs as a consequence of incomplete resection of: 1) microscopic suprahyoid ductules and/or 2) infra- and perihyoid tissue. Study Design: The senior author has been using the concept of the posterior hyoid space as applied to the Sistrunk procedure for more than 20 years. A retrospective study was done on cases from April 2003 to August 2008, and outcome was reviewed and compared to historical controls to determine the impact of applying this anatomic concept. Methods: A retrospective chart review was undertaken on 60 surgical cases performed for a 5-year period with clinical follow-up extended to an additional 7 months. Data collected included age at surgery, presenting symptoms, imaging characteristics, thyroid status, pathology results, and postoperative complications. All 60 were under the age of 18 who underwent a modified Sistrunk procedure and had a postoperative diagnosis of TGDC. Each patient had a minimum follow-up period of 4 months to check for recurrences. No revision was included in this study. Results: Sixty patients met criteria for the study. There was one recurrence (1.67%); a complication rate of 6.67%. Complications were minor and wound related. Mean follow-up was 17 months. Conclusions: The technique of applying the concept of a PHS to ensure the complete resection of the middle third of the hyoid bone and offending tissues is believed to decrease recurrence of TGDC secondary to incomplete resection in the perihyoid area. Laryngoscope, 2010

Objectives: We undertook to identify data that facilitate determination of an accurate diagnosis of the cause of stridor in infants and to develop a framework to conceptualize the problem. Methods: We reviewed medical records of patients less than 1 year of age with the presenting symptom of stridor who were initially evaluated in the outpatient setting of a tertiary children's hospital. Infants with obvious congenital syndromes, cerebral palsy, or hypotonia were excluded. All infants underwent history-taking, physical examination, and when symptoms were mild, office flexible laryngoscopy. With moderate or severe stridor, a more complete endoscopic evaluation was undertaken in the operating room. Results: Of 202 patients, 119 (59%) were boys and 83 (41%) were girls. Their ages ranged from 3 days to 11 months; 175 (87%) were 6 months of age or younger. Congenital anomalies were diagnosed as the cause of stridor in 170 (84%). Congenital laryngeal anomalies caused stridor in 157 (78%); congenital tracheal abnormalities were the cause in 13 (6%). The most common congenital laryngeal anomaly was laryngomalacia (94%). Forty-two (21%) of the 202 patients had at least 1 other anomaly that contributed to airway compromise. Half of all patients had laryngopharyngeal reflux, the most common associated condition. Of patients referred with a presumptive diagnosis by non-otolaryngologists, 28 of 94 (30%) were referred with erroneous presumptive diagnoses for which they were being treated, the most common of which was tracheomalacia. Conclusions: A standard, rational approach to the evaluation of stridor in infants facilitates management. A framework for evaluation is presented.

Introduction: Closed reduction nasal fracture is a common and well established procedure in the otolaryngology literature. The Laryngeal mask airway (LMA) is being used more frequently for otolaryngologic procedures in recent years because it has been proven safe for select procedures especially in the pediatric population. The frequency of closed reduction nasal fracture repair and the increased propensity to use LMA anesthesia for otolaryngologic cases warrants investigation. Objective: We sought to investigate the benefits, risks and safety of using LMA anesthesia for pediatric patients during closed reduction nasal fracture compared to case controlled equivalents that underwent ETT intubation. Methods: We performed a retrospective case-control study in which all cases of closed reduction nasal fracture at a single pediatric institution by a single surgeon were studied. This included patients from 2007 to 2013 at Ann & Robert H Lurie Children’s Hospital of Chicago. The primary outcomes assessed were postoperative VAS and FACES pain scores, blood loss, cough, stridor and aspiration. Secondary outcomes assessed included timing data to determine if one technique led to greater optimization of operating room (OR) time and/or total hospital stay. The timing data included overall OR duration, prep to cut time, cut to close time, non-operative OR time and the total hospital stay in minutes. Results: Fifty patients met the inclusion criteria. Of the 50 patients included an endotracheal tube was used in 16 patients and a LMA was used for 34 patients. Two of the LMA group 2/34 (6%) had aspiration documented compared to zero of the ETT group. The average total length of hospital stay was 268.5 m when both groups were included. The average total hospital stay was 252.6 minutes for the LMA group and 312.4 for ETT group. The average postoperative VAS pain score, as documented 0-10 by the RN, was 0.47 for the LMA group as opposed to 0.56 for the ETT group. A total of 24 patients had cough noted, 15/34 (44%) of the LMA group and 9/16 (56%) of the ETT group. Ten patients had stridor noted, 5/34 (15%) of the LMA group and 5/16 (31%) of ETT group. Conclusion: These results support the hypothesis that using an LMA versus an ETT for short procedures does save time when assessing overall hospital stay. Additional benefits of the LMA are reduced cough, pain, stridor and ease of placement. The data also supports our second hypothesis that using an LMA for close reduction nasal fracture can lead to more frequent post operative airway obstruction when compared to the ETT. Our data and review suggest that it is the combination of deep extubation (lack of airway protection) and the use of an LMA (allows for blood accumulation) that result in the increase risks of airway obstruction postoperatively. For operations in the pediatric population with a significant risk of bleeding into the pharynx we recommend using an ETT due to the risks of aspiration. If an LMA is used we recommend to only removing the LMA after the patient has been deemed in the state of anesthesia which is awake. For short cases with a low risk of immediate post operative bleeding into the pharynx, we are proponents of the LMA due to its’ time saving effect.

Otolaryngologists are frequently consulted for the evaluation and treatment of pediatric epistaxis. There is a lack of consensus as to the optimal approach to this problem. This study evaluated an approach used to evaluate and treat patients referred on an outpatient basis.Retrospective study.Charts from 90 patients referred for the treatment of epistaxis were reviewed.Anemia was identified in 22% of patients. An abnormal coagulation study was identified in 7.8% of patients. Computed tomography (CT) imaging of the sinuses was obtained in nearly 90% of patients and revealed no suspicious masses. Opacification of the sinuses consistent with sinusitis was commonly seen. The majority of cases were resolved by the first follow-up visit with a topical nasal emollient.The outpatient evaluation of epistaxis should include a screen for anemia and coagulopathy. Routine CT imaging of the sinuses is unhelpful and is not recommended. The majority of cases are easily treated with rehydration of the nasal mucosa. Consideration should be given to rhinosinusitis as a co-existing factor in patients with epistaxis.

The embryology, presentation, imaging, and treatment of the thyroglossal duct cyst will be reviewed. Anatomic features and surgical technique to prevent complications and recurrence will be discussed. Included in the discussion will be the management of thyroglossal duct cyst malignancy and ectopic thyroid.

Defects of embryologic development give rise to a variety of congenital lesions arising from the epithelium and are among the most common congenital lesions of the head and neck in the pediatric population. This article presents several congenital lesions of epithelial origin, including congenital midline cervical cleft, pilomatrixoma, dermoid, foregut duplication cysts, and preauricular sinuses and pits. In addition, the management of these lesions is reviewed.

Malignant tumors are extremely uncommon in infants, specifically in the head and neck region. We present a three-day-old infant with a large, polypoid, soft tissue mass arising from the floor of the mouth. Histologically, this neoplasm consisted of hypercellular and myxoid areas. A mixture of poorly oriented, small, undifferentiated, hyperchromatic, and round to elongate spindle cells was seen. A high degree of striated muscle differentiation was present, along with areas marked by a herringbone pattern, as well as hemangiopericytic vessels and rare mitosis. Immunohistochemical examinations revealed strong nuclear staining for myogenin and diffuse cytoplasmic staining for desmin and muscle-specific actin (HHF-35). The tumor did not stain for S-100. Based on histologic results and immunostains, this lesion was diagnosed as spindle cell rhabdomyosarcoma. This type of lesion involving the tongue is rarely seen in females, neither in association with a herringbone pattern nor with hemangiopericytic vessels. Furthermore, rare benign and malignant spindle lesions, such as cellular fibromatosis, fetal rhabdomyoma, infantile hemangiopericytoma, infantile rhabdomyofibrosarcoma, and infantile fibrosarcoma, should be in the differential diagnosis and excluded.

An intra-thyroid thyroglossal duct cyst (ITTDC) presented as a congenital anterior neck mass in a 10-year-old male. Diagnosis, work-up, management approach, and differential diagnosis of thyroid nodules are discussed, as well as distinguishing features between thyroglossal duct cyst (TDC) and branchial cleft cyst (BCC). This is the fourth case of ITTDC reported in the pediatric population, and ITTDC should remain in the differential diagnosis of pediatric neck mass.

Objectives:Sleep loss is problematic in adults and children. Decline in sleep duration has paralleled an increase in the prevalence of obesity and diabetes. The aim of this study was to analyze the association between sleep duration, severity of obstructive sleep apnea (OSA), and metabolic variables in obese children.Methods:In this study, patients between the ages of 2 and 12 years who had overnight polysomnography (PSG) at a tertiary care medical center were included. Patients were identified from a xenobase search of medical records. All patients had lipid levels, blood glucose, and insulin evaluated within 3 months of PSG. The demographics, laboratory data, body mass index (BMI), and blood pressure were collected from the medical records.Results:A total of 31 patients were studied. Twenty-one (67.7%) were male, and the mean age of patients was 8.5 ± 1.9 years. The mean BMI z score was 2.7 ± 0.81. All patients were obese. Patients were categorized into groups with total sleep duration >6 hours and