Pediatric ear foreign body retrieval: A comparison across specialties.

OBJECTIVES: To analyze what characteristics of patients and/or ear foreign bodies should prompt referral to otolaryngology with the goal to maximize successful removal and minimize complications. METHODS: This was a retrospective chart review of pediatric patients who presented for ear foreign body removal from January to December 2016 at a tertiary hospital center. Data collection included successful removal, major or minor complications, use of general or conscious sedation, use of otic or oral antibiotics, age of patient, comorbid behavioral disorders, and foreign body characteristics. Major complications included tympanic membrane perforation or ossicular damage. Minor complications included injury of the canal wall. Patients with retained or extruded tympanostomy tubes were excluded. RESULTS: Of 275 patients aged 1-18 years, 16% presented initially to otolaryngology (ENT), 48.4% presented to the emergency department (ED), 21.8% presented to a pediatrician, and 13.8% presented to ENT after prior attempts at removal. Rate of successful retrieval by ENT was significantly higher than by PCP (95.4% vs 75.0%) or by ENT after prior failed attempts (65.8%), but not when compared to removal in the ED (85.7%). Retrieval by ENT after prior failed attempts had the highest rate of minor complications (26.3% vs 2.3-6.0%). There were two tympanic membrane perforations that were noted by ENT after prior failed attempts. Rate of operative intervention was significantly higher in patients who presented to ENT after prior attempts compared to patients who presented initially to ENT (34.2 vs 4.6%, p = 0.001). Of the patients who presented to ENT after previous failed attempts, there was a higher rate of complications and operative intervention if the patient was age 5 or under or the foreign body was difficult to grasp. CONCLUSIONS: Pediatric ear foreign body presentation is common. Repeated attempts at removal are associated with higher rates of minor complications and operative intervention. Early consultation to otolaryngology should be considered if the foreign body is deemed difficult to grasp such as a bead or stone, especially if the patient is age five or younger.

An Unusual Hybrid Salivary Gland Tumor: Molecular Analysis Informs the Potential Pathogenesis of This Rare Neoplasm.

BACKGROUND: The presence of two or more tumor entities growing in adjacent locations within the salivary gland is very rare, and pathologic studies on such lesions are limited, particularly those with molecular information. Since the clinical history and imaging studies are usually nonspecific, accurate diagnosis and clinical management largely depend on a thorough histological examination. METHODS AND RESULTS: We describe a 71-year-old man with an unusual case of hybrid salivary gland tumor composed of mucoepidermoid carcinoma and basal cell adenoma. Molecular analysis revealed differing driver genetic alterations in each component. CONCLUSIONS: Hybrid salivary gland tumors are rare, and their pathogenesis is controversial. The combination of mucoepidermoid carcinoma and basal cell adenoma has not been previously described. While malignant transformation of adenoma to carcinoma seems plausible, gene sequencing was more suggestive of their independent derivation. Key to appropriate surgical management is identifying the more aggressive component, ideally at the time of intraoperative consultation.

Utility of intraoperative and postoperative radiographs in pediatric cochlear implant surgery.

OBJECTIVE: Routine plain film radiographs are often obtained to confirm proper placement of electrode after pediatric cochlear implant surgery. Objective is to evaluate necessity of routine radiographs in pediatric cochlear implant cases. STUDY DESIGN: Retrospective review. SETTING: Two tertiary care academic centers. SUBJECTS AND METHODS: Review of all children that underwent cochlear implantation from January 2003 thru June 2015. Exclusions include patients without intraoperative evoked compound action potential (ECAP) data or radiographs and patients undergoing revision surgeries. RESULTS: 235 pediatric patients underwent 371 cochlear implants. ECAP measurements were not available in two cases and were excluded from study. Radiographs were obtained in 35/369 cases due to intraoperative concern and four had abnormal findings. All four cases underwent change in management. One other patient had an x-ray because of difficult insertion and abnormal ECAP. Radiograph was normal; however, incision was opened and electrodes inserted further. Overall, 5/369 cases had changes in management intraoperatively. In all five cases, abnormalities were suspected by clinician judgment or abnormal ECAP measurements. Routine radiographs were completed in 349/369 cases and one was abnormal. This patient had known partial insertion due to cochlear fibrosis from meningitis and abnormal radiograph did not result in change in management. CONCLUSION: Clinician suspicion and/or abnormal ECAP prompted suspicion for abnormal electrode placement prior to evaluation with radiograph in all cases in which change in management occurred. Intraoperative radiographs may be valuable in setting of clinical suspicion. Routine radiographs do not result in change in management and are, therefore, unnecessary.

Polysomnography results in pediatric patients with mild obstructive sleep apnea: Adenotonsillectomy vs. watchful waiting.

OBJECTIVE: There is a lack of consensus and a paucity of data regarding how to best treat pediatric patients with mild obstructive sleep apnea. The objective of our study was to compare outcomes following adenotonsillectomy vs. observation in children with mild obstructive sleep apnea based on polysomnography results. METHODS: A retrospective chart review was performed on children ages 9 months to 9 years with 2 or more polysomnograms completed at a tertiary care academic center. Children diagnosed with mild obstructive sleep apnea (obstructive apnea-hypopnea index 1-5) on polysomnography performed from 1999 to 2013 were included. Patients underwent adenotonsillectomy or watchful waiting for obstructive sleep apnea. The primary outcome was the change in apnea-hypopnea index. RESULTS: There were 62 patients who met inclusion criteria for the study; 19 of the 62 patients were obese, while 15 had a craniofacial syndrome or hypotonia. Eighteen patients underwent adenotonsillectomy for mild obstructive sleep apnea while 44 were observed. The mean apnea-hypopnea index of patients after adenotonsillectomy improved from 3.50 (95% Confidence Interval [CI] 2.97-4.03) to 2.69 (95% CI 1.48-3.90), while the mean apnea-hypopnea index of the observation group worsened from 3.09 (95% CI 2.76-3.42) to 5.18 (95% CI 2.46-7.90). Between-group analysis showed significant improvement in the surgery group (p=0.03), with a persistent improvement on multivariate analysis adjusting for baseline apnea-hypopnea index (p=0.05). This difference was seen mostly in non-obese, non-syndromic children (p=0.04). There was no significant difference between groups amongst obese (p=0.25) and syndromic (p=0.36) patients. CONCLUSIONS: Adenotonsillectomy leads to a significant improvement in apnea-hypopnea index on follow-up polysomnography over an observational approach, especially in non-obese, non-syndromic children. A prospective, randomized trial is necessary to help determine appropriate treatment strategies for pediatric mild obstructive sleep apnea.