Comparison of Tympanostomy Tubes Under Local Anesthesia Versus General Anesthesia for Children.

OBJECTIVE: Tympanostomy tube insertion (TTI) is typically accomplished under general anesthesia (GA) in the operating room. We aimed to compare pain between GA and local anesthesia (LA) in surgically naïve children undergoing TTI. Secondary objectives examined patient's quality of life (QoL) and parent's satisfaction. STUDY DESIGN: Prospective single-center study. SETTING: Tertiary pediatric academic center. METHODS: Consecutive children who underwent TTI under GA were compared to patients under LA. Pain standardized observational pain scales (Face, Legs, Activity, Cry, Consolability Scale [FLACC], Children's hospital of Eastern Ontario Pain Scale [CHEOPS]) were completed pre-procedure, during the first tympanostomy and second tympanostomy, and post-procedure, as well as 1 week postoperatively. General health-related QoL (PedsQL) and QoL specific to otitis media (OM-6) were measured before insertion and 1 month postoperatively. Parental satisfaction was also evaluated using a qualitative scale. RESULTS: LA group had statistically significant higher pain levels at the beginning (7.3 vs. 0), during the first tympanostomy (7.8 vs. 0), during the second tympanostomy (7.7 vs. 0), and at end of the procedure (6.9 vs. 0) with the FLACC scale (all p < 0.01). Results were similar with the CHEOPS scale. No pain was noted 1 week after surgery in either group. Both groups had similar improvement in their QoL (p > 0.05). Minor complication occurred at a similar rate (p > 0.05). Parents were equally satisfied with their choice of anesthesia in both groups when initially questioned after the procedure (p > 0.05). CONCLUSIONS: Children experienced significantly less pain under GA than LA. If LA is to be used, pain and distress-reducing strategies are critical. Shared decision-making with families is essential. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2422-2429, 2024.

Tympanostomy Tubes Under Local Versus General Anesthesia for Children: A Prospective Long-Term Study.

OBJECTIVES: Tympanostomy tube insertion (TTI) under local anesthesia (LA) is gaining popularity but literature comparing long-term outcomes for children undergoing TTI under LA versus general anesthesia (GA) is limited. This study compares the long-term quality of life (QoL) between LA and GA in children undergoing TTI. Secondary objectives included long-term behavioral changes, parental satisfaction, tube durability, and postoperative complications. METHODS: We prospectively followed children aged under 6 who underwent TTI, under LA or GA, 2 years prior. We assessed QoL using validated scales (OM6, PedsQL), analyzed behavioral changes and parental satisfaction through qualitative scales, and retrieved data on tube durability and non-immediate complications. RESULTS: A total of 84 children (LA = 42; GA = 42) had complete data and a minimum of 1 year of follow-up. Demographic data were similar, except for younger patients in the LA group (1.4 vs. 1.9 years, p = 0.02). LA group exhibited increased fear of health care professionals following TTI (LA: Likert scale 2.1/5, GA: 1.5/5, p = 0.04). Tube retention rate was shorter in the LA group (at 15 months: GA:72%, LA:50%, p = 0.039). Two years post-TTI, there were no differences regarding QoL (OM-6 score; LA: 15.2/100, GA: 21.4/100, p = 0.18, and PedsQL score; LA: 84.3/100, GA: 83.8/100, p = 0.90), parental satisfaction with anesthesia (GA: 4.5/5, LA: 4.6/5, p = 0.56), and postoperative complications (GA: 3/42, LA: 7/42, p = 0.18). CONCLUSIONS: TTI under LA in children is associated with an increased fear of health care professionals and shorter functionality of tympanostomy tubes as compared to GA. No difference was observed in long-term QoL, parental satisfaction, and complications rate. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Treatment of bilateral choanal atresia in the premature infant.

An innovative technique for choanal atresia repair was used for a unique case of bilateral choanal atresia in a 28-week premature newborn. Endoscopic transnasal KTP laser was employed as an alternative to standard instrumentation to reach the very small atretic plate of a premature nose, providing good visualization of the operative field, thereby avoiding damage to the adjacent structures. The successful repair allowed for early extubation and avoidance of a tracheotomy. The clinical and surgical aspects of the case are discussed. With the likelihood of encountering more premature infants with choanal atresia given the improving neonatal intensive care, we propose that KTP laser repair be considered as an alternative to conventional procedures for this particular population.

Treatment of lymphangiomas with OK-432 (Picibanil) sclerotherapy: a prospective multi-institutional trial.

OBJECTIVE: To describe and to determine the robustness of our study evaluating the efficacy of OK-432 (Picibanil) as a therapeutic modality for lymphangiomas. DESIGN AND SETTING: Prospective, randomized trial and parallel-case series at 13 US tertiary care referral centers. SUBJECTS: Thirty patients diagnosed as having lymphangioma. Ages in 25 ranged from 6 months to 18 years. Twenty-nine had lesions located in the head-and-neck area. INTERVENTION: Every patient received a 4-dose injection series of OK-432 scheduled 6 to 8 weeks apart unless a contraindication existed or a complete response was observed before completion of all injections. A control group was observed for 6 months. OUTCOME MEASURES: Successful outcome of therapy was defined as a complete or a substantial (>60%) reduction in lymphangioma size as determined by calculated lesion volumes on computed tomographic or magnetic resonance imaging scans. RESULTS: Overall, 19 (86%) of the 22 patients with predominantly macrocystic lymphangiomas had a successful outcome. CONCLUSIONS: OK-432 should be efficacious in the treatment of lymphangiomas. Our study design is well structured to clearly define the role of this treatment agent.

New treatment options for lymphangioma in infants and children.

Lymphangiomas are congenital malformations of the lymphatic system. These lesions occur most often in the head and neck area, and their treatment continues to be a challenge. Fortunately, a number of advances have occurred in the diagnosis and management of lymphatic malformations in the past decade. The purpose of this article is to clarify the embryology, pathogenesis, histopathology, and classification of these lesions, as well as to describe their various forms of clinical presentation. We provide a complete review of the diagnostic measures available and thoroughly discuss new therapeutic interventions proposed to treat lymphangiomas.

Training: simulating pediatric airway.

Training in the management of pediatric airway cases has been limited by the number of cases and by the involved risks to the child. Simulation is an alternative and accessible means to practice that complex psychomotor task in a safe and reproducible environment. A high-fidelity baby mannequin provides an acceptable airway anatomic resemblance combined with measurable respiratory and cardiovascular parameters, allowing practice to be interactive and challenging. The availability of simulation laboratories within hospitals and the development of pathology-inspired accessories for the mannequins will determine the rate of adherence of ENT departments to this evolving field of simulation-based education.

Intraparotid neurofibroma: review of the literature.

OBJECTIVE: To perform a literature review of intra-parotid neurofibromas. These tumours present a challenge because of their risk of malignant transformation and their high probability of operative facial nerve compromise. DESIGN: A description of one case of intraparotid neurofibroma. A systematic MEDLINE review was performed to document all reported cases. SETTING: Pediatric tertiary care centre. METHODS: An 14-month-old boy was referred with a nontender right-sided 4 × 2.5 cm preauricular mass, which was slowly increasing in size for 8 months. No facial nerve compromise was present. MAIN OUTCOME MEASURES: During superficial parotidectomy, the mass was found to involve the facial nerve and complete resection was performed, on which a cerebrospinal fluid (CSF) leak originating from the stylomastoid foramen occurred. Mastoidectomy revealed an intramastoid division of the facial nerve. The leak coming from the facial nerve was successfully controlled with anastomosis of the major division with the distal nerves. RESULTS: Histopathologic analysis revealed a diffuse neurofibroma. Twenty-two previous cases of intraparotid neurofibroma have been described, although this is the first reported case of the diffuse subtype. Preoperative fine-needle aspiration was inconclusive, and incisional biopsy was dangerous. CONCLUSION: It seems prudent to delay surgery for asymptomatic pediatric patients with facial neurofibroma. Surgery with primary facial nerve grafting is an effective option for patients with facial function of grade III or worse or when the tumour is large, disfiguring, and aggressive. Potential complications of treatment vary depending on the location of the tumour. These include disease recurrence, facial nerve compromise, and CSF leak.

Propranolol as first-line treatment of head and neck hemangiomas.

OBJECTIVES: To report the efficacy of propranolol as first-line treatment of head and neck hemangiomas in children and to present an optimized protocol for treating hemangiomas. DESIGN: Multi-institutional retrospective study. SETTING: Two tertiary care referral pediatric centers. PATIENTS: Thirty-nine children with head and neck infantile hemangiomas were treated. MAIN OUTCOME MEASURES: Review of clinical records. RESULTS: Propranolol was the sole treatment in 60% of patients and was started at a mean age of 4.1 months (age range, 1-11 months) for early interventions among 33 of 39 patients. Propranolol therapy resulted in lightening and reduction of hemangiomas at 37 of 39 locations within 2 days to 2 weeks. One subglottic hemangioma and 1 nasal tip hemangioma did not respond or showed only a partial response; in these patients, propranolol therapy was delayed and followed other treatment failures. After successful therapeutic regression, 6 recurrences occurred; when reintroduced, propranolol was again effective. Recurrences were avoided by prolonged treatment. Twenty-six hemangiomas occurring at locations for which corticosteroid treatment previously would not have been initiated (nose, lips, and parotid area) unless a complication had occurred were treated with propranolol and were rapidly controlled. The mean duration of propranolol therapy was 8.5 months. No instances of ß-blocker discontinuation because of complications occurred, but propranolol was substituted by acebutolol in 5 patients because of trouble sleeping. CONCLUSIONS: Propranolol is an effective treatment of head and neck infantile hemangiomas, especially when started early within the rapid growth phase, and is first-line treatment of orbit and larynx hemangiomas. The efficacy and tolerability of propranolol led us to treat some hemangiomas in patients whom we previously would have observed rather than subject to corticosteroid therapy. Relapse was avoided if treatment was prolonged after theoretical involution (age 12 months). Questions remain about optimal dosing and age at treatment cessation.

3-year impact of a provincial choking prevention program.

OBJECTIVE: To determine the impact of a provincial choking prevention program (CPP) on the incidence of aerodigestive foreign body cases among children. METHODS: The CPP, including posters, pamphlets, an informative video, and annual participation in the Parents & Kids Fair, was launched throughout Quebec in October 1999. The incidence rates of aerodigestive foreign body cases prior to implementation (during 1997-1998) and subsequently (2000-2002) within the province and our tertiary care centre (Sainte-Justine Hospital) were compared by estimating incidence rate ratios (IRRs) and associated 95% confidence intervals (95% CIs). RESULTS: No significant changes in the incidence of aerodigestive foreign body cases after program implementation were observed in our hospital (age-adjusted IRR 0.92, 95% CI 0.79-1.07). The provincial rates were higher after program implementation (age-adjusted IRR 1.15, 95% CI 1.05-1.25). CONCLUSIONS: To influence choking prevention habits, modifications to the campaign are required. Strategies are discussed.

Ultrasonography and videobronchoscopy to assess the subglottic diameter in the paediatric population: a first look.

OBJECTIVE: The aim of the study was to evaluate the efficacy of ultrasonography and videobronchoscopy in measuring the subglottic diameter in the paediatric population. DESIGN: A double-blinded, prospective clinical study carried out at the Montreal Children's Hospital, McGill University. METHODS: Children undergoing non-life-threatening bronchoscopy for various reasons had the subglottic diameters measured with ultrasonography, videobronchoscopy, and the traditional method of endotracheal tube sizing during the operative period. Ten patients were enrolled in the study. Parental consent was obtained prior to the procedure. RESULTS: Statistical analysis revealed that although ultrasonography was highly correlated with both videobronchoscopy and endotracheal tube sizing in measuring the subglottic diameter in the paediatric population, the measurements were not accurate in giving an exact value of the diameters in question. Videobronchoscopy was found to highly correlate with endotracheal tube sizing but had values that were slightly larger. CONCLUSION: This study is the first to examine the ability of ultrasonography and videobronchoscopy in evaluating the subglottic diameter in the paediatric population. Videobronchoscopy was shown to correlate highly with the present standard of measurement, namely, endotracheal tube sizing. The difference in measurement between the two was shown to be statistically significant, with videobronchoscopy being the consistently larger of the two. These results are in keeping with the limitations of measurement by the endotracheal tube. Similarly, ultrasonography was also correlated with both videobronchoscopy and endotracheal tube sizing. In contrast, ultrasonography was found to provide measurements that were significantly smaller than the other two methods. This suggests that ultrasonography may be a good technique to follow the change in lesions of the subglottis but may be poor for absolute measurements of this area as it always underestimated the size of the lumen.

Mutations in a novel gene, TMIE, are associated with hearing loss linked to the DFNB6 locus.

We have identified five different homozygous recessive mutations in a novel gene, TMIE (transmembrane inner ear expressed gene), in affected members of consanguineous families segregating severe-to-profound prelingual deafness, consistent with linkage to DFNB6. The mutations include an insertion, a deletion, and three missense mutations, and they indicate that loss of function of TMIE causes hearing loss in humans. TMIE encodes a protein with 156 amino acids and exhibits no significant nucleotide or deduced amino acid sequence similarity to any other gene.