Hearing Outcomes in Patients with Cleft Lip and Palate in a Resource Limited Setting.

To compare hearing outcomes of early versus late tympanostomy tube insertion in patients with cleft lip and palate in a resource limited setting.Retrospective cohort study.Conducted at Queen Sirikit National Institute of Child Health, a tertiary care hospital in Bangkok, Thailand.Included 76 patients under 18 with cleft anomalies undergoing tympanostomy tube insertion between January 2018 and July 2022, categorized into early (n = 11) and late (n = 65) tympanostomy groups.Early tympanostomy tube placement at ≤ 3 months old, coordinated with cleft lip repair, following failed transitory evoked otoacoustic emission (TEOAE) and Type B tympanogram. Late tympanostomy tube placement preceded by a diagnosis of middle ear effusion and typically a failed TEOAE and subsequent level of testing.Primary outcomes: normal hearing rates and age at normal hearing. Secondary outcomes: repeated tympanostomy tube placement rate, postoperative complications, and length of hospital stays.Early tympanostomy tube placement was associated with higher rates of normal hearing (100% vs. 75%. P = .103) and significantly younger age at normal hearing (11 vs. 19 months, P = .036). Time to normal hearing was shorter in the early group. Postoperative complications, including otorrhea, occurred more frequently in the early group, but differences were not significant.Early tympanostomy tube insertion improves hearing outcomes in pediatric patients with cleft lip and palate, achieving normal hearing at a significantly younger age. This approach offers a valuable alternative in resource-limited settings with constrained audiological services. Further research on long-term speech outcomes and cost-effectiveness is warranted.

The Trend of Cleft Care at a Children's Referral Center in Thailand.

OBJECTIVE: To investigate the trend in cleft care at a major children's referral center in Bangkok, Thailand. STUDY DESIGN: Retrospective chart review. PATIENTS AND METHODS: A review of 129 patients under 18 years of age who had underwent care by the senior author for cleft treatment between January 2015 and October 2017 was done. The impact of varying factors on patient care was analyzed. We compare our demographics and treatment timeline to that of previously published literature in more developed countries. SETTING: Tertiary care medical center. RESULTS: One hundred and two patient charts were reviewed with 53% male patients. Most patients had both cleft lip and cleft palate, 44%. Cleft lips most commonly were complete and occurred on the left side. In all, 77.4% of clefts were nonsyndromic. On average, primary cleft lip surgery was delayed being performed about 11 months of age. Sixteen percent of patients were treated with an obturator, while 11 patients had nasoalveolar molding use. Hearing screenings occurred on average at around 6 months of age. Abnormal tympanograms were evident in 32% of individuals. There was a significant difference in timing of surgery for patients who lived a distance greater than 30 kilometers from the hospital versus those from the Bangkok metropolis (P < .05). CONCLUSION: Reviewing data from a high-volume referral center in Thailand reveals mild variance with regard to cleft care timing compared to published literature from the developed world. Distance traveled was found to impact timing of surgery.

Minimally Invasive Approach for Resection of Masseteric Vascular Malformations.

OBJECTIVE: Vascular malformations (VMs) in the head and neck region often cause esthetic as well as functional problems for patients. Intramuscular VMs (IVM), such as those in the masseter, can cause severe facial asymmetry and typically are excised transcutaneously to facilitate wide exposure and safe dissection from the facial nerve. This requires extensive dissection, prolonged healing, and can lead to suboptimal facial scarring. METHODS: We describe the technique of resecting large IVMs of the masseter muscle in 3 patients using an entirely intraoral approach with continuous nerve monitoring and without visible facial scarring or secondary deformity. Preoperative injection of sclerotherapy was performed to reduce intra-operative bleeding and optimize resection. RESULTS: Successful excision was performed without complication in 3 patients to date. Total average operating room time was 120 minutes (range 95-145 minutes). Estimated blood loss was 213 mL (range 180-240 mL). The patients were discharged home either post-operative day (POD) 1 or 2, with 1 returning to work POD 4. Facial nerve function was normal postoperatively and no hematomas developed. Subjective masticatory function was equivalent to preoperative levels in all patients. CONCLUSIONS: Intraoral excision of VMs of the masseter muscle can be safely performed without added risk or complication. Continuous facial nerve monitoring allows minimally invasive approaches to be considered with less risk of iatrogenic facial nerve injury. We purport that this is a safe and effective method with substantially better esthetic outcomes compared with traditional transcutaneous approaches.

Current trends of balloon laryngoplasty in Thailand.

OBJECTIVE: To describe the current trend in balloon laryngoplasty usage and experience by practicing otolaryngologists in Thailand. STUDY DESIGN: Anonymous 11 question online and paper survey of otolaryngologists on their current balloon laryngoplasty practices. SUBJECTS AND METHODS: Current practices and experience in balloon laryngoplasty were queried with multiple choice and open-ended questions. RESULTS: Laser use is the most commonly utilized instrument to treat airway stenosis in Thailand. 86% of respondents do not have experience with balloon dilatation; yet, almost half (47.6%) report they perform a minimum of five airway surgeries per year. Most respondents had been in practice for less than 6 years (41%) and reported that they did not have exposure to balloon use during residency training. The largest barrier reported for the use of balloon instrumentation in the airway is inexperience (44.4%) followed by cost (38.3%), yet most feel that treatment in airway stenosis could benefit by usage of balloons (95.5%). CONCLUSIONS: Most otolaryngologists in Thailand do not have experience with the use of balloon dilatation and lack of exposure remains the largest barrier to its use. Otolaryngologists in Thailand feel that increased usage of balloons in the airway could improve airway stenosis treatment in the country.

Traumatic dislocation of intact mandibular condyle into middle cranial fossa.

INTRODUCTION: A 10-year-old girl presented to the Emergency Department with temporomandibular joint pain, malocclusion, and trismus after a bicycle accident. METHODS: CT of the temporal bones showed displacement of the right mandibular condyle into the middle cranial fossa with small intraparenchymal hemorrhage. The condyle was reduced using closed reduction technique and the patient was placed in maxillomandibular fixation. RESULTS: Complete reduction of the displaced condyle with resultant normal occlusion and persistent bony defect in the temporal bone. CONCLUSION: In early follow-up assessments the patient has had complete resolution of symptoms with residual bony defect from the site of fracture in the temporal bone.

Neurofibromatosis of the larynx causing stridor and sleep apnea.

BACKGROUND: Neurofibromatosis type 1 can rarely present in the larynx. Patients typically do not present with complete obstructive symptoms, but partial obstruction and stridor. We review our health centers' case series of two patients, the first of whom presented with persistent sleep apnea post tonsillectomy and adenoidectomy, and the second who presented with noisy breathing. Additionally, we will review the literature on the management and treatment options for children with this rare clinical entity. METHODS: Retrospective case review. CASE REPORT & RESULTS: A two-year old male underwent a sleep endoscopy following persistent evidence of obstructive sleep apnea on polysomnography after initial tonsillectomy and adenoidectomy. Family elicited concerns about noisy breathing at night and an accompanying video documented stridor while sleeping during the monitored polysomnography. Flexible fiberoptic laryngoscopy in the operating room revealed what appeared to be a cystic mass along the right aryepiglottic fold causing deviation of the laryngeal introitus towards the contralateral side. Subsequent direct laryngoscopy and excisional biopsy revealed pathology results consistent with a plexiform neurofibroma. A six-month-old patient with stertor and stridor was found to have a laryngeal mass, subglottic stensosis, and progressive airway obstruction due to plexiform neurofirboma in the supraglottis, subglottis, and trachea. We present a series of two patients incidentally diagnosed with neurofibromatosis type 1 by way of a laryngeal neurofibroma and review the literature on management options. Both patients were found to have accompanying café au lait spots. Both patients required tracheostomy for airway management, and one was successfully decannulated. CONCLUSION: Laryngeal neurofibroma is a rare anomaly that can manifest with airway obstruction. Both patients presented here subsequently were noted to have café au lait spots on physical examination. The Otolaryngologist should be reminded of this anomaly when evaluating a child with evidence of a submucosal laryngeal mass. We present our series including that of a patient whose diagnosis was prompted by persistent sleep apnea following adenotonsillectomy tonsillectomy and a patient with airway obstruction and subglottic stenosis due to a neurofibroma. The treatment of choice is complete excision of the neurofibroma while maintaining functionality of the larynx. This can lead to successful decannulation.

Molecular and genetic markers of follicular-cell thyroid cancer: etiology and diagnostic and therapeutic opportunities.

Thyroid cancer has an increasing incidence in the US population and worldwide, with 95% of the cancers being of follicular cell origin-papillary, follicular, or anaplastic thyroid carcinomas. Both follicular and papillary thyroid cancers portend good survival rates, with estimated 5-year survival amongst differentiated thyroid cancer approaching 97%. On the other hand, the median survival for a patient with anaplastic thyroid carcinoma is measured in months. Despite the optimistic survival rates for papillary and follicular thyroid carcinoma, a subset of this population demonstrates resistance to radioactive iodine, and a proclivity for more aggressive tumors with higher rates of recurrence and metastasis.As there is an increased understanding of the molecular etiology of thyroid cancer, there is also a new interest in alternative treatment methods for those nonresponsive to typical treatment. Multiple signaling pathways have been identified, including the mitogen activated protein kinase pathway, as crucial to thyroid tumor formation and progression. Additionally, particular oncogenes have been identified as prevalent in anaplastic thyroid carcinoma and thought to be involved in the transformation from differentiated to anaplastic histology.We review the current literature and evidence describing the molecular and genetic etiology of non-medullary (follicular cell derived) thyroid carcinomas including papillary, follicular, and anaplastic thyroid carcinoma. Additionally, we evaluate the current literature on emerging and established therapies of molecular and genetic targets in these cancers.

Predictive factors for prolonged hospital stay in pediatric tonsillectomy patients.

OBJECTIVE: To determine factors that may potentially predict a prolonged hospital stay after scheduled tonsillectomy in the pediatric population. STUDY DESIGN: Retrospective chart review. SUBJECTS AND METHODS: A review of pediatric patients who had undergone a tonsillectomy at a tertiary medical center from July 2007 to November 2010 was made. Preoperative variables were analyzed to determine predictors of prolonged hospital stay (defined as >24 h) that may have influenced their length of stay. SETTING: Tertiary care medical center. RESULTS: 827 patient charts were reviewed. One hundred and one patients (12.2 %) had hospital stays >24 h. Indications for tonsillectomy included obstructive sleep apnea (69.2 %), tonsillitis (13.8 %), and tonsillar asymmetry (0.9 %). Seventy-seven (76.2 %) patients of the extended stay group had a delayed discharge because of poor oral intake. Fever and respiratory complications accounted for 0.5 and 1.8 % respectively of those patients who had extended stays. Patients with extended stays were younger (p < 0.001) and weighed less (p < 0.001). Patients with a history of sickle cell crises, reactive airway disease, bronchodilator use, and anti-reflux medication use (p < 0.05) were more likely to have a prolonged hospital stay. CONCLUSION: Factors from the history and physical of pediatric patients may predict which children are at higher risk for extended hospital stays after routine tonsillectomy. Predictors of extended stays include those under the age of four and children weighing <20 kg, those with a history of sickle cell crises or reactive airway disease, and those using bronchodilators or anti-reflux medication.

Increased Intervals Between Paediatric Tracheostomy Tube Changes: Is it a Safe Technique?

To evaluate the safety of changing tracheostomy tubes every three months in paediatric patients and determine the occurrence of tube-related complications. Retrospective observational chart review was completed from 2018 to 2021 at a tertiary medical centre in Thailand. Tube associated complications were assessed with regards to interval length between tracheostomy tube changes. The rate of complication was compared with previous studies. Out of a total of 108 visits, the average interval between each tube change was 87 days. Of all encounters, 6.48% resulted in a tube-related complication. Of these seven visits, two had an admission for a respiratory infection within 30 days, three experienced accidental decannulation and two resulted in excess granulation tissue formation. A p-value of 0.8 was obtained from a chi-squared test. An interval of 90-days between paediatric tracheostomy tube changes does not increase the rate of tracheostomy tube related complications. This interval may be practical for those in resource limited settings.

Nasal Sidewall Dimensions in the Asian Nose: A Thai Cadaveric Study.

Nasal bone length remains a commonly referenced attribute when referring to the aesthetic nose. Short nasal bone length is suggested to predispose to a greater risk of middle vault collapse after rhinoplasty. We report on normative measurements of nasal bones and associated structures in Thai cadavers. Using twelve adult cadavers, common external nasal landmarks were identified and measured to approximate the dimensions of the nasal bones and upper lateral cartilages. These clinically relevant surface landmarks were correlated to direct measurements of dissected nasal bones and the upper lateral cartilage in these same cadavers. Additionally, external landmarks of ten volunteers were examined. The average measured length of the nasal bone was 19.00 mm; the average measured length of the upper lateral cartilage was 13.15 mm. Measurements obtained via external landmarks were 17.60 mm and 13.05 mm respectively. The relationship of the nasal bone internal length to the external measurement (A) was a ratio of 1.10:1, whereas the internal length of the upper lateral cartilage to the corresponding external measurement (B) was 1.04:1. On average the nasal bones contributed to 59% of the middle vault nasal sidewall. The average length of the Thai adult nasal bone is 19.00 mm while that of the upper lateral cartilage is 13.15 mm. The relationships of the accepted external landmarks to the underlying anatomic structures were established using a t test. This normative data will generate useful parameters when evaluating the Asian rhinoplasty patient.

Necrotizing fasciitis secondary to bisphosphonate-induced osteonecrosis of the jaw.

Osteonecrosis of the jaw is an uncommon consequence of biphosphonate therapy. This has most commonly been a bone complication with little if any soft tissue involvement. An unusual case of necrotizing fasciitis with extensive soft tissue infection stemming from a prolonged case of osteonecrosis of the jaw presented. The management of this patient (aggressive surgical debridement and prolonged wound care) is reviewed as well as the review of the underlying processes.

Comparison of exhaled nitric oxide levels in pediatric patients with allergic rhinitis.

OBJECTIVE: To determine whether the measurement of exhaled nitric oxide (eNO) can help distinguish children with allergic rhinitis (AR) from healthy controls and whether eNO in children with AR correlates with disease severity. METHODS: From August 2015 to 2016, children aged 5-15 years of age grouped into those with allergic rhinitis (n = 40) and those classified as healthy control subjects (n = 40) had exhaled nitric oxide (eNO) levels measured. The eNO level was additionally compared to the patient's clinical disease severity according to the ARIA (Allergic Rhinitis and its Impact on Asthma) classification. RESULTS: Mean eNO in children with AR (12.64 ±â€¯14.67 ppb) was significantly higher than that in the healthy control group (7.00 ±â€¯6.33 ppb) (p-value = 0.046). In the persistent AR group (17.11 ±â€¯18.40 ppb), eNO level was significantly higher than individuals in the intermittent AR group (8.59 ±â€¯8.88 ppb, p-value = 0.024) and the healthy control group (7.00 ±â€¯6.33 ppb, p-value = 0.008). Among children with AR, eNo was not significantly different with relationship to gender, age, weight and passive smoking exposure. CONCLUSIONS: Exhaled nitric oxide may be elevated in children with AR that do not have concomitant asthma. This suggests exhaled nitric oxide may show utility as a parameter to monitor the severity of allergic rhinitis and to monitor the efficacy of the treatment. Physicians should consider comorbid AR when utilizing exhaled nitric oxide as a monitoring parameter in the treatment of asthma.

Tracheocutaneous fistula closure in children.

OBJECTIVE: Systematic review of surgical techniques for tracheocutaneous fistula closure in children and successful closure or development of adverse events. DATA SOURCES: PubMed, EMBASE, Web of Science, and Cochrane Library. REVIEW METHODS: A medical librarian was utilized to perform a systematic review. RESULTS: Fourteen studies were identified. Eight studies reported outcomes for primary closure alone; one discussed results for secondary closure alone; and five included a combination of children who underwent either primary and secondary closure alone. No difference between surgical techniques was identified for effectiveness of closure (RR = 1.03, 95% CI: 0.97 to 1.10) and major (RR = 1.68, 95% CI: 0.56 to 5.05) or minor complications (RR = 1.28, 95% CI: 0.50 to 3.27). No mortalities were identified. CONCLUSIONS: Both primary and secondary closure techniques for persistent tracheocutaneous fistulas in children are effective and associated with acceptable rates of complications. Given the available evidence, neither approach appears to be superior. Considerations for decision making in surgical approach may include family and social considerations, facility resource utilization, and cost differential. Further investigation may be directed at improving patient selection.

Pediatric laryngotracheal separation following a go-cart injury.

Less than one percent of trauma admission cases are categorized as pediatric neck trauma [13]. Nevertheless, due to an increasingly mobile society, there has been an increasing frequency of pediatric neck trauma with motor vehicle accidents being the most common mechanism of injury [8]. We present a case of laryngotracheal separation from a blunt, clothesline injury to the neck in a pediatric patient. We also review the literature and discuss the benefit of balloon airway dilation and its assistance in the management of laryngeal trauma and its resultant effects.

Metastatic squamous cell carcinoma of the tonsil presenting as otorrhea: a case report.

We describe the case of a 52-year-old man with a history of squamous cell carcinoma (SCC) of the tonsil who presented with right subacute otalgia and otorrhea. Dedicated computed tomography of the temporal bones showed opacification within the mastoid process with destruction of bony mastoid septations consistent with coalescent mastoiditis. Preoperative imaging showed no destruction or expansion of the bony eustachian tube that would indicate that a direct spread had occurred. An urgent cortical mastoidectomy was performed. Intraoperatively, a friable white mass surrounded with purulence and granulation tissue was biopsied and returned as SCC. The discrete metastasis was removed without complication. Postoperatively, the patient was prescribed palliative chemotherapy. This case shows that a metastatic SCC can be masked by an overlying mastoiditis, and thus it should be considered in the differential diagnosis of a patient with a history of oropharyngeal cancer.

Evaluating the impact of allergic rhinitis on quality of life among Thai students.

BACKGROUND: The prevalence of allergic rhinitis (AR) in Thailand continues to rise. We report the prevalence and evaluate its impact upon quality of life (QoL) in students on a metropolitan campus. METHODS: From March 2013 to February 2014, 222 students from Thammasat University Medical School were evaluated using the International Study of Asthma and Allergies in Childhood Questionnaire (ISAAC) questionnaire and the rhinoconjunctivitis QoL questionnaire (Rcq-36) to assess subjective symptoms. Those students with clinical symptoms of AR underwent skin prick testing (SPT) using 5 common allergens found in Thailand. The association between AR and QoL was then determined using a paired t test. RESULTS: A total of 222 students were enrolled in the study; 86 (38.7%) were men. There were 183 (81.9%) students with AR symptoms and 130 (71.4%) students with positive results for SPT. The students' QoL as defined by the Rcq-36 revealed a significant worsening in students who self-reported rhinitis symptoms within the past 12 months. Compared to the non-AR group, in those with AR, eye symptoms were significantly more common. CONCLUSION: The prevalence of AR at a college campus was 58.5%. The presence of rhinitis symptoms was the highest predictor of the presence of AR, with 67.7% having subsequent positive SPT. Students with AR had poorer scores in every dimension of QoL as defined by the Rcq-36 when compared to their non-AR counterparts. Educational performances among the 2 groups were unaffected.

Comparison of SPECT/CT and planar MIBI in terms of operating time and cost in the surgical management of primary hyperparathyroidism.

We conducted a retrospective study to compare operating times and costs in patients who underwent guided parathyroidectomies with either (1) technetium-99m ((99m)Tc) multiplex ion-beam imaging (MIBI) parathyroid scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images or (2) sestamibi dual-phase (99m)Tc MIBI planar parathyroid scintigraphy alone preoperatively. Our study population was made up of the first 24 patients at our facility who had undergone SPECT/CT parathyroid imaging with technetium-99m ((99m)Tc) MIBI and a group of 24 patients who had undergone MIBI planar imaging alone. Patient demographics, preoperative laboratory test results, operating times, and hospital charges were analyzed. We found that less operating time was required for the planar MIBI group than in the SPECT/CT group (mean: 135 vs. 158 min), although the difference was not statistically significant. Likewise, the total cost of treatment was lower in the planar MIBI group (mean: $10,035 vs. $11,592); the difference was statistically significant by one measure (p × 0.02, Wilcoxon rank sum test) but not by another (p × 0.06, Student t test). Although SPECT/CT is efficient for patients with small and difficult-to-localize adenomas, it has yet to demonstrate greater efficacy or cost-effectiveness than planar MIBI for routine parathyroidectomy in patients with primary hyperparathyroidism when an easily identifiable parathyroid adenoma is localized.

Revision rates and speech outcomes following pharyngeal flap surgery for velopharyngeal insufficiency.

IMPORTANCE: Velopharyngeal insufficiency in children with cleft palate (and other causes) contributes to difficulty with communication and quality of life. The pharyngeal flap is a workhorse to address hypernasality and nasal air escape. However, there is a paucity of literature on the characteristics of cases that require revision. OBJECTIVE: To measure the revision rate of pharyngeal flaps, compare the preperceptual and postperceptual speech scores, and identify the characteristics of those patients who required revision. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review was completed for patients who underwent pharyngeal flap surgery from June 1, 2008, through January 31, 2013, at a tertiary academic center. MAIN OUTCOMES AND MEASURES: Perceptual speech analyses and surgical revision rates. Perceptual speech patterns before and after surgery were compared using nasal air emission and resonance scores. The association between requiring revision surgery and covariates was analyzed using multivariable mixed-effects logistic regression. RESULTS: Sixty-one patients were identified, including 24 boys (39%) and 37 girls (61%). The mean (SD) patient age at the time of pharyngeal flap surgery was 8.2 (6.8) years (range, 3-55 years). Velopharyngeal insufficiency was associated with cleft palate in 51 patients (84%), and 17 patients (28%) had a syndrome. The mean (SD) time to surgery after the speech evaluation was 225 (229) days (range, 14-1341 days). The mean (SD) nasal air emission scores decreased by -1.1 (2.0 [1.1] preoperatively to 0.8 [1.1] postoperatively). The mean (SD) resonance score decreased by -1.5 (2.4 [1.1] preoperatively to 0.9 [1.1] postoperatively; P < .001). Flaps were revised in 12 patients (20%), including port revision in 9, complete flap revision in 2, and flap takedown in 1. The only covariate that was significantly associated with revision rates was increased age at surgery, which was associated with a higher probability of revision surgery (odds ratio, 1.31; 95% CI, 1.03-1.66; P = .04). CONCLUSIONS AND RELEVANCE: Pharyngeal flap surgery, when appropriately selected, was effective at improving speech with a revision rate of 20%, which is comparable to previously published studies. Increased age at the time of the pharyngeal flap surgery was associated with an increased need for revision surgery, supporting evidence that cleft centers should encourage early childhood speech evaluations with consistent documentation and prompt treatment. LEVEL OF EVIDENCE: 3.

Transoral robotic study of the vascular anatomy of the head and neck.

We aimed to explore, highlight and accurately identify the vascular anatomy of the oropharynx, hypopharynx and supraglottis utilizing the transoral robotic perspective. This was a case series using anatomic studies of cadaveric specimens. The cadavers were injected with red- and blue-dyed silicone through the arterial and venous systems to define the macro- and microvasculature. Following injection of the specimen, a da Vinci robotic surgical system was engaged to perform a transoral dissection of the oropharynx, hypopharynx and supraglottic regions. Dissection was carried out under high-definition optics. Vascular structures were identified and followed to their terminal branches. We successfully performed transoral robotic dissections of five fresh frozen cadaveric human heads which had been injected with dyed silicone. The injection technique and use of a high-definition magnifying camera allowed us to visualize and identify the vasculature of the head and neck in a unique fashion. The cadaveric model provides an excellent educational tool to aid in training. Additionally, the use of this model and the transoral approach has allowed us to identify vessels which typically may not be visible on routine dissection. We believe this to be very relevant in training and improving performance for safe and bloodless transoral robotic surgery. To our knowledge this is the first study using the transoral robotic approach to examine the vascular anatomy of the oropharynx and larynx.