Age at diagnosis, but not HPV type, is strongly associated with clinical course in recurrent respiratory papillomatosis.

BACKGROUND: Recurrent Respiratory Papillomatosis (RRP) is a rare disease characterized by the growth of papillomas in the airway and especially the larynx. The clinical course is highly variable among individuals and there is poor understanding of the factors that drive an aggressive vs an indolent course. METHODS: A convenience cohort of 339 affected subjects with papillomas positive for only HPV6 or HPV11 and clinical course data available for 1 year or more, from a large multicenter international study were included. Exploratory data analysis was conducted followed by inferential analyses with frequentist and Bayesian statistics. RESULTS: We examined 339 subjects: 82% were diagnosed prior to the age of 18 years, 65% were infected with HPV6, and 69% had an aggressive clinical course. When comparing age at diagnosis with clinical course, the probability of aggressiveness is high for children under five years of age then drops rapidly. For patients diagnosed after the age of 10 years, an indolent course is more common. After accounting for confounding between HPV11 and young age, HPV type was minimally associated with aggressiveness. Fast and Frugal Trees (FFTs) were utilized to determine which algorithms yield the highest accuracy to classify patients as having an indolent or aggressive clinical course and consistently created a branch for diagnostic age at ~5 years old. There was no reliable strong association between clinical course and socioeconomic or parental factors. CONCLUSION: In the largest cohort of its type, we have identified a critical age at diagnosis which demarcates a more aggressive from less aggressive clinical course.

Stroke after adenotonsillectomy in patients with undiagnosed moyamoya syndrome.

IMPORTANCE: Moyamoya syndrome is a rare, occlusive cerebrovascular arteriopathy with significant risk for stroke. Populations that frequently undergo otolaryngologic procedures, including patients with Down syndrome and sickle cell disease, are particularly at risk for moyamoya. The initial presentation of moyamoya syndrome as stroke in the perioperative period of an otolaryngologic procedure has not been reported. OBSERVATIONS: A retrospective medical record review assessed the relationship of otolaryngologic operations and the onset of moyamoya symptoms. Moyamoya syndrome was present in 137 patients. Of these, 19 patients underwent otolaryngologic procedures; 3 children had strokes 2 to 4 days after adenotonsillectomy, including 2 children with Down syndrome. Intraoperative carotid artery injury was considered but was proven not to be the cause of stroke. Bilateral moyamoya disease was diagnosed in all 3 patients via vascular imaging studies; all subsequently underwent revascularization procedures. CONCLUSIONS AND RELEVANCE: Clinicians should be aware of an elevated prevalence of moyamoya syndrome in Down syndrome and sickle cell disease populations and should consider moyamoya syndrome in the differential diagnosis of postoperative stroke. Stroke risk is magnified in the perioperative setting related to perioperative dehydration and hypotension. Awareness and screening for cerebral vasculopathy in high-risk populations could prompt measures to decrease the occurrence of postoperative strokes after adenotonsillectomies.

Prevention of pressure ulcers after pediatric tracheotomy using a Mepilex Ag dressing.

OBJECTIVES/HYPOTHESIS: Skin irritation and ulceration beneath the tracheostomy tube or ties secondary to pressure and shearing forces on the skin frequently complicate pediatric tracheotomy in the immediate postoperative period. The aim of this study is to determine the effectiveness of Mepilex Ag dressings in reducing posttracheotomy wound complications. STUDY DESIGN: Retrospective study. METHODS: We identified 134 pediatric tracheotomies performed between June 2005 and June 2011 at a tertiary care academic pediatric hospital. Peristomal skin breakdown was documented at the time of the first tracheostomy tube change. Starting in February 2010, the application of Mepilex Ag, a silver-impregnated foam dressing, underneath the tracheostomy tube and twill ties became standard practice. The rates of wound breakdown before and after the introduction of Mepilex Ag were compared. Age, indication for tracheotomy, comorbidities, and severity of wound breakdown were also compared. RESULTS: Patients undergoing tracheotomies prior to February 2010 had no dressing applied under the tracheotomy at the end of the procedure (n = 93). Beginning in February 2010, Mepilex Ag barrier was applied beneath the tracheostomy and ties in all subjects undergoing tracheotomy (n = 41). In the cohort without Mepilex Ag, 11.8% developed skin breakdown by the time of first tracheostomy tube change. When Mepilex Ag was used to pad the tracheotomy site, no peristomal skin breakdown occurred (P = 0.02). No comorbidities were associated with postoperative ulcer formation in either cohort. CONCLUSIONS: The use of Mepilex Ag after pediatric tracheotomy reduces the occurrence of postoperative peristomal pressure ulcers.