Timeline to dysphagia resolution after endoscopic intervention of an interarytenoid defect based on Video Fluoroscopic Swallow Study dysphagia severity.

INTRODUCTION: We previously reported that endoscopic repair of a Type 1 Laryngeal Cleft (LC1) or Deep Interarytenoid Groove (DIG) improves swallowing function postoperatively. However, caregivers often ask about the timeline to resolution of the need for thickening. This study re-examines this cohort to answer this important caregiver-centered question. METHODS: We reassessed a 3-year retrospective, single-center dataset of children with dysphagia found to have a LC-1 or DIG on endoscopic exam. The primary outcome was rate of complete resolution of dysphagia at 2, 6, and 12 months after endoscopic intervention. A sub-group analysis was made based on severity of dysphagia prior to intervention and by type of endoscopic repair. RESULTS: Thirty-nine patients with mean age 1.35 years that had a LC-1 or DIG met criteria for inclusion. Rate of complete dysphagia resolution increased over time. Those with mild dysphagia (flow-reducing nipple and/or IDDSI consistency 1 or 2) had brisker resolution than those with moderate dysphagia (IDDSI consistency 3 or 4) at 2 months (67% vs 5%, p < 0.01) and at 6 months (80% vs 18%, p < 0.01) after endoscopic repair. There was no difference in dysphagia resolution between patients grouped by type of endoscopic repair. CONCLUSION: Addressing an interarytenoid defect in patients will not result in immediate, complete dysphagia resolution in most patients. However, patients that only require a flow-reducing nipple and/or thickening to an IDDSI consistency 1 or 2 have brisker resolution of the need for thickening than those that require an IDSSI consistency 3 or 4 prior to intervention. These results inform pre-operative discussions of the timeline to resolution based upon severity of dysphagia and help manage caregiver expectations.

Hyper-glycemia and insulinemia induce morphological changes and modulate secretion of S100B, S100A8, amyloid ß 1-40 and amyloid ß 1-42, in a model of human dopaminergic neurons.

Glucose metabolism in neuronal tissue declines during neurodegenerative disorders in a progressive, region-specific, and disease-specific manner. Studies have shown that extracellular hyper-glycemia affects the functioning of adenosine triphosphate (ATP) sensitive potassium channels located in neurons and astrocytes. Also, hyper-insulinemia contributes to the formation and progression of Alzheimer's disease (AD) via competition with amyloid ß (Aß) for insulin-degrading enzyme. Aß disruption is phosphatidylinositol 3-kinase pathway dependent, and increased circulatory insulin concentrations lead to Aß accumulation. In 2008, based on assessment of brain glucose utilization disorders and insulin signaling disruptions, it was proposed that AD could be called "type III diabetes". Proteins from the S100 family are actively secreted during metabolic and oxidative stress, but their role in neuronal cells has yet to be clarified. However, it has been demonstrated that they act in a dose-dependent manner, which may be crucial in the modulation of glucose and insulin metabolism in the brain. The goal of this paper was to elucidate the association between high glucose and insulin concentrations with extra- and intracellular S100B and S100A8 proteins levels as well as the correlation with toxic (Aß42) and physiologic (Aß40) forms of Aß. Medium and high glucose concentrations mimicking pre-diabetic and diabetic state, caused statistically significant discharge of S100b and S100A8 protein to the extracellular compartment. Similar effect was observed after 50 nM insulin incubation. Furthermore, the correlation coefficient patterns between those proteins shows similar associations which highlights possible effective and modulating role of S100 family in the metabolic disturbances occurring in neuropathological disorders.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients.

INTRODUCTION: The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients. METHODS: A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05. RESULTS: 449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05). CONCLUSION: In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Human salivary immunoglobulin and antigen-specific antibody activity after tonsillectomy.

The importance of the lymphoid tissue collectively known as Waldeyer's ring, which includes the palatine, lingual and nasopharyngeal tonsils, in the induction and contribution of specific antibody responses in human saliva is not clear. The purpose of this study was to determine whether salivary immunoglobulin A (IgA) levels differ in quantity and quality between subjects who have had a tonsillectomy and age, sex and race-matched controls. Parotid saliva, whole saliva, and blood serum samples were collected from 25 volunteer children who had undergone tonsillectomy (T-) within 6-14 months of sampling and from 25 age, sex and race-matched controls. The levels of total IgA (and subclasses) in saliva, and of antigen-specific salivary IgA and serum IgA and IgG antibodies to 4-9 relevant antigens were analyzed by ELISA. No significant difference was observed in the mean total IgA and IgA subclass levels in parotid and whole saliva, although the mean levels for children with a T- were slightly lower. Children with a T- had significantly higher parotid salivary IgA and IgA1 specific/total activity than controls. The total and specific whole saliva IgA and the specific serum IgA or IgG activities were not significantly different from controls. These results indicate an association between the removal of tonsils and increased levels of specific IgA activity in parotid saliva within the first year after a T-.

Chloroma of the masseteric muscle.

Chloroma (leukemic infiltrate or granulocytic sarcoma) is a localized extramedullary mass of immature granulocytic cells. They are uncommon tumors that usually occur in patients with leukemia, mostly of the myeloid type. Involvement in the head and neck region is rare. Granulocytic sarcomas of the face, maxilla, paranasal sinuses, temporal bone, and pharynx have all been documented in the past. We present the first reported case of a granulocytic sarcoma involving the masseteric muscle in an 8-month-old white male diagnosed with acute myeloid leukemia (AML). The lesion resolved with chemotherapy but the patient subsequently died. This case reaffirms the importance of including chloroma in the differential diagnosis of lesions in patients with AML and the prognostic value they hold.

Postsurgical follow-up of children with tympanostomy tubes: results of the American Academy of Otolaryngology-Head and Neck Surgery Pediatric Otolaryngology Committee National Survey.

Postsurgical follow-up of children with tympanostomy tubes is becoming a contentious issue in this era of managed care. Primary care providers believe themselves to be capable of evaluating these children. Otolaryngologists, on the other hand, have more specialized equipment available to them (suction apparatus, otomicroscopes, audiology devices, etc) for treating suppurative infections and monitoring the tympanic membrane for structural changes. In addition, the otolaryngologist is placed in an uncomfortable legal and ethical position if access to the patient with a tube-related complication is denied by the primary care provider. Attempts to develop an American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) policy statement have been hampered by a lack of data on the incidence and severity of tube-related complications and the role that otolaryngologists can play in reducing these sequelae. A survey designed by the AAO-HNS Pediatric Otolaryngology Committee was distributed to 1000 board-certified otolaryngologists and all members of the American Society of Pediatric Otolaryngologists and the American Academy of Pediatrics-Otolaryngology Section regarding current practice patterns and practitioners' experiences with tympanostomy tube complications. Specific information regarding complications that could have been avoided with earlier otolaryngology referral was also obtained. The results of the survey and its implications for AAO-HNS policy are presented.

Congenital anomalies of the larynx and trachea.

A variety of congenital anomalies arise within the laryngeal or tracheal airway. Symptoms primarily include airway obstruction, hoarseness, and difficulty feeding. The diagnosis is typically made by a combination of clinical presentation, physical examination, and endoscopic evaluation. Definitive intervention may be necessary requiring endoscopic or open laryngeal surgery. Some of the more common congenital laryngeal and tracheal anomalies are discussed with respect to their diagnostic evaluation, clinical presentation, and management.

Single central maxillary incisor with nasal pyriform aperture stenosis--CT diagnosis prior to tooth eruption.

Two children with nasal pyriform aperture stenosis had the diagnosis of single central maxillary incisor made with CT scanning prior to tooth eruption and the clinical appreciation of this finding. The surgical and clinical implications of this diagnosis will be presented.

High-risk human papillomavirus types and squamous cell carcinoma in patients with respiratory papillomas.

Respiratory papillomas (RPs) are benign, virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RPs are thought to be the result of infection with the human papillomaviruses (HPVs) types 6 and 11. We surveyed archival RP specimens to determine whether there were correlations of HPV type with patient characteristics or clinical course. Paraffin-embedded papilloma specimens of 45 different patients were analyzed. We assessed HPV types using the polymerase chain reaction with E6 consensus primers, hybrid capture assays (high or low risk), and dot blot hybridization of generic E6 PCR products with E6 type-specific oligonucleotide probes. The presence and type of HPV were correlated with patient data from a retrospective chart review. We found that RPs may have either low- or high-risk HPV types and some contain multiple HPV types. Respiratory infection with high-risk HPV apparently introduces a long-term risk of squamous cell carcinoma development, even in the absence of conventional cofactors. Low-risk HPV infection may also act in association with these cofactors to promote carcinogenesis. Our data also show a racial imbalance in RP that may indicate a difference in genetic resistance and/or susceptibility to HPV infection and the development of RP.

Risk factors for hearing loss from meningitis in children: the Children's Hospital experience.

OBJECTIVES: To identify statistically significant risk factors for hearing loss in children with meningitis, determine the overall incidence of hearing loss in a large group of children with confirmed meningitis, and quantify the percentage of children with progressive or fluctuating hearing loss after meningitis. DESIGN: Retrospective analysis. PATIENTS AND OTHER PARTICIPANTS: Four hundred thirty-two children admitted to the Children's Hospital, Birmingham, Ala, from January 1, 1985, to December 31, 1995, with the diagnosis of meningitis. RESULTS: Of 432 children with meningitis, 59 (13.7%) had the development of hearing loss. Of these 59 children, 46 (78.0%) had stable sensorineural hearing loss and 13 (22.0%) had either progressive or fluctuating hearing loss. Of the variables examined using multiple logistic regression backward-elimination modeling, only 5 appeared to be significantly associated with the development of hearing loss: computed tomographic scan evidence of increased intracranial pressure (estimated odds ratio [OR] = 2.3), male sex (OR= 1.9), the common logarithm of glucose levels in the cerebrospinal fluid (OR = 0.58), Streptococcus pneumoniae as the causative organism (OR= 2.1), and the presence of nuchal rigidity (OR = 1.9). In the children with progressive hearing loss, the time for progression varied from 3 months to 4 years before hearing stabilized. CONCLUSIONS: In this study of children diagnosed as having meningitis, hearing loss developed in 59 (13.7%). Forty-six (78.0%) of these children with hearing loss had stable auditory thresholds over time, and 13 (22.0%) exhibited deterioration or fluctuation of acuity over time. Evidence of increased intracranial pressure by computed tomographic scan, male sex, low glucose levels in the patients' cerebrospinal fluid, S pneumoniae as the causative organism, and the presence of nuchal rigidity appear to be significant predictors for future hearing loss.

Pharyngeal fibrovascular polyp in a child.

Fibrovascular polyp of the upper aerodigestive tract is an uncommon tumor that may present in pediatric patients with symptoms ranging from dysphagia to asphyxiation and death. We present a unique case of a pediatric patient with an asymptomatic fibrovascular polyp noted as an incidental finding on a cervical ultrasound evaluation. This lesion extended from the posterior tonsillar pillar and prolapsed freely into the nasopharynx and esophagus. The literature relevant to this case is reviewed, and the etiology, pathophysiology, and management principles are discussed.

Isolated epithelial cysts of the uvula in children: a report of three cases.

Epidermoid cysts are unusual benign cysts that occur in the oral cavity less than 2% of the time. Epidermoid cysts isolated to the uvula are rare. A review of the literature has revealed only three confirmed cases of isolated uvular epidermoid cysts. We present a series of three such cases, two of which presented with significant symptomatology. The diagnosis and management of these unusual lesions will be discussed, as well as the differential diagnosis.

Unilateral choanal atresia: initial presentation and endoscopic repair.

The purpose of this study was to investigate the severity of presenting symptomatology in patients with unilateral choanal atresia and to assess the surgical results of patients undergoing transnasal endoscopic repair. A retrospective review of all patients with choanal atresia presenting to the author between 1990 and 1997 was performed, identifying 13 patients with unilateral choanal atresia. These patients were analyzed with respect to presenting symptomatology, preoperative computed tomography scans, appearance, type of surgical repair, and surgical results for patients undergoing endoscopic transnasal repair. Eleven patients underwent successful endoscopic transnasal repair, one patient underwent conversion to transpalatal repair after an unsuccessful attempt at transnasal endoscopic repair and one patient underwent a planned transpalatal repair. Eleven patients who underwent repair by transnasal endoscopic technique have all done well with follow-up ranging from 3 months to 7 years. Although the symptomatology of unilateral choanal atresia is not as dramatic as bilateral choanal atresia, significant airway symptomatology may be present, especially in children presenting at a very young age. It appears that transnasal repair of unilateral choanal atresia is an excellent treatment modality with excellent postoperative surgical results.

Paediatric Airway Clinic: an 18-month experience.

OBJECTIVE: The management of paediatric airway disease is an integral aspect of paediatric otolaryngology. Recently, paediatric tertiary referral centres have developed centres of excellence for various aspects of paediatric care. The Pediatric Otolaryngology Airway Clinic at The Children's Hospital of Alabama, was developed as a regional referral centre for the management of children with difficult airway problems. Primary participants include the paediatric otolaryngologist, the airway management nurse, and the speech pathologist, in addition to other health care personnel. Over an 18-month period, 195 patients were seen in the clinic. The purpose of this study was to assess both the demography and the airway pathology in this patient population-specifically evaluating presenting diagnoses, diagnostic evaluation techniques, surgical intervention, geographic and racial distribution, insurance coverage, and referral patterns. CONCLUSION: This multidisciplinary approach to the management of children with chronic tracheotomies and other conditions involving the airway provides a unique environment that optimizes care for these complex patients.

Erbe constant voltage electrocautery versus conventional variable voltage electrocautery for tonsillectomy in children.

This prospective, randomized study was performed to compare postoperative pain, blood loss, and procedure time using the Erbe electrocautery device and conventional electrocautery. The Erbe device differs from conventional cautery devices in that it produces constant voltage and variable wattage whereas conventional devices produce variable voltage and constant wattage. This means that the conventional devices allow voltage surges and constant wattage no matter what type of tissue is encountered. The Erbe device has the inherent capability to maintain constant voltage, i.e. no surging as well as varying wattage according to tissue resistance. This, in theory, allows the Erbe device to impose less tissue damage and, theoretically, less postoperative pain. Fifty-seven patients 5-21 years of age who were scheduled for adenotonsillectomy were enrolled in the study. Results indicated less postoperative pain, although blood loss appeared to be increased compared to conventional electrocautery. The Erbe electrocautery device appears to be a viable device to perform tonsillectomy in children.