Cognitive and language outcomes for pediatric hearing loss with otologic surgery.

OBJECTIVES: To test the hypothesis that surgical otologic intervention for any type of pediatric hearing loss decreases the odds for incident adverse cognitive and linguistic developmental outcomes. STUDY DESIGN: Retrospective cohort database study. METHODS: Electronic medical record data from the TriNetX Research Network were queried for children with congenital, sensorineural, conductive, and mixed hearing loss (HL) between ages 0 and 5 years. Patients were further stratified by presence (HL + surgery) or absence (HL-surgery) of surgical intervention at any point following diagnosis, including cochlear implantation, tympanoplasty with or without mastoidectomy, and tympanostomy. Primary outcomes were defined as odds for new adverse cognitive or linguistic outcomes at any point given HL treatment status [odds ratio with 95% confidence interval, (OR; 95%CI, p-value)]. Cohorts were balanced using propensity-score matching (PSM) based on US census-defined demographics and clinically relevant congenital conditions. RESULTS: Of 457,636 total patients included in the study, 118,576 underwent surgery (HL + surgery cohort) and 339,060 did not (HL-surgery). In matched cohorts, surgical otologic intervention significantly decreased the odds of developing cognitive disorders including scholastic, motor, psychological developmental disorders, and pervasive developmental delays (p < 0.01). CONCLUSIONS: Surgical interventions for treatment of pediatric HL including cochlear implantation, tympanoplasty with or without mastoidectomy, and tympanostomy should be considered as they may prevent delays in development.

Cortical Auditory Evoked Potential Testing in Children With Auditory Neuropathy Spectrum Disorder.

PURPOSE: In the present report, we reviewed the role of cortical auditory evoked potentials (CAEPs) as an objective measure during the evaluation and management process in children with auditory neuropathy spectrum disorder (ANSD). METHOD: We reviewed the results of CAEP recordings in 66 patients with ANSD aged between 2 months and 12 years and assessed the relationship between their characteristics (prevalence, morphology, latencies, and amplitudes) and various clinical features, including the mode of medical management. RESULTS: Overall, the CAEPs were present in 85.2% of the ears tested. Factors such as prematurity, medical complexity, neuronal issues, or presence of syndromes did not have an effect on the presence or absence of CAEPs. CAEP latencies were significantly shorter in ears with cochlear nerve deficiency than in ears with a normal caliber nerve. Three different patterns of CAEP responses were observed in patients with bilateral ANSD and present cochlear nerves: (a) responses with normal morphology and presence of both P1-P2complex and N2 components, (b) responses with abnormal morphology and presence of the N2 component but undefined P1-P2complex peak, and (c) entirely absent responses. None of the patients with normal, mild, or moderate degree of hearing loss had a complete absence of CAEP responses. No significant differences were uncovered when comparing the latencies across unaided and aided children and children who later received cochlear implants. CONCLUSIONS: The CAEP protocol used in our ANSD program did inform about the presence or absence of central auditory stimulation. Absent responses typically fit into an overall picture of complete auditory deprivation and all of these children were ultimately offered cochlear implants after failing to develop oral language. Present responses, on the other hand, were acknowledged as a sign of some degree of auditory stimulation but always interpreted with caution given that prognostic implications remain unclear.

A 15-year Review of 260 Children With Auditory Neuropathy Spectrum Disorder: II. Management and Outcomes.

OBJECTIVES: Following a review of the demographic and clinical characteristics of all pediatric patients diagnosed with auditory neuropathy spectrum disorder (ANSD) by a pediatric health care system from 2005 to 2020, the present report highlights the type and timing of intervention and outcomes in the same 260 patients with ANSD. DESIGN: This was a retrospective study reviewing the demographic data, medical history, imaging studies, audiological and speech language data, type of audiological intervention (hearing aids or cochlear implants), and mode of communication in 260 pediatric patients diagnosed with ANSD over a 15-year period. RESULTS: A significant decrease over time in the age at hearing aid fitting was observed. While a similar reduction in the age at implantation occurred over time, cochlear implantation is still rarely performed by 12 months of age in most ANSD patients. Among bilateral ANSD patients fitted with hearing aids, the majority (89.2%) did not benefit from conventional amplification and most received cochlear implants. Some hearing aid benefit for speech and language development was observed in 5.8%, though communication difficulties were persistent and most used a combination of oral and sign language for communication. Only six patients (5%) received significant benefit from their hearing aids for speech and language development. CONCLUSIONS: This review of ANSD management over a 15-year period reveals that hearing aids are not a viable option to develop speech and language for most infants and children with ANSD. This finding confirms previous reports and suggest that while hearing aid trials are warranted, children must be tracked closely so as to avoid delays in decision making. Cochlear implantation constitutes the major (if not only) rehabilitative intervention that allows for speech perception in patients who do not benefit from conventional amplification.

A 15-Year Review of 260 Children With Auditory Neuropathy Spectrum Disorder: I. Demographic and Diagnostic Characteristics.

OBJECTIVES: The aim of the study was to review the demographic and clinical characteristics of all pediatric patients diagnosed with auditory neuropathy spectrum disorder (ANSD) by a pediatric health care system from 2005 to 2020 and examine whether or not our diagnostic capabilities in an ANSD population have evolved as our institutional experience has grown and knowledge in the field has expanded. DESIGN: This was a retrospective study reviewing the demographic data, medical history, imaging studies, audiological and speech-language data, type of audiological intervention and mode of communication in 260 pediatric patients diagnosed with ANSD over a 15-year period. RESULTS: The study revealed that male and female children were equally affected with all levels of hearing detection being represented and that about 40% of affected children were premature and most were admitted to the neonatal intensive care unit. More than a third of our patients presented with a complex medical history and/or neural involvement while about 30% were full-term newborns with normal pregnancy, no prenatal complications or infections, normal birth weight, no neonatal intensive care unit need, no hyperbilirubinemia, no respiratory distress requiring ventilation, and no known syndrome. Review of audiological findings confirms that otoacoustic emissions are not always present in ANSD cases, and that the presence of an abnormal wave V on the auditory brainstem response tracings (only present at high intensities and with an absent intensity/latency function) is not a rare finding and should not immediately be dismissed as not being a case of ANSD. CONCLUSIONS: This review of ANSD diagnosis over a 15-year period clearly reveals the drastic improvements made in the identification of ANSD, with a drastic decrease in the age at diagnosis and a reduction in the percentage of misdiagnosed patients. The study also stresses the need for continued improvement in different areas such as genetic studies and physiological measures to help clinicians distinguish between pre- and postsynaptic ANSD.

Hearing outcomes in children with Congenital Cytomegalovirus: A multi-center, single-enterprise experience.

BACKGROUND: Cytomegalovirus (CMV) is the most common cause of non-genetic sensorineural hearing loss (SNHL) in the United States; yet screening for congenital CMV (cCMV) remains controversial. CMV related SNHL can be present at birth, or develop in a delayed manner, and it is a consistent feature in children with either symptomatic or asymptomatic disease. A retrospective chart review was performed to determine the characteristics of patients diagnosed with cCMV and SNHL. METHODS: The electronic database warehouse of the Nemours Children's Health System (NCHS) was queried from 01/01/2004 to 10/05/2019. ICD 9 (771.1) and ICD 10 (B25.9, P35.1) diagnostic codes were used to identify patients throughout the system with a diagnosis of cCMV infection. Patient demographics including gender, race/ethnicity, age of diagnosis, results of newborn hearing screening (NBHS), detection and progression of hearing loss, presence of antiviral therapy, and frequency of monitoring were collected, and descriptive statistics performed. RESULTS: Of the 170 patients confirmed to have cCMV, 153 (90%) were symptomatic and 17 (10%) were asymptomatic. CNS involvement (63.5%), radiographic evidence of disease present (69.4%), and SNHL (50.6%) were the most common manifestations of the disease. Of these 170 patients, 83 (48.8%) were determined to have SNHL eligible for evaluation. For these patients with SNHL, the average time of hearing monitoring was 50.6 months. At the time of initial reported detection 63 of 83 (76%) had bilateral hearing loss and 20 (24%) had unilateral loss. Over the study period 3 (15%) progressed from unilateral to bilateral involvement, and 32 (47%) had a deterioration in hearing, with severe to profound SNHL in at least one ear identified at the last visit in 53 (64%) patients. Newborn hearing testing results were available for 69 (83%) of those with hearing loss and 26 patients passed initial testing. However, of the 26 patients who passed, 22 (85%) eventually developed SNHL by their last visit. Within our cohort, females with cCMV were significantly more likely to have SNHL than males with cCMV (62.3% versus 37.6%; p < 0.01). CONCLUSION: In the absence of targeted or universal cCMV screening, the majority of children identified with this condition present symptomatically. Approximately one half of children with symptomatic cCMV failed NBHS at birth while at least 25% develop SNHL later in life. Children with cCMV are at high risk of delayed onset loss and such children, particularly females, should be monitored closely.

Minimally invasive endoscopic approaches to pediatric skull base pathologies.

OBJECTIVE: Endoscopic endonasal approaches to pediatric skull base lesions are rare, challenging, and present distinct considerations from adult pathology. In this study, we describe our endoscopic technical approach to various skull base lesions demonstrating the efficacy and nuances of these approaches in pediatric patients. METHODS: Pediatric patients underwent endoscopic approach for skull base lesions from January of 2015 to April of 2021 were included in the study. Presenting symptoms, indications for surgery, surgical outcomes, intraoperative and postoperative complications, length of hospital stay, and length of follow-up were documented. RESULTS: A total of 18 patients (median age 12, age-range 1-15, 53% male) underwent 19 endoscopic transsphenoidal procedures. The pathologies included craniopharyngioma (N = 5), biopsy for an unknown disease (n = 2; orbital meningioma and pituitary lymphocytic hypophysitis), pituitary adenoma (N = 2; ACTH-secreting and non-functional), Rathke's cleft cyst (n = 2), CSF leak repairs (n = 2; post-traumatic and spontaneous meningocele), juvenile nasopharyngeal angiofibroma (n = 3, 1 patient had 2 procedures) and rhabdomyosarcoma (n = 1). GTR was achieved in 11 out of 15 procedures (73.3%). Out of 10 patients with a sellar lesion, 6 patients had intraoperative CSF leak (60%). No patients experienced post-operative CSF leak. The median follow-up for all patients was 14 months (1-36 months). CONCLUSION: Anterior and middle skull base pathology in pediatric patients can be effectively operated via an endoscopic approach across a wide variety of patient ages and conditions. Minimally invasive techniques with middle turbinate and nasal septum preservation can be achieved without compromising outcomes. A wide variety of surgical repair strategies can be successfully utilized.

Cochlear implantation in a patient with mucopolysaccharidosis IVA.

Mucopolysaccharidosis IVA (OMIM 253000; also known as Morquio A syndrome) is associated with skeletal, airway, and hearing abnormalities. Cochlear implantation is an effective intervention for patients with severe-to-profound hearing loss. Patients can gain substantial improvement in auditory performance, speech perception, and their quality of life from cochlear implantation. Although severe progressive sensorineural hearing loss is a common feature of mucopolysaccharidosis IVA, no detailed description of cochlear implantation for mucopolysaccharidosis IVA has been reported. To review the effectiveness and special considerations associated with cochlear implantation in patients with mucopolysaccharidosis IVA, we here report the case of cochlear implantation in mucopolysaccharidosis IVA by a multidisciplinary team. A retrospective chart review was conducted on a 34-year-old female with mucopolysaccharidosis IVA, who received a cochlear implant. Audiometric thresholds, speech perception scores, and cochlear implant processor mapping information were reviewed during the first 12 months following cochlear implantation. The results of audiological tests indicate improved hearing thresholds as well as remarkable enhancement of speech perception skills over 12 months of cochlear implant use. Cochlear implantation improved auditory performance in a mucopolysaccharidosis IVA patient with postlingually severe-to-profound sensorineural hearing loss. The benefits of cochlear implantation could be meaningful for other Morquio patients with progressive hearing loss, although the risks of surgery and anesthesia should be carefully considered by a multidisciplinary team of experts during the cochlear implant candidacy process.

Transmastoid access in branchio-oto-renal syndrome: A reappraisal of computed tomography imaging.

OBJECTIVE: To evaluate for temporal bone abnormalities that might affect transmastoid surgery such as cochlear implantation in cases of branchio-oto-renal syndrome (BOR). STUDY DESIGN: Retrospective review. METHODS: Qualitative assessment of temporal bone computed tomography imaging was performed by a neuroradiologist for 30 individuals with BOR (60 ears) and 20 controls with normal hearing (20 ears). Transmastoid access was assessed categorically across 4 features: tip development, cortex pneumatization, tegmen height, and facial recess pneumatization. The appearance of 4 standard landmarks (Koerner's septum, antrum, prominence of the horizontal semicircular canal, incudal short process) was also dichotomized as normal or abnormal. Data were compared using Fisher's exact testing. RESULTS: Mastoid height differed between the groups with tip underdevelopment noted in 72% of BOR ears vs. 40% of controls (p = 0.02), and a low tegmen was seen in 68% of BOR ears and 25% of controls (p < 0.01). Significant differences in pneumatization were also found for the mastoid cortex (28% non-pneumatized in BOR vs. 5% in controls; p = 0.03) and the facial recess (27% non-pneumatized in BOR vs. 0% in controls; p = 0.01). Standard landmarks were easily identified in all of the control mastoids. In the BOR group, Koerner's septum was abnormally located or absent in 45%, and the antrum was severely hypoplastic or absent in 50%. Similarly, the prominence of the horizontal semicircular canal and the short process of the incus were dysplastic in 73% (44/60) and 62% (37/60), respectively. CONCLUSIONS: Mastoid abnormalities are common in BOR syndrome. Restricted transmastoid access and abnormal or absent mastoid landmarks should be anticipated in those patients with BOR who become cochlear implant candidates. LEVEL OF EVIDENCE: 4.

Natural History of Tympanic Membrane Retraction in Children with Cleft Palate.

OBJECTIVES: The natural history of tympanic membrane retraction is unpredictable. To obtain prognostic information for guiding surveillance and treatment, a cohort of children with retraction from cleft palate were prospectively followed for over 5 years. MATERIALS AND METHODS: This was a prospective observational study at a tertiary academic institution. Children with pars tensa retraction were selected from a cohort of 143 children with cleft palate. Thirty-seven ears were assessed with otoendoscopic image capture and audiometry at a median age of 9 years and reassessed at a median follow-up interval of 6.4 years. The severity of tympanic membrane retraction in the serial images of each ear was compared by four pediatric otolaryngologists blinded to the dates of the images. RESULTS: Initially, 19/37 retractions (51%) demonstrated contact with the incus and/or promontory. Follow-up images were rated as stable (n=16) or better (n=12) for 28/37 retractions (76%). Of the nine retractions that became more extensive, two developed cholesteatoma (5% of the total). No ossicular erosion developed in ears without cholesteatoma. Conductive hearing loss (4-tone average air-bone gap >25 decibels hearing level) was initially present in five ears, worsened in one, and normalized without intervention in others. No ears with initial normal hearing developed hearing loss. CONCLUSION: Most tympanic membrane retractions remained stable or improved over time in this cohort of children who were at a risk of persistent eustachian tube dysfunction. Clinically significant progression occurred infrequently, justifying the conservative approach taken to manage these retractions. Such data are necessary to weigh the potential benefit of preventive intervention over observation.

Monopoly Airplane Lands in Esophagus Leading to Difficult Extraction: A Case Report on Anesthesia and Surgical Considerations.

A 2-year-old child presented with an airplane game piece from the board game Monopoly lodged in her esophagus. The airplane's wings, engines, and winglets acted like fish hooks that entered the esophageal mucosa easily but were difficult to extract. Chest radiographs were used to estimate the airplane wingspan dimensions, and a Foley catheter was used to dilate the esophagus to allow foreign body extraction via rigid esophagoscopy with optical forceps. Deliberate deep placement of the endotracheal tube facilitated surgical manipulation. This case report highlights the importance of teamwork, communication, and the involvement of multiple disciplines, each with their unique experience and expertise, to formulate a plan of action for patients during unique surgical emergencies.

Preliminary experience using a cochlear implant with a novel linear pedestal design.

OBJECTIVE: To assess the safety and efficiency of cochlear implantation using a novel device with a linear silastic pedestal (2 mm wide, 2 mm deep, 10 mm long) on the flat undersurface. METHODS: Operative times required to drill a linear groove (LG) for the new linear pedestal design were prospectively accrued for 46 implantations in 30 children (median age 3). Intra-operative safety was assessed during each case. Instances of dural exposure in the base of the LG were noted. Length of stay was also recorded as a secondary measure of efficiency. RESULTS: Across all surgeons, the mean time needed to create the LG was 1.9 ± 1.5 min (±SD) with a median time of 1.5 min (95% Cl: 1-2 min). The range in time was 1-10 min. No intraoperative complications occurred. Intended device positioning was confirmed with on-table post-operative x-rays in all cases. 43% of patients were discharged on the day of surgery. CONCLUSIONS: The novel linear pedestal design allows for deliberate device placement while adding little additional operative time and complexity, an improvement on our current standard of care.

Vestibular evoked myogenic potential testing as an objective measure of vestibular stimulation with cochlear implants.

OBJECTIVES/HYPOTHESIS: To determine if vestibular potentials could be elicited with electrical stimulation from cochlear implants. STUDY DESIGN: Prospective cohort study. METHODS: Vestibular responsiveness to electrical stimulation from cochlear implants was assessed via vestibular evoked myogenic potential (VEMP) testing in 53 pediatric and young adult patients. RESULTS: Thirty-one participants (58%) showed at least one vestibular potential in response to acoustic stimulation; 33 (62%) had an electrically evoked vestibular response. A cervical VEMP (cVEMP) was present in 45 of the 96 tested ears (47%) in response to acoustic stimulation, and in 34 ears (35%) with electrical stimulation. An ocular VEMP (oVEMP) was elicited acoustically in 25 ears (26%) and electrically in 34 (35%) ears. In the ears with absent responses to acoustic stimuli, electrically evoked cVEMPs and oVEMPs were present in 14 (27%) and 18 (25%) ears, respectively. Electric VEMPs demonstrated shorter latencies than acoustic VEMPs (P < .01). Whereas an increased prevalence of VEMPs was seen at high stimulation levels (P < .01), there was no difference between prevalence proportions with basal (electrode 3) or apical (electrode 20) stimulation (P > .05). CONCLUSIONS: VEMPs can be elicited with electrical stimulation in a proportion of children with cochlear implants, demonstrating current spread from the cochlea to the vestibular system. The presence of electric VEMPs in acoustically nonresponsive ears, along with the shorter latencies of electrically driven VEMPs, suggests that electrical current can bypass the otoliths and directly stimulate vestibular neural elements. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:E75-E81, 2017.

Assessment of Mastoid Function with Magnetic Resonance Imaging after Canal Wall Up Cholesteatoma Surgery.

OBJECTIVE: To use magnetic resonance imaging (MRI) to assess the extent of mastoid opacification after canal wall up (CWU) cholesteatoma surgery. MATERIALS AND METHODS: Thirty-five children in whom post-operative MRI had been obtained after CWU surgery. Cholesteatoma confined to the meso- and/or epi-tympanum was removed using a transcanal approach (n=18). More extensive disease required a combined approach tympanomastoidectomy (CAT, n=17). Mastoid opacification was assessed in both ears by a neuroradiologist blind to surgical details using an ordinal scale from 0 (no opacification) to 6 (completely opacified). The primary outcome measure was presence of normal mastoid ventilation, defined by evaluation of non-operative ears as a score ≤2. The presence of normal ventilation, as well as the raw opacification scores, were compared according to type of cholesteatoma surgery: 1) transcanal, with no mastoidectomy and 2) CAT. RESULTS: Mastoid ventilation was normal in 18 post-operative ears (51%). There was no significant difference in the proportion of normally ventilated mastoids in the CAT (n=17) and transcanal (n=18) groups (p=0.318; Fisher's exact). However, mastoid opacification scores were significantly higher in the CAT group than in the transcanal group (p=0.036; Mann-Whitney U). CONCLUSION: The mastoid frequently fails to become normally ventilated after cholesteatoma surgery. Subgroup analysis suggests cortical mastoidectomy does not increase the likelihood of normal mastoid ventilation after CWU cholesteatoma surgery. MRI provides a non-invasive tool to assess mastoid function, which contributes to the current debate on optimum surgical strategies for management of the mastoid in cholesteatoma surgery. Further research will determine whether this measure of mastoid health correlates with risk of recurrent cholesteatoma.

Stimulation from Cochlear Implant Electrodes Assists with Recovery from Asymmetric Perceptual Tilt: Evidence from the Subjective Visual Vertical Test.

Vestibular end organ impairment is highly prevalent in children who have sensorineural hearing loss (SNHL) rehabilitated with cochlear implants (CIs). As a result, spatial perception is likely to be impacted in this population. Of particular interest is the perception of visual vertical because it reflects a perceptual tilt in the roll axis and is sensitive to an imbalance in otolith function. The objectives of the present study were thus to identify abnormalities in perception of the vertical plane in children with SNHL and determine whether such abnormalities could be resolved with stimulation from the CI. Participants included 53 children (15.2 ± 4.0 years of age) with SNHL and vestibular loss, confirmed with vestibular evoked myogenic potential (VEMP) testing. Testing protocol was validated in a sample of nine young adults with normal hearing (28.8 ± 7.7 years). Perception of visual vertical was assessed using the static Subjective Visual Vertical (SVV) test performed with and without stimulation in the participants with cochleovestibular loss. Trains of electrical pulses were delivered by an electrode in the left and/or right ear. Asymmetric spatial orientation deficits were found in nearly half of the participants with CIs (24/53 [45%]). The abnormal perception in this cohort was exacerbated by visual tilts in the direction of their deficit. Electric pulse trains delivered using the CI shifted this abnormal perception towards center (i.e., normal; p = 0.007). Importantly, this benefit was realized regardless of which ear was stimulated. These results suggest a role for CI stimulation beyond the auditory system, in particular, for improving vestibular/balance function.

Advances in the diagnosis, management, and treatment of neonates with laryngeal disorders.

Neonatal airway obstruction due to laryngeal pathology may cause significant morbidity and even mortality. The most frequently occurring etiologies anatomically from superiorly to inferiorly include: laryngomalacia, saccular cyst, vocal fold paralysis, anterior glottic web, laryngeal atresia, laryngeal cleft, subglottic stenosis, and subglottic hemangioma. The pathophysiology, presentation, and treatment options for each of these entities are discussed with a focus on a multidisciplinary, evidence-based approach.

A preliminary report of percutaneous craniofacial osteoplasty in a rat calvarium.

OBJECTIVES/HYPOTHESIS: To evaluate the potential for injectable, permanent bone augmentation by assessing the biocompatability and bioactivity of subperiosteal hydroxylapatite (Radiesse) deposition in a rat model. STUDY DESIGN: Randomized controlled animal model. METHODS: Fourteen adult Sprague Dawley rats were injected in the parietal skull with 0.2 ml of hydroxylapatite (10 animals) or 0.2 ml of a carrier gel control (4 animals), using a subperiosteal injection technique on the right and a subcutaneous injection technique on the left. At 1, 3, and 6 months, three rats (1 negative control, 2 variables) were sacrificed and the calvaria were harvested. At 12 months, the remaining five rats were sacrificed. After each harvest, the specimens were processed and then examined under both light and polarized microscopy for new bone growth at the injection sites. RESULTS: The inflammatory response was limited with both hydroxylapatite and carrier injections. Injectables were still present 12 months after the injection. New bone formation was only observed when the injection was located deep to a disrupted periosteum The odds of new bone formation was 48.949 times higher (95% confidence intervals CI [2.637, 3759.961]; P=0.002) with subperiosteal hydroxylapatite injections compared to all other combinations of injection plane and injectable. CONCLUSIONS: This preliminary report of subperiosteal hydroxylapatite (Radiesse) injection in a rat model has verified the biocompatibility of injectable hydroxylapatite at the bony interface and suggests the potential for new bone formation. LEVEL OF EVIDENCE: N/A.

Resource analysis of tonsillectomy in children.

OBJECTIVES/HYPOTHESIS: To analyze variables that affect time and cost parameters of pediatric adenotonsillectomy. STUDY DESIGN: Longitudinal 7-month retrospective review of sequential tonsil and adenoid surgery at a university pediatric tertiary care hospital. METHODS: All children aged 2 to 12 years who underwent adenotonsillectomy from May 2008 to October 2008 had charts and billing records analyzed for variations in charges and times of adenotonsillectomy according to patient age, body mass index for age (BMIFA), American Society of Anesthesiologists (ASA) status, surgical indication, technology used, and teaching status of case. A total of 214 children had records reviewed. RESULTS: Statistically significant variations were observed for all measured parameters except for indications for surgery. Children 3 years and younger had shorter procedures (P = .005) and total operating room times (P = .037). Charges for supplies were lower for ASA 1 patients than for ASA 2 patients (P = .010). Obese children with elevated BMIFA required longer procedures (P = .039) and more expensive surgery (P = .003). Procedure times were shorter for Coblation (ArthroCare, Austin, TX) compared with electrocautery (P = .27) and for microdebrider compared with electrocautery (P < .001). Charges for Coblation were substantially higher (P < .001). Teaching cases took longer (P < .001). CONCLUSIONS: Charges and times for adenotonsillectomy surgery varied by patient age, BMIFA, ASA status, tonsillectomy technique, and teaching case status. Clinically salient differences were noted for ASA status, BMIFA, and surgical technique. This method of cost analysis provides useful information for resource management in tonsillectomy.

Incidence and management of rhinosinusitis after complex orbitofacial reconstruction.

OBJECTIVES/HYPOTHESIS: To examine the sinus-related sequelae of free flap reconstruction for complex orbitofacial defects. STUDY DESIGN: Retrospective chart review. METHODS: Demographic, clinical, and radiographic data on a series of 55 patients who had undergone free tissue transfer for orbitofacial reconstruction was retrospectively reviewed. Follow-up of ≥ 3 months was available for 49 patients. Outcome measures studied included clinical or radiographic evidence of sinusitis and the need for sinus surgery. RESULTS: The most commonly involved sinuses were the ethmoid (n = 40) and maxillary (n = 38) sinuses, and the anterolateral thigh was the most common flap used (n = 41). Clinical and/or radiographic sinusitis was evident in 21 patients (43%), and 10 patients (20%) required sinus surgery at some point during follow-up. Involvement of multiple sinuses in the initial orbitofacial surgery was associated with a significantly increased need for subsequent sinus surgery (P = 0.009). Adjuvant radiotherapy and adjuvant chemoradiotherapy were associated with a significantly increased risk for the development of rhinosinusitis (P = 0.045 and 0.016, respectively). CONCLUSION: Rhinosinusitis and the need for operative management of sinus obstruction are common in patients having undergone complex orbitofacial reconstruction. Careful management of the paranasal sinuses is an important component of the multidisciplinary treatment of such patients.

Microvascular free flap reconstruction of orbitocraniofacial defects.

PURPOSE: To examine the etiology, surgical extent and techniques, complications, and outcomes of microvascular free flaps (MFF) in the reconstruction of orbitocraniofacial defects. DESIGN: A retrospective, institutional review board approved study was performed of all patients undergoing MFF to repair orbitocraniofacial defects over 51 months. PARTICIPANTS: Fifty-eight patients undergoing MFF to repair orbitocraniofacial defects were included. MATERIAL AND METHODS: Variables analyzed included demographics, etiology, resection area(s), donor site, flap size, duration of surgery, complications, length of hospital stay, flap survival, and mortality. RESULTS: Fifty-eight patients underwent 61 MFFs from June 2007 to September 2011. The majority of patients were white (79.3%) and male (72.4%). The mean age was 64.1 years. The most common etiology was intraorbital and skull base extension of cutaneous squamous cell carcinoma (29.3%) followed by sinonasal squamous cell carcinoma (13.8%). Dura and/or brain were exposed in 44.8% of cases. MFFs were harvested from the anteriolateral thigh in 71.4% of cases with a 180.9 cm(2) mean flap area. The mean length of hospital stay was 15.3 days and mean length of surgical time was 11 h and 17 min. CONCLUSIONS: Complex orbitocraniofacial defects require a multi-disciplinary team skilled in surgical extirpation and advanced reconstructive techniques. MFF should be considered in the management of large defects, especially when there is dura or brain exposure. Intensive postoperative monitoring is indicated for both systemic and flap-related complications. MMFs provide excellent coverage of large areas of exposed critical skull base structures, including dura and brain, and may allow for earlier adjuvant treatment.