Current Ear and Hearing Care Practices for Infants and Toddlers with Cleft Palate in the United States.

OBJECTIVE: To examine ear and hearing clinical practices across American Cleft Palate-Craniofacial Association (ACPA) approved teams in the United States. DESIGN: Multi-site prospective, observational, longitudinal study. SETTING: Seventeen Cleft Palate Teams in the United States. PATIENTS, PARTICIPANTS: Children with cleft palate, with or without cleft lip (CP ± L), born between 2015 and 2022, evaluated by 18 months (n = 1246). INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Standard of care otolaryngology and audiology appointments evaluated in the context of whether otolaryngology and audiology services were provided as embedded care within the team visit or as ancillary services. RESULTS: Over 71% of infants passed newborn hearing screening (NBHS). By age 18 months, only 40% of infants received audiologic follow-up while 93.6% of children received otolaryngology care. Follow-up was significantly better for infants served by teams with embedded providers versus those who refer families for ancillary services; the odds of seeing an audiologist by 18 months were three times as high among participants seen by teams with embedded audiology (OR = 3.25; CI = 2.0, 5.2) while those seen by teams with embedded otolaryngologists had more than double the odds of seeing an otolaryngologist by 18 months (OR = 2.2; CI = 1.5, 3.2). CONCLUSIONS: There is considerable variability across ACPA-approved centers in the US regarding the timing and completion of otolaryngology and audiologic follow-up for children with CP ± L. This study highlights the importance of following established standards of care and the impact that team composition and access to clinical services can have on equity of care.

Assessing Adherence to Audiologic Parameters of Care for Children With Cleft Palate: A Quality Improvement Initiative.

OBJECTIVE: To evaluate and increase adherence to an evidence-based audiologic management protocol for children with cleft palate. DESIGN: Prospective, multidisciplinary quality improvement initiative. SETTING: Tertiary pediatric hospital. PATIENTS, PARTICIPANTS: Children with cleft palate (with or without cleft lip) between the ages of 0 and 5 years (n = 205). INTERVENTIONS: A multidisciplinary team identified key drivers for nonadherence to recommended audiological follow-up and implemented interventions to improve adherence. Key drivers included provider practices and preferences, clinic logistics and flow, and patient/family awareness and education. Several interventions were implemented between 2016 and 2020, including developing an evidence-based audiologic protocol, maximizing access to audiologic clinic visits across multiple departments, cleft team education, and improved team communication. MAIN OUTCOME MEASURE(S): Completion of recommended audiologic assessment at 5 separate care milestones. RESULTS: After implementation of interventions between 2016 and 2020, adherence to recommended audiologic follow-up increased from 59% to 84%. Analysis of individual care milestones revealed that increased access to audiologic testing during team clinics resulted in the largest increase in adherence to recommended follow-up. Additionally, cause-effect analysis revealed that nonadherence due to provider-related causes decreased over the project period to a greater extent than patient/family-related causes. CONCLUSIONS: Implementation of an evidence-based audiologic care protocol and improvements in access to early hearing care are feasible in a high-volume multidisciplinary cleft clinic. Adherence to recommended audiologic management can be improved by establishing strategies to improve access to care, team member and family education, and enhanced team communication.

Differences in the Tensor Veli Palatini Muscle and Hearing Status in Children With and Without 22q11.2 Deletion Syndrome.

PURPOSE: To investigate the dimensions of the tensor veli palatini (TVP) muscle using high image resolution 3-dimensional magnetic resonance imaging (MRI) of the soft palate among children with normal velopharyngeal and craniofacial anatomy and to compare values to individuals with a diagnosis of 22q11.2 deletion syndrome (22q11DS). We also sought to determine whether there is a relationship between hypoplasia of the TVP and severity of middle ear dysfunction and hearing loss. METHODS: Three-dimensional MRI were used to collect and analyze data obtained across 53 children between 4 and 12 years of age, including 40 children with normal velopharyngeal and craniofacial anatomy and 13 children with a diagnosis of 22q11.2 DS. Tensor veli palatini muscle length, thickness, and volume as well as bihamular distance were compared among participant groups. RESULTS: A Welch's t-test revealed that the TVP in participants with 22q11DS is significantly shorter (P = .005, 17.3 vs 19.0 mm), thinner (P < .001, 1.1 vs 1.8 mm), and less voluminous (P < .001, 457.5 vs 667.3 mm3) than participants without 22q11DS. Participants with 22q11DS also had a greater (P = .006, 27.7 vs 24.7 mm) bihamular distance than participants without 22q11DS. There was an inverse relationship between TVP abnormalities noted above and the severity of audiologic and otologic histories. CONCLUSION: The TVP muscle is substantially reduced in volume, length, and thickness in children with 22q11DS. These findings serve as preliminary support for the association of patient hearing and otologic severity and TVP dysmorphology.

Subcutaneous Midline Nasal Mass in an Infant due to an Intramuscular Lipoma.

Intramuscular lipomas are rare, benign, mesenchymal tumors occurring deep in the fascia, typically involving large muscle groups in adults. We report a case of an intramuscular lipoma occurring as a subcutaneous midline nasal mass in a 3-month-old infant. The differential diagnosis of a midline mass on the glabella of an infant is important and should include developmental anomalies such as nasal glioma, nasal dermoid cyst, and encephalocele, so neuroimaging is an essential first step in evaluating these lesions to exclude intracranial extension.

The relationship between head and neck position and endotracheal tube intracuff pressure in the pediatric population.

BACKGROUND: Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2 O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients. METHODS: Patients less than 18 years of age, undergoing surgery, requiring endotracheal intubation with a cuffed ETT were eligible for inclusion. No alteration in the technique of anesthetic induction or maintenance was required for the study. Following endotracheal intubation and inflation of the cuff with the head and neck in a neutral position, the intracuff pressure was measured. The intracuff pressure was then subsequently measured with the head turned to the right, head turned to the left, head and neck flexed, and head and neck extended. RESULTS: A total of 200 patients were included in the study resulting in a total of 1000 intracuff pressure readings. When compared to the neutral position, the intracuff pressure increased in 545 instances (68.1%) with changes in position of the head and neck. An increase in intracuff pressure was noted more frequently and to the greatest degree with head and neck flexion. The pressure decreased in 153 instances (19.1%), most frequently with neck extension. CONCLUSION: Significant changes in the intracuff pressure occur with changes in head and neck position. In several cases, this resulted in a significant increase in the intracuff pressure. For prolonged cases with the head and neck turned from the neutral position, the intracuff pressure should be measured following patient positioning to ensure that the intracuff pressure is within the clinically recommended range.

Beyond laryngoscopy: Trends in advanced technique endotracheal intubation in pediatric intensive care units across the United States.

OBJECTIVES: Endotracheal intubation (ETI) is a lifesaving procedure in critically ill children. Direct laryngoscopy (DL) is the most utilized method for ETI, however advanced techniques beyond DL are indicated in some patients. The purpose of this study is to describe trends of advanced ETI techniques in the critical care setting. MATERIALS AND METHODS: Using the National Emergency Airway Registry for Children (NEAR4KIDS), advanced technique ETI quality improvement data were prospectively collected for ETIs in PICUs from April 2018 to September 2021. Those who underwent ETI with only DL or who underwent exchange of an existing endotracheal tube were excluded. RESULTS: A total of 79 patients underwent advanced technique ETI with a median age of 8 (IQR 1-17) years. Advanced technique ETI was successful on the first attempt in 46.8 % of cases, with an overall success rate of 91.1 %. 1.3 % of patients received emergent surgical airway management. The most utilized advanced ETI technique was video laryngoscopy, followed by flexible bronchoscopy, and intubation through a laryngeal mask airway (LMA). The provider discipline ultimately successful in performing advanced technique ETI was most often pediatric critical care medicine (n = 26, 32.9 %), followed by anesthesia (n = 20, 25.3 %), and otolaryngology (n = 16, 20.3 %). CONCLUSION: While often indicated in challenging clinical scenarios, advanced ETI techniques are ultimately successful in the vast majority of cases. Advanced technique ETI is a highly multidisciplinary process.

Near-Total Ear Avulsion Repaired With Primary Closure and Hyperbaric Oxygen: A Case Series and Review of the Literature.

INTRODUCTION: Near-total ear avulsion is a rare and challenging problem to repair with many techniques described; primary repair is an attractive option but is not always successful. Healing may be augmented with postoperative hyperbaric oxygen therapy (HBOT), but this technique is under-reported, and an ideal regimen is not known. The study objective is to discuss the role of HBOT in the management of ear avulsion by reviewing 2 unique cases. METHODS: Case report and review of the literature. A Pubmed search using the terms ear avulsion and postoperative hyperbaric oxygen was performed. RESULTS: Two pediatric patients presented with near-total avulsion of the auricle after suffering a dog bite. Various management options were discussed including observation, primary repair, post-auricular cartilage banking, graft reconstruction with periauricular tissue or rib cartilage, or microsurgical replantation. The decision was made to perform primary reattachment, followed by adjuvant hyperbaric oxygen therapy (HBOT). The patients achieved favorable esthetic results and continue to maintain the function of the reattached ear. Photo documentation was obtained throughout the process. DISCUSSION: There is no consensus on the management of near-total ear avulsion. Primary repair is ideal from a cosmetic and ease-of-operation standpoint but does not always yield viable tissue. The use of postoperative HBOT is an attractive option that may boost success rates, but the ideal HBOT regimen is unknown. These cases represent a successful application of this innovative technique in a pediatric patient.

Type IA Oromandibular-Limb Hypogenesis Syndrome: A Case Report and A Case Update.

Hypoglossia is a rare congenital anomaly resulting in a small rudimentary tongue. It is classified under the oromandibular-limb hypogenesis syndrome and can be found in isolation (Type IA) but is more often associated with other congenital disorders, such as limb defects. Isolated hypoglossia cases are rare, and while feeding disorders are common, in some cases, neonatal airway obstruction is the most problematic. In the present report, we discuss two cases of newborns presenting with hypoglossia without limb deformities or visceral anomalies: one new case and a 10-year update of a previously reported case. These two cases highlight the variability in presenting symptoms and the challenges in diagnosis and management of a rare clinical entity. We focus on the discussion of early diagnosis, multidisciplinary management, and shared decision-making, with emphasis on the current therapeutic strategies available to the clinician and their limitations during the neonatal period. Early surgical multivector mandibular distraction osteogenesis can be proposed with minimal short- and long-term morbidity, pending a consistent follow-up. This clinical entity will require multidisciplinary team care into adult years.

Improving emergency airway cart efficiency in compliance with Joint Commission standards.

BACKGROUND AND OBJECTIVE: Emergency Airway Carts (EAC) are essential for pediatric otolaryngologists to provide rapid bedside care for emergent airway scenarios. At many institutions, EAC bronchoscopy equipment is individually peal-packaged due to Joint Commission (JC) standards, creating significant inefficiency in equipment assembly during time sensitive clinical settings. The objective of this quality improvement initiative was to improve the efficiency of use of our emergency airway cart equipment. METHODS: Individually peel-packaged bronchoscope equipment was replaced with JC compliant sets. Otolaryngology trainees (N = 8) and pediatric otolaryngology attending physicians (N = 11) were tested in a simulated airway emergency scenario, requiring bronchoscope assembly. Complete bronchoscope assembly and time to tracheal visualization (TTV) was measured for each participant, which started with initial clinical scenario presentation and ended with successful visualization of the trachea using the rigid bronchoscope. RESULTS: Pre-airway cart interventions, 68.4% of participants built a complete bronchoscope with no missing pieces, which improved to 100% with the new cart organization. Post-EAC interventions, all 19 participants reduced TTV significantly by a mean of 177.7 s (p < 0.001). Trainees reduced TTV by a mean of 251.2 s (46.2%, p < 0.0001) and attendings by 124.2 s (31.5%, p < 0.0022). All participants found the new airway cart sets easier to use and improved equipment setup efficiency. CONCLUSIONS: Compiling bronchoscope equipment into sterile sets allowed for improved TTV and bronchoscope quality for trainees and attending physicians while maintaining JC standards. Simulation improved confidence among both trainees and attending surgeons in providing optimal patient care in airway emergencies.

The "Frankentower:" A clinician-driven approach to enhancing endoscopic data technology.

OBJECTIVE: To develop a more efficient endoscopy tower and evaluate its capability to improve retrieval and storage of videos across 6 clinical sites. METHODS: Descriptive study that took place at tertiary care Pediatric Otolaryngology Department over a 2 year period. In collaboration with our Information Services Department and Otolaryngology endoscopy vendors, we assembled our "Frankentower" endoscopy cart using components from 3 medical device manufacturers. RESULTS: It is feasible to create a functional composite endoscopic tower. Implementation of "Frankentower" improved overall management and retrieval of endoscopy video and images in our department which lead to better patient care and facilitated education for medical students, residents and faculty. CONCLUSIONS: The "Frankentower" is a feasible, cost-effective solution to streamline the capture, access and storage of patient endoscopy exams across our operating rooms, inpatient consult service, Emergency Department and outpatient clinics.

Radiologic, genetic, and endocrine findings in isolated congenital nasal pyriform aperture stenosis patients.

BACKGROUND: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of upper airway obstruction in neonates. It can occur either associated with a solitary median maxillary central incisor (SMMCI) in 40-75% of cases or as an isolated morphogenic variant. Brain MRI is routinely performed in patients with CNPAS with a SCMMI due to the concomitant risks of intracranial midline defects of the hypothalamic-pituitary axis (HPA), holoprosencephaly, or associated endocrine dysfunction. However, the role of routine brain imaging and endocrinologic evaluation in patients with isolated CNPAS is not frequently studied given the assumption that isolated CNPAS is unlikely to be associated with any intracranial findings. OBJECTIVES: To evaluate intracranial findings on dual brain MRI imaging in isolated CNPAS patients and to determine if any radiologic, endocrinologic, or genetic abnormalities existed in these patients. METHODS: We performed a single-institution retrospective review and case series of patients with isolated CNPAS from 2006 to 2019. Findings from dual brain MRI imaging, cytogenetic and karyotype testing, and formal endocrinologic testing were analyzed for each patient and compared to reported findings in isolated CNPAS patients within the literature. RESULTS: From 2006 to 2019, 16/29 patients were identified at our institution with isolated CNPAS. Inpatient otolaryngologic consultation, CT, and brain MRI imaging was obtained after a mean postnatal age of 3.21 days, 13.5 days, and 35.91 days, respectively. Dual brain MRI imaging was obtained in 12/16 (75%) patients. In our patients, abnormal MRI findings included hypothalamic hamartoma, pars intermedius cyst, and grades 1 and 4 germinal matrix hemorrhages. No holoprosencephaly was found in any patient. Genetic testing was performed on 10/16 (62.5%) patients. Karyotyping was normal in all patients and microarray testing was abnormal in 2/10 patients that represented a 2p16.3 deletion in one patient and a 7q36 deletion causing an unbalanced translocation mutation of the Sonic Hedgehog gene in the second patient. In the latter patient, a hypothalamic hamartoma and panhypopituitarism was found. Endocrine evaluation was performed in 5 patients and was normal in 3/5 patients. CONCLUSIONS: Our case series of isolated CNPAS patients identified multiple abnormalities on radiologic, genetic, and endocrine testing; one of which that involved a defect of the HPA with panhypopituitarism resulting from a hypothalamic hamartoma. Based upon our findings, dedicated brain MRI imaging, endocrinologic, and genetic testing, should likely be considered for any newly diagnosed, isolated CNPAS patient given the uncommon but potential risk for associated intracranial abnormalities.

Perioperative Care of a Child With Cri Du Chat Syndrome.

Cri du chat syndrome (CdCS) is a chromosomal disorder resulting from a deletion in the short arm of chromosome 5. Anatomical abnormalities of the larynx result in a distinctive high-pitched, cat-like cry for which the disorder is named. Typical findings of the syndrome involve the upper airway, cardiovascular, and central nervous system (CNS). Of particular concern during anesthetic care is the potential for airway abnormalities leading to difficulties with endotracheal intubation as well as the presence of congenital heart disease (CHD). We present a 15-month-old child with CdCS who required anesthetic care during direct laryngoscopy and supraglottoplasty. The perioperative concerns of such patients are discussed, and previous reports of anesthetic care reviewed.

Factors Influencing Poor Outcomes in Synthetic Tissue-Engineered Tracheal Replacement.

OBJECTIVES: Humans receiving tissue-engineered tracheal grafts have experienced poor outcomes ultimately resulting in death or the need for graft explantation. We assessed the performance of the synthetic scaffolds used in humans with an ovine model of orthotopic tracheal replacement, applying standard postsurgical surveillance and interventions to define the factors that contributed to the complications seen at the bedside. STUDY DESIGN: Large animal model. SETTING: Pediatric academic research institute. SUBJECTS AND METHODS: Human scaffolds were manufactured with an electrospun blend of polyethylene terephthalate and polyurethane reinforced with polycarbonate rings. They were seeded with autologous bone marrow-derived mononuclear cells and implanted in sheep. Animals were evaluated with routine bronchoscopy and fluoroscopy. Endoscopic dilation and stenting were performed to manage graft stenosis for up to a 4-month time point. Grafts and adjacent native airway were sectioned and evaluated with histology and immunohistochemistry. RESULTS: All animals had signs of graft stenosis. Three of 5 animals (60%) designated for long-term surveillance survived until the 4-month time point. Graft dilation and stent placement resolved respiratory symptoms and prolonged survival. Necropsy demonstrated evidence of infection and graft encapsulation. Granulation tissue with signs of neovascularization was seen at the anastomoses, but epithelialization was never observed. Acute and chronic inflammation of the native airway epithelium was observed at all time points. Architectural changes of the scaffold included posterior wall infolding and scaffold delamination. CONCLUSIONS: In our ovine model, clinically applied synthetic tissue-engineered tracheas demonstrated infectious, inflammatory, and mechanical failures with a lack of epithelialization and neovascularization.

Clinical validation and reproducibility of endoscopic airway measurement in pediatric aerodigestive evaluation.

BACKGROUND: Endoscopic airway measurement (EAM) combines optical endoscopic instruments with open source image processing to accurately obtain airway dimensions. Preclinical models have demonstrated EAM as an accurate technique of airway measurement with the added advantage of characterizing multilevel stenosis, non-circular lesions, and distal obstruction. The aim of this prospective clinical study was to compare EAM to airway measurements obtained from endotracheal tube approximation (ETTA) during pediatric aerodigestive evaluation and to evaluate reproducibility of EAM across practitioners. METHODS: Thirty-seven pediatric patients undergoing routine microlaryngoscopy and bronchoscopy at a single tertiary care children's hospital were prospectively recruited. Patients undergoing emergent procedures were excluded. Two blinded reviewers performed airway measurements using ImageJ (NIH) as previously described and average values were compared to ETTA measurements. Additional EAMs were obtained from an ex vivo airway model by 28 separate clinicians and were analyzed by the same reviewers to evaluate reproducibility. RESULTS: EAM and ETTA measurements were themselves significantly different (p = 0.0003); however, the average absolute difference between the two methods was small (Mean: 0.5 mm, 95%CI: -2.6-1.6 mm). There were notable differences between raters such that estimates of raters with more experience were more similar to ETTA. Despite observed differences between EAM and ETTA, endoscopic airway measurement was highly correlated with ETTA (p = 0.0002, Spearman r = 0.4185), and strong agreement was observed (Bias: -0.4974 ±â€¯1.083 mm, 95% LOA: -2.62-1.625 mm). CONCLUSION: Clinical use of EAM is a valid and precise approach for quantification of airway luminal dimensions. This method may provide advantages over traditional ETTAs for evaluation of asymmetric airway morphology in the pediatric population.

Recurrent unilateral periorbital cellulitis in a pediatric patient--an anatomic abnormality.

A 2-year-old male, otherwise healthy, suffered a total of 7 episodes of recurrent right-sided periorbital celluitis (POC) which began at 11 months of age. Five of the 7 episodes of right eye swelling/erythema required hospital admission for intravenous antibiotics. Imaging studies demonstrated a well-defined dehiscence in the lamina papyracea. Endoscopic sinus surgery was performed and an abnormal uncinate process was visualized, fused to the lateral nasal wall and ethmoid bulla. Post-operatively, the patient had no further infections. Nasal endoscopy and high-resolution imaging in pediatric patients with recurrent POC could identify those who would benefit from early surgical intervention.

Long-term follow-up with mention of complications in pediatric microvascular mandibular reconstruction.

The fibular free flap has become the gold standard for mandibular reconstruction. Despite its vast array of benefits, this procedure has the potential for several complications. In the pediatric setting, the immature skeleton sets the stage for an increased risk of future skeletal abnormalities, both in the jaw, and in the donor site. Herein we describe the case of a toddler who underwent mandibular reconstruction using a fibula free flap and, years later, subsequently developed ankle instability as a result of residual fibula migration. This indicates the need for careful consideration of long-term issues in the growing pediatric skeleton prior to surgery.

Quantification of tissue-engineered trachea performance with computational fluid dynamics.

OBJECTIVES/HYPOTHESIS: Current techniques for airway characterization include endoscopic or radiographic measurements that produce static, two-dimensional descriptions. As pathology can be multilevel, irregularly shaped, and dynamic, minimal luminal area (MLA) may not provide the most comprehensive description or diagnostic metric. Our aim was to examine the utilization of computational fluid dynamics (CFD) for the purpose of defining airway stenosis using an ovine model of tissue-engineered tracheal graft (TETG) implantation. STUDY DESIGN: Animal research model. METHODS: TETGs were implanted into sheep, and MLA was quantified with imaging and endoscopic measurements. Graft stenosis was managed with endoscopic dilation and stenting when indicated. Geometries of the TETG were reconstructed from three-dimensional fluoroscopic images. CFD simulations were used to calculate peak flow velocity (PFV) and peak wall shear stress (PWSS). These metrics were compared to values derived from a quantitative respiratory symptom score. RESULTS: Elevated PFV and PWSS derived from CFD modeling correlated with increased respiratory symptoms. Immediate pre- and postimplantation CFD metrics were similar, and implanted sheep were asymptomatic. Respiratory symptoms improved with stenting, which maintained graft architecture similar to dilation procedures. With stenting, baseline PFV (0.33 m/s) and PWSS (0.006 Pa) were sustained for the remainder of the study. MLA measurements collected via bronchoscopy were also correlated with respiratory symptoms. PFV and PWSS found via CFD were correlated (R2 = 0.92 and 0.99, respectively) with respiratory symptoms compared to MLA (R2 = 0.61). CONCLUSIONS: CFD is valid for informed interventions based on multilevel, complex airflow and airway characteristics. Furthermore, CFD may be used to evaluate TETG functionality. LEVEL OF EVIDENCE: NA. Laryngoscope, E272-E279, 2018.

Designing a tissue-engineered tracheal scaffold for preclinical evaluation.

OBJECTIVE: Recent efforts to tissue engineer long-segment tracheal grafts have been complicated by stenosis and malacia. It has been proposed that both the mechanical characteristics and cell seeding capacity of TETG scaffolds are integral to graft performance. Our aim was to design a tracheal construct that approximates the biomechanical properties of native sheep trachea and optimizes seeding with bone marrow derived mononuclear cells prior to preclinical evaluation in an ovine model. METHODS: A solution of 8% polyethylene terephthalate (PET) and 3% polyurethane (PU) was prepared at a ratio of either 8:2 or 2:8 and electrospun onto a custom stainless steel mandrel designed to match the dimensional measurements of the juvenile sheep trachea. 3D-printed porous or solid polycarbonate C-shaped rings were embedded within the scaffolds during electrospinning. The scaffolds underwent compression testing in the anterior-posterior and lateral-medial axes and the biomechanical profiles compared to that of a juvenile ovine trachea. The most biomimetic constructs then underwent vacuum seeding with ovine bone marrow derived mononuclear cells. Fluorometric DNA assay was used to quantify scaffold seeding. RESULTS: Both porous and solid rings approximated the biomechanics of the native ovine trachea, but the porous rings were most biomimetic. The load-displacement curve of scaffolds fabricated from a ratio of 2:8 PET:PU most closely mimicked that of native trachea in the anterior-posterior and medial-lateral axes. Solid C-ringed scaffolds had a greater cell seeding efficiency when compared to porous ringed scaffolds (Solid: 19 × 104 vs. Porous: 9.6 × 104 cells/mm3, p = 0.0098). CONCLUSION: A long segment tracheal graft composed of 2:8 PET:PU with solid C-rings approximates the biomechanics of the native ovine trachea and demonstrates superior cell seeding capacity of the two prototypes tested. Further preclinical studies using this graft design in vivo would inform the rational design of an optimal TETG scaffold.

The treatment of otorrhea in children with cleft palate: An institutional review.

We conducted a retrospective observational chart review to characterize otorrhea in patients with cleft palate (CP) after tympanostomy tube placement in terms of the bacteria profile, treatment effectiveness, and overall disease burden. A total of 157 patients over 6 years were reviewed. Fifty of the 157 patients (31.8%) experienced postoperative otorrhea. Of the 50 patients with otorrhea, all received topical antibiotics, 30 received oral antibiotics, and 12 received povidone-iodine irrigations. The average duration of otorrhea was 5.2 months for patients with povidone-iodine irrigations and 8.5 months for those without povidone-iodine irrigations. Methicillin-resistant Staphylococcus aureus was the most commonly cultured microorganism. The average number of total healthcare visits over a 12-month period was 13.6 per patient. We conclude that postoperative otorrhea is a common problem after tympanostomy tube placement in children with CP and places a significant burden on these patients and the healthcare system. The bacteriologic profile may be different in this population compared with the non-CP population with otorrhea after tympanostomy, and a search for more effective treatment options is warranted, including further investigation into povidone-iodine irrigations.

Routine Bronchoscopy and Fogarty Catheter Occlusion of Tracheoesophageal Fistulas.

INTRODUCTION: Use of a Fogarty catheter for emergent occlusion of tracheoesophageal fistulas (TEFs) has been described for use in unstable neonates. Our purpose was to describe a case series of elective Fogarty catheter occlusion of the TEF. MATERIALS AND METHODS: A formal operative laryngoscopy and rigid bronchoscopy were performed with Fogarty catheter placement into the fistula before surgical intervention. The balloon was inflated and gentle traction provided occlusion of the tract. An endotracheal tube was then placed in a midtracheal location irrespective of fistulous tract location. The Fogarty catheter was removed at the time of fistula ligation. RESULTS: Six patients underwent Fogarty catheter occlusion of the TEF at the time of repair. The average gestational age was 38 ± 2 weeks and birth weight was 2499 ± 399 g. Associated anomalies or comorbidities were present in 2 of 6 patients (33%). Five patients (83%) had an esophageal atresia with distal TEF, all of whom underwent surgical intervention before day of life (DOL) 2. Of these patients, 3 were performed thoracoscopically, 1 was converted from thoracoscopic to open, and 1 was initiated as an open procedure. One patient had an H-type fistula, which was repaired through a cervical approach on DOL 48. Average time required for both bronchoscopy and Fogarty placement was 10 ± 2 minutes. There were no complications associated with Fogarty catheter placement and catheter dislodgement did not occur during any of the procedures. CONCLUSION: Elective Fogarty catheter occlusion of TEF can be performed safely and expeditiously, alleviating many perioperative challenges of TEF.