Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database.

OBJECTIVES: This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO). DESIGN: Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012. SETTING: Inpatient database from the United States. PARTICIPANTS: Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic. INTERVENTIONS: Mandibular distraction osteogenesis. MAIN OUTCOME MEASURES: Length of hospital stay, adjunct airway and nutritional interventions and disposition. RESULTS: The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32). CONCLUSIONS: Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.

Feeding Performance and Outcomes in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis.

To describe perioperative feeding performance in infants with Robin sequence (RS) who underwent mandibular distraction osteogenesis (MDO).A retrospective study of infants that underwent MDO from May 2010 to December 2019.Tertiary pediatric hospital.A total of 40 patients underwent MDO and 20 met inclusion criteria. Of the included infants, 6 had an associated syndrome and 80% were male.Time to full oral feeds, rate of G-tube placement, and change in weight percentile following MDO.Average oral intake prior to MDO was 22.1% of individual goal feeds. Among the 15 (75%) children that did not require G-tube placement, mean time to full oral feeds after MDO was 11 days ± 5.7 days, with 80% of infants reaching full oral feeds within 2 weeks after extubation. The proportion of G-tube placement in patients with a syndrome was higher than in isolated RS (-0.6; 95% CI: -1.0, -0.2). Mean percentages of weight-for-age percentile decreased during the first 3 months after the procedure. This was followed by a mean upturn in weight starting after the third month after MDO with a recovery to preoperative mean weight-for-age percentiles by 6 months after surgery.This study suggests that infants with RS may achieve full oral feeds despite poor feeding performance before MDO. Infants with syndromic RS are more likely to require G-tube. These findings may be used to inform G-tube discussion and offer a timeline to work toward goal oral feeds for infants with RS after MDO.

Catalytic Asymmetric Radical-Polar Crossover Hydroalkoxylation.

Asymmetric intramolecular hydrofunctionalization of tertiary allylic alcohols is described. This metal hydride-mediated catalytic radical-polar crossover reaction delivers corresponding epoxides in good to high enantioselectivity and constitutes the first example of asymmetric hydrogen atom transfer-initiated process. A series of modified cobalt salen complexes has proven optimal for achieving good efficiency and asymmetric induction. Experimental data suggest that cationic cobalt complexes may be involved in the enantiodetermining step, where cation-π interactions in the catalyst contribute to the asymmetric induction.

Congenital Vallecular Cyst as a Cause of Neonatal Stridor and Apnea.

An infant who presents with stridor and apnea constitutes a challenge for emergency physicians in terms of diagnosis and management. Among the rarest of causes for these symptoms, congenital vallecular cysts can cause devastating outcomes if left undiagnosed. Reported here is a case of intermittent episodes of stridor and apnea in a 4-day-old neonate with a previously undiagnosed vallecular cyst. The process by which the infant was stabilized, correctly diagnosed, and successfully treated for a life-threatening airway obstruction is explained. After a discussion of vallecular cysts, methods for preparing for and executing proper airway management in an infant who presents with apnea and stridor are considered.

Regio- and Stereospecific C- and O-Allylation of Phenols via π-Allyl Pd Complexes Derived from Allylic Ester Carbonates.

Two complementary strategies have been developed for the C- and O-allylation of phenols via a common π-allyl Pd complex. While O-allylation of phenols by this method is a well-recognized reaction of general utility, the associated para-selective C-allylation reaction is still in its infancy. Cationic π-allyl Pd intermediates, derived from allylic ester carbonates and palladium(0) catalyst, were found to undergo the Friedel-Crafts-type para-selective C-allylations with nine different phenols. Both C- and O-allylated products were obtained in good to excellent yields following a metal-catalyzed regio- and stereospecific substitutive 1,3-transposition. Conditions were also identified that control access to either allylated product. Finally, a study of the equilibrium established between the two allylation products revealed that the O-allylated compound was the kinetic product and the C-allylated compound the thermodynamic product.

Occupational Noise Exposure in the Pediatric Dental Setting.

Purpose: To evaluate the noise levels recorded in a hospital-based pediatric dental clinic and evaluate the occupational exposure personnel have to potentially hazardous levels of noise. Methods: A SoundAdvisor™ Sound Level Meter Model 831C was used to gather 19 days of background sound data (equivalent continuous sound levels, measured as LAeq) in the open bay, quiet room, sedation suite, and operating room settings. A Spartan™ Wireless Noise Dosimeter Model 730 (Larson Davis) was utilized to capture data about personal noise exposure of pediatric dental residents over 81 clinic sessions. Personal noise exposure was compared to the Occupational Safety and Health Administration (OSHA) stand- ard. Results: Background A-weighted sound pressure level was significantly less for the open bay than in the operating room, quiet room, and oral sedation setting (P<0.05), while the operating room was significantly less than the oral sedation setting (P=0.038). Personal LAeq was significantly less for the open bay than the quiet room (P=0.007) and oral sedation settings (P=0.007). There was a significantly larger percentage of time above 80 dBA captured in the oral sedation suite compared to the open bay (P=0.010) or operating room (P=0.023). Conclusions: Daily occupational noise exposure did not exceed the thresholds set forth by OSHA. Sedation and quiet room treatment settings were noted to be the loudest pediatric dental clinical environments.

Congenital Cytomegalovirus Testing Outcomes From the ValEAR Trial.

OBJECTIVE: To determine the positivity rate of congenital cytomegalovirus (cCMV) testing among universal, hearing-targeted CMV testing (HT-cCMV) and delayed targeted dried blood spot (DBS) testing newborn screening programs, and to examine the characteristics of successful HT-cCMV testing programs. STUDY DESIGN: Prospective survey of birth hospitals performing early CMV testing. SETTING: Multiple institutions. METHODS: Birth hospitals participating in the National Institutes of Health ValEAR clinical trial were surveyed to determine the rates of cCMV positivity associated with 3 different testing approaches: universal testing, HT-cCMV, and DBS testing. A mixed methods model was created to determine associations between successful HT-cCMV screening and specific screening protocols. RESULTS: Eighty-two birth hospitals were surveyed from February 2019 to December 2021. Seven thousand six hundred seventy infants underwent universal screening, 9017 infants HT-cCMV and 535 infants delayed DBS testing. The rates of cCMV positivity were 0.5%, 1.5%, and 7.3%, respectively. The positivity rate for universal CMV screening was less during the COVID-19 pandemic than that reported prior to the pandemic. There were no statistically significant drops in positivity for any approach during the pandemic. For HT-cCMV testing, unique order sets and rigorous posttesting protocols were associated with successful screening programs. CONCLUSION: Rates of cCMV positivity differed among the 3 approaches. The rates are comparable to cohort studies reported in the literature. Universal CMV prevalence decreased during the pandemic but not significantly. Institutions with specific order set for CMV testing where the primary care physician orders the test and the nurse facilitates the testing process exhibited higher rates of HT-cCMV testing.

Ultrasound characterization of middle ear effusion.

PURPOSE: To further enhance and assess the ability to characterize middle ear effusion (MEE) using non-invasive ultrasound technology. MATERIALS AND METHODS: This is a prospective unblinded comparison study. Fifty-six children between the ages of 6 months and 17 years scheduled to undergo bilateral myringotomy with pressure equalization tube placement were enrolled. With the child anesthetized, the probe was placed into the external ear canal after sterile water was inserted. Ultrasound recordings of middle ear contents were analyzed by computer algorithm. Middle ear fluid was collected during myringotomy and analyzed for bacterial culture and viscosity. RESULTS: Ultrasound waveforms yielded a computer algorithm interpretation of middle ear contents in 66% of ears tested. When a result was obtained, the sensitivity and specificity for successfully characterizing middle ear fluid content as either void of fluid, thick fluid (mucoid), or thin fluid (serous or purulent) were at least 94%. Mucoid effusions had higher measured viscosity values (P=.002). Viscosity measures were compared to culture result, and those with low viscosity (thin consistency) had a higher likelihood of having a positive culture (P=.048). CONCLUSION: The device sensitivity and specificity for fluid detection were 94% or greater among interpretable waveforms (66% of those tested). Although this technology provides important information of the middle ear effusion presence and characteristic, further technological improvements are needed.

Paediatric mandibular distraction: optimizing outcomes.

PURPOSE OF REVIEW: The purpose of this review is to summarize current evidence surrounding the use of mandibular distraction osteogenesis in children and to highlight recent advances in our knowledge of this subject. RECENT FINDINGS: Distraction osteogenesis of the mandible has gained in popularity since its initial description about 30 years ago. Its efficacy and safety have been well described. More recently, proper patient selection, technique modifications and long-term outcomes have been the subject of much discussion around this revolutionary technique. SUMMARY: Distraction osteogenesis of the mandible is a powerful tool for surgeons. Technological advances and high-quality research have allowed for optimization of this technique within the field of craniomaxillofacial surgery.

Simulation of laryngotracheal reconstruction with 3D-printed models and porcine cadaveric models.

Objectives: Laryngotracheal reconstruction (LTR) is a complex operation used to treat subglottic stenosis. The use of simulator models is a valuable tool in surgical trainee education, particularly for operations such as LTR that are less common outside high-volume centers. Three-dimensional (3D) printing of the human airway may provide an effective and more accessible alternative to porcine cadaveric models. The objective of this study is to compare the educational value of a 3D-printed model and a porcine cadaveric model as LTR simulation methods. Methods: Simulated LTR procedures were completed by 12 otolaryngology residents and a faculty physician on the cadaveric model and the 3D-printed simulator model. Both models were evaluated by fellowship-trained pediatric otolaryngologists to establish construct validity. Pre-procedure surveys of participants evaluated confidence and attitude toward models and post-procedure surveys evaluated confidence, overall impressions, relevance, content validity, and face validity. Results: Participants reported a similar mean increase in confidence after performing LTR on the 3D-printed model (14%) and cadaveric model (11%). Participants rated both models similarly for utility as an overall training tool and in teaching surgical planning and improving operative techniques. However, participants found the 3D-printed model more useful for teaching anatomy (p = .047). Conclusion: 3D-printed models have practical benefits over cadaveric models; they do not decompose and can be custom made to model a disease state such as subglottic stenosis. Participants reported a similar mean increase in confidence after using either simulation. The 3D-printed model is a promising simulation candidate as it compares well to an animal model and has the advantage of being more anatomically true to pediatric patients.Level of Evidence: Level 2.

Association of Pediatric Patient Demographic Factors and Scar Anatomic Features With Scar Outcomes After Surgical Repair of Cleft Lip.

IMPORTANCE: Scar outcomes following cleft lip repair are an important component of pediatric patient and family satisfaction and indicate the need for future surgical interventions. OBJECTIVE: To assess the association of pediatric patient demographic factors and scar anatomic features with scar outcomes following cleft lip surgical repair. DESIGN, SETTING, AND PARTICIPANTS: A case-control study was conducted involving 58 pediatric patients who underwent surgical repair of a cleft lip from October 31, 2008, to August 4, 2016, at a tertiary care pediatric specialty hospital. Data on patient demographic factors, cleft type, and the surgical technique used were collected and analyzed from June 11, 2009, to November 21, 2017. Scar outcomes were subjectively rated by 3 physicians at 6-month and 12-month postoperative intervals. MAIN OUTCOMES AND MEASURES: Overall scar outcomes at 6-month and 12-month postoperative intervals were based on rating of scar appearance, color, width, height, and alignment by using a subjective, 5-point scar-assessment scale in which 1 indicated the poorest aesthetic appearance and 5, the ideal aesthetic appearance. RESULTS: A total of 58 pediatric patients who underwent cleft lip repair were evaluated; mean (SD) age at time of repair, 4.8 (3.0) months. Of these, 44 (76%) were male and 14 (24%) were female, 37 (64%) were white, 11 (19%) were black, 7 (12%) were Hispanic, 2 (3%) were Asian, and 1 (2%) was of another race/ethnicity. Scores on the Cohen κ interrater test indicated either a substantial or almost perfect strength of agreement among the physicians grading the scar outcomes. At 12 months, patients with black skin type had worse overall scar outcomes than patients with white skin type (odds ratio [OR], -0.31; 95% CI, -1.15 to -0.14; P = .03). A depressed scar height (OR, -0.54; 95% CI, -1.32 to -0.49; P < .001), and hypopigmented scar color (OR, -0.45; 95% CI, -1.34 to -0.32; P = .002) were associated with worse scar outcomes at 12 months following surgery. The overall median lip scar outcome significantly improved between the 6-month and 12-month follow-up assessments (scar-assessment scale score, 3.3; interquartile range [IQR], 2.7-4.0 vs 4.0; IQR, 3.3-4.3; P < .001). No association was observed between the anatomic type and severity of the cleft lip and scar outcomes (unilateral vs bilateral cleft, complete vs incomplete or microform cleft, and lip height ratio of the unilateral noncleft to cleft lip). CONCLUSIONS AND RELEVANCE: This study's findings suggest that, compared with white pediatric patients, black pediatric patients exhibited worse overall scar outcomes. A depressed scar and a hypopigmented scar also were associated with overall worse scar appearance after surgical repair. Cleft lip scar outcomes were not significantly associated with the type and severity of the cleft lip.

Nonsteroidal anti-inflammatory drugs and postoperative bleeding following adenotonsillectomy in pediatric patients.

OBJECTIVE: To assess the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on bleeding for pediatric adenotonsillectomy in a retrospective study, based on the common practices at 2 different tertiary care facilities. DESIGN: A retrospective study. SETTING: Two different tertiary care facilities. PATIENTS: Children up to 16 years of age, who underwent elective adenotonsillectomy or tonsillectomy, were included in the study. All indications for adenotonsillectomy, and all surgical techniques were included. Children with a bleeding tendency, and those with contraindications to the use of NSAIDs (eg, because of allergy), were excluded from the study. INTERVENTIONS: Nonsteroidal anti-inflammatory drugs. MAIN OUTCOME MEASURE: Postoperative bleeding in patients. RESULTS: A total of 1160 patients were selected who met the criteria: 673 patients underwent an adenotonsillectomy or tonsillectomy and did not receive any preoperative and postoperative ibuprofen, and 487 patients underwent routine adenotonsillectomy or tonsillectomy and were given postoperative ibuprofen. We noted a 0.7% postoperative bleeding rate in patients who were not allowed to take ibuprofen perioperatively. There was a 1.0% postoperative bleeding rate in patients who were allowed to take ibuprofen perioperatively (P = .75). CONCLUSION: Ibuprofen is not a contraindication to adenotonsillectomy or tonsillectomy and should be used in the control of postoperative pain if it is indicated in the patient.

Hearing loss in children with growth hormone deficiency.

OBJECTIVE: Although insulin-like growth factor 1 (IGF-1) has been shown to be important for inner-ear development in animal models, little is known about the otologic and audiologic findings of children with growth hormone deficiency (GHD). The goal of this study is to evaluate the prevalence, type, and severity of hearing impairment in children with GHD. METHODS: Audiologic, otologic, and demographic data were recorded for children with a diagnosis of GHD in the AudGen database. Data for each patient were selected based on the first encounter with available complete audiometric data or the first encounter with a type of hearing loss documented. The patients were then stratified by type and severity of hearing loss, and otologic issues were documented. A separate cohort comprised of children with GHD without hearing loss was compared as a control. RESULTS: 209 children with GHD met inclusion criteria. 173 (83%) of these patients had hearing loss. 79% of losses were bilateral and 21% were unilateral (309 total ears with hearing loss). 293 of the 309 ears with hearing loss had audiograms with ear-specific thresholds; 47 had conductive, 24 had sensorineural, 65 had mixed and 157 had undefined hearing loss with incomplete audiograms. Pure-tone averages (PTA) were higher among patients with mixed hearing loss compared to patients with all other loss types. CONCLUSION: Hearing loss is prevalent in children with GHD with a predisposition to be bilateral. These findings suggest the need for increased awareness and routine hearing screening for patients with GHD. Further studies may elucidate the etiology of the hearing impairment in children with GHD to better aid pediatricians, endocrinologists, otolaryngologists and audiologists when assessing and managing these children.

PANDAS: A systematic review of treatment options.

INTRODUCTION: Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) is a rare but important condition for pediatric otolaryngologists to recognize. Several treatment options exist including tonsillectomy, antibiotic treatment/prophylaxis, intravenous immunoglobulin (IVIG), and psychiatric medications/therapy. METHODS: A systematic review of the PubMed, EMBASE, and Scopus databases was performed searching for articles that focused exclusively on the aforementioned treatment modalities in the PANDAS population. Review articles, single patient case reports, and studies examining the natural history or diagnostic strategies were excluded. RESULTS: Five articles regarding tonsillectomy treatments with level of evidence (LOE) 4 were found but no clear benefit could be determined. Three articles were selected involving the use of antibiotic therapy. One prospective study and one double-blind randomized control trial (DB RCT) supported the use of antibiotics but a separate DB RCT showed no benefit. Two selected articles described the use of IVIG: one unblinded RCT and one retrospective study. One prospective study on cognitive-behavioral therapy (CBT) showed benefit in PANDAS. CONCLUSION: There is a paucity of high-level studies regarding this rare disorder and no hard treatment recommendations can be made. Tonsillectomy should only be performed in those who are surgical candidates based on current published guidelines. Antibiotics are an option but provide uncertain benefit. CBT remains a low-risk option. Studies support the use of IVIG, however more investigation is needed prior to widespread adoption of this treatment given its potential risks.

Objective Outcomes of Supraglottoplasty for Children With Laryngomalacia and Obstructive Sleep Apnea: A Meta-analysis.

IMPORTANCE: Surgical intervention is the main treatment alternative for patients with severe laryngomalacia. Supraglottoplasty offers effective treatment results not only for laryngomalacia but also for concurrent obstructive sleep apnea (OSA). OBJECTIVE: To quantify the objective outcomes of supraglottoplasty for laryngomalacia with OSA via polysomnography data in the pediatric population. DATA SOURCES: A comprehensive literature search of the PubMed database was performed on May 20, 2015, using the search terms supraglottoplasty, epiglottoplasty, aryepiglottoplasty, laryngomalacia, obstructive sleep apnea, Apnea-Hypopnea Index (AHI), children, and polysomnography. There were no date restrictions. STUDY SELECTION: The literature search identified English-language studies that used polysomnography to evaluate patients with laryngomalacia and OSA after supraglottoplasty. Two reviewers screened titles and abstracts of the studies. The full texts of the studies were examined to assess their relevance to the meta-analysis. DATA EXTRACTION: Numerical polysomnography data were extracted and compared among studies where appropriate. A fixed- or random-effects model was used, when appropriate, to analyze the data and calculate effect sizes. RESULTS: Four studies were included in various subsets of the meta-analysis. After supraglottoplasty, the Apnea-Hypopnea Index (AHI) improved by a mean of 12.5 points in 4 studies (95% CI, -21.14 to -3.78; P = .005), oxygen saturation as measured by pulse oximetry nadir by 9.49 in 4 studies (95% CI, 4.87-14.12; P < .001), and Obstructive AHI by 21 points in 2 studies (95% CI, -50.3 to -8.29; P = .16). Twenty-nine of 33 children (88%) had residual disease. Patients 7 months and older had significant improvement in the AHI (P = .03). CONCLUSIONS AND RELEVANCE: Supraglottoplasty is an effective treatment modality for patients with laryngomalacia and OSA with objectively measurable benefits; however, patients will frequently have residual disease. Additional polysomnography after treatment is advised to ensure adequate resolution of the disorder.

Mononuclear phagocytes migrate into the murine cochlea after acoustic trauma.

Acoustic injury results in destruction of hair cells and numerous nonsensory cells of the cochlea. How these injured structures undergo repair is not well understood. This study was designed to examine the cochlea for the presence of mononuclear phagocytes after tissue injury caused by noise damage. We used octave band noise (8--16 kHz) at three levels (106, 112, and 120 dB) for 2 hours and studied the mice at 1, 3, 7, and 14 days after noise exposure to determine how noise affected hearing thresholds, hair cell number, and tissue injury in the cochlea. Furthermore, we assessed the cochlea for presence of inflammation by performing immunohistochemistry for CD45, common leukocyte antigen. We counted the number of CD45(+) cells that were present in the cochlea at the above-mentioned time points after noise. CD45 is present on all bone marrow-derived white blood cells and is not otherwise expressed in the inner ear. We found that, after noise exposure, there is a large increase in CD45(+) cells. These marrow-derived cells are concentrated in the spiral ligament and spiral limbus, areas that are known to be susceptible to acoustic injury. It is possible that this inflammatory response plays a role in propagating cellular damage in these areas. Immunohistochemistry demonstrates that these cochlear cells are derived from the monocyte/macrophage lineage and serve a phagocytic function in the inner ear.

Postcricoid hemangioma presenting as dysphagia: a report of 4 cases.

Hemangiomas involving the postcricoid region of the hypopharynx are rare. This report reviews our experience with 4 cases of postcricoid hemangioma, including a set of twin siblings. All patients underwent panendoscopy. All patients were managed nonsurgically. Three patients did well with dietary modification. One patient, with multiple medical problems, remains partially dependent on her gastrostomy tube. To our knowledge this report represents the largest series in the literature and the first to describe similar lesions in twin siblings. This report highlights the importance of a complete fiberoptic office examination of children who present with symptoms of dysphagia or aspiration.

Ultrasonic detection of middle ear effusion: a preliminary study.

OBJECTIVE: To assess the ability to detect and characterize middle ear effusion in children using A-mode ultrasonography. DESIGN: Prospective nonblinded comparison study. SETTING: Tertiary children's hospital. PATIENTS: Forty children (74 ears) scheduled to undergo bilateral myringotomy with pressure equalization tube placement. INTERVENTIONS: Before myringotomy, ultrasound examination of the tympanic membrane and middle ear space was performed on each ear. Afterward, myringotomy was performed and the type of effusion (serous, mucoid, or purulent) was recorded. Pressure equalization tubes were then placed. MAIN OUTCOME MEASURE: Comparison of ultrasound findings with the visual assessment of the type of middle ear effusion present. RESULTS: Of the 74 ears tested, 45 (61%) had effusion on direct inspection. The effusion was purulent in 8 ears (18%), serous in 9 ears (20%), and mucoid in 28 ears (62%). Ultrasound identified the presence or absence of effusion in 71 cases (96%) (P = .04). Ultrasound distinguished between serous and mucoid effusion with 100% accuracy (P = .04). The probe did not distinguish between mucoid and purulent effusion. CONCLUSIONS: Ultrasonography is an accurate method of diagnosing middle ear effusion in children. Moreover, it can distinguish thin from mucoid fluid. Further refinements in probe design may further improve the sensitivity of fluid detection and allow differentiation of sterile vs infectious effusion.

Stepped-dose protocol of cidofovir therapy in recurrent respiratory papillomatosis in children.

OBJECTIVE: To evaluate a stepped-dose protocol for intralesional injection of cidofovir in children with recurrent respiratory papillomatosis (RRP). DESIGN: Prospective, nonrandomized case series. SETTING: Tertiary care children's hospital. PARTICIPANTS: Eleven children undergoing evaluation for RRP from June 1, 2000, through December 31, 2001. INTERVENTION: Intralesional injection of cidofovir was performed after microlaryngoscopy and carbon dioxide laser treatment. Patients received 4 monthly injections at a concentration of 5 mg/mL and returned 1 month after the last injection for follow-up. Patients with recurrent or recalcitrant disease then started a series of 4 monthly injections at a concentration of 10 mg/mL. OUTCOME MEASURE: Papilloma stage (0-3) documented at multiple subsites by means of serial microlaryngoscopy. We calculated a severity score by summing the scores at all affected subsites. RESULTS: The severity score decreased in each of the 11 patients during the course of therapy, from a mean +/- SD of 13.7 +/- 6.0 at enrollment to 2.1 +/- 3.4 at 1-month follow-up. Six patients experienced complete resolution (stage 0) and 4 others had mild disease (stage,