Attenuation of Helper T Cell Capacity for TH1 and TH17 Differentiation in Children With Nontuberculous Mycobacterial Infection.

Nontuberculous mycobacteria (NTM) infect children with increasing frequency worldwide. Using blood and lymph node tissue from children with NTM lymphadenitis, and uninfected lymph node tissue from community controls, we evaluated helper T (TH) cells in functional assays of TH1/TH17 differentiation and measured the concentration of their associated cytokines at the site of infection. Circulating TH cells from infected children were attenuated in their TH1/TH17 differentiation capacity and expressed less interferon γ and interleukin 17 after polyclonal stimulation. Similar differences were observed at the site of infection, where most cytokine concentrations were unchanged relative to controls. Our data are consistent with a model wherein TH1/TH17 differentiation is attenuated in NTM-infected children.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Endoscopic management of recurrent congenital tracheoesophageal fistula: a review of techniques and results.

OBJECTIVE: Recurrent tracheoesophageal fistula (TEF) is a difficult problem in both diagnosis and management. Revision open repair with thoracotomy is challenging and has a significant associated morbidity. Because of the technical difficulty and the substantial morbidity, several authors have suggested and implemented endoscopic management. This paper reviews and describes the endoscopic techniques and management of recurrent TEF. METHODS: This retrospective study evaluates three patients who underwent endoscopic (bronchoscopic) management of recurrent TEF at Children's Memorial Hospital in Chicago, Illinois. Median follow-up is 48 months. A current literature review is presented with a synthesis of the data on techniques and results. RESULTS: Two of the three patients had successful bronchoscopic closure using fibrin adhesive. The mean number of procedures required was two. Including these patients, 62 patients with endoscopic closure of congenital TEF have been reported in the literature. The overall success rate is 60% with a mean of 2.1 procedures per patient. Of the obliterating agents described, tissue adhesive and fibrin adhesive have been employed most frequently with success rates of 48 and 55%, respectively. CONCLUSION: Endoscopic repair of recurrent TEF is an effective and safe alternative to second thoracotomy and open surgical repair. More than one endoscopic procedure is usually necessary for successful closure.

Pepsin as a biomarker for laryngopharyngeal reflux in children with laryngomalacia.

OBJECTIVES/HYPOTHESIS: Laryngomalacia is a common cause of newborn stridor. Laryngopharyngeal reflux (LPR) has been associated with laryngomalacia. Although pepsin, a component of LPR, has been associated with inflammatory diseases of the aerodigestive tract, its presence in the airways of laryngomalacia patients is unknown. STUDY DESIGN: Prospective case-control study comparing patients under age 3 years with laryngomalacia to children without laryngomalacia. METHODS: Children less than 3 years old undergoing supraglottoplasty for laryngomalacia or surgery unrelated to the airway, without a history of laryngomalacia, reflux, or respiratory disease, were offered enrollment. Supraglottic lavage samples (3 mL) were obtained from all subjects. Two-millimeter arytenoid biopsies were collected from laryngomalacia patients. Pepsin Western blot and enzyme-linked immunosorbent assay were performed. RESULTS: Ten laryngomalacia and five control subjects were enrolled. Pepsin was detected in lavages of laryngomalacia patients (8/10) but absent in controls (0/5; P = .007). Pepsin was observed more frequently in lavages (8/10) than biopsies (4/10; P = .046) of laryngomalacia subjects. Higher median pepsin concentration was observed in laryngomalacia than control lavages (P = .025). CONCLUSIONS: Pepsin in supraglottic specimens demonstrated an association with laryngomalacia, supporting a role for refluxed pepsin in laryngomalacia. These data corroborate previous work implicating pepsin in inflammatory diseases of the upper airways. Further studies are warranted to investigate the contribution of pepsin to the pathophysiology of laryngomalacia. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:2413-2417, 2017.

Safety of Ultrasound-Guided Botulinum Toxin Injections for Sialorrhea as Performed by Pediatric Otolaryngologists.

OBJECTIVE: To evaluate incidence of complications and hospital readmission as a result of ultrasound-guided botulinum toxin injections to manage sialorrhea. STUDY DESIGN: Case series with chart review. SETTING: Children's Hospital of Wisconsin. SUBJECTS AND METHODS: A case series with chart review was performed of all cases of ultrasound-guided injection of botulinum toxin by pediatric otolaryngologists from March 5, 2010, to September 26, 2014,. Primary outcomes included complications such as dysphagia, aspiration pneumonia, and motor paralysis. Secondary outcomes included hospitalization, intubation, and nasogastric tube placement. RESULTS: There were 48 patients, 111 interventions, and 306 intraglandular injections identified. Botulinum toxin type A and type B were utilized in 4 and 107 operative interventions, respectively. Type A was injected into 4 parotid and 4 submandibular glands, utilizing doses of 20 U per parotid and 30 U per submandibular gland. Type B was injected into 98 parotid and 200 submandibular glands, with average dosing of 923 U per parotid and 1170 U per submandibular gland, respectively. There were 2 instances of subjectively worsening of baseline dysphagia that self-resolved. No cases were complicated by aspiration pneumonia or motor paralysis. No patients required hospital readmission, intubation, or nasogastric tube placement. CONCLUSION: Prior published data indicated 16% complication incidence with ultrasound-guided injection of botulinum toxin. Our study found a low complication rate (0.6%) with ultrasound-guided injections of botulinum toxin to manage sialorrhea, without cases of aspiration pneumonia or motor paralysis. Of 306 intraglandular injections, there were 2 cases of worsening baseline subjective dysphagia that self-resolved.

The use of botulinum toxin B in the treatment of a post-traumatic sialocele in a 4-year-old child: A case report.

Parotid sialoceles are bothersome complications of parotidectomy and penetrating injury to the parotid gland. Though typically self-limited and responsive to conservative management, they can be particularly difficult to manage in the pediatric population where even conservative interventions are less well tolerated. We present the case of a 4-year-old child with a post-traumatic parotid sialocele that was successfully managed with a single injection of botulinum toxin B. To our knowledge, this is the first reported case of the use of botulinum toxin for this purpose in the pediatric population.

Recurrence patterns of cervical infections in children.

OBJECTIVES: (1) Elucidate the recurrence rate of pediatric cervical cellulitis and abscess (2) Evaluate the impact of pre-procedural imaging, length of stay, culture results, age and gender on readmission rate. METHODS: A retrospective review of all admissions to a tertiary pediatric hospital for cellulitis and abscess of the neck (ICD-9 682.1) from 2007 to 2013 including all readmissions within 91 days. RESULTS: There were a total of 178 admissions (171 patients) with the diagnosis of cellulitis and abscess of the neck between 2007 and 2013. The rate of surgical intervention was 74% (n=128). The overall readmission rate within 91 days was 3.5% (n=6). All patients requiring readmission had undergone a procedure during the initial admission and a second procedure during readmission. The readmission rate for patient who initially required a procedural intervention was 4.6%. There was no statistically significant effect of pre-procedural imaging, length of stay, culture results, age or gender on readmission rate. Patients with abscess >20mm in diameter had a significantly longer LOS than patient with smaller abscesses (4.265 days vs 3.667 days, p<0.001). Furthermore, in patients 3 years old or greater, the patients with a larger diameter (>20mm) and larger total size were more likely to need surgical drainage. CONCLUSIONS: This retrospective review of patients admitted with neck cellulitis and abscess at a tertiary care pediatric hospital shows an overall readmission rate of 3.5%. All readmissions required a surgical procedure. Older children with larger abscess are more likely to require surgical drainage.

Factors influencing successful peer-reviewed publication of original research presentations from the American Society of Pediatric Otolaryngology (ASPO).

OBJECTIVE: To analyze factors associated with progression of an original scientific presentation at the American Society of Pediatric Otolaryngology (ASPO) Annual Meeting to publication in a peer-reviewed journal. A dataset of presenters was created to enable prospective follow-up to assess early impressions regarding publication success with longer-term publication outcomes. METHODS: Prior to the Annual ASPO meeting in 2013, a survey consisting of 10 questions was e-mailed to all 59 presenters. Questions were designed to assess presenter expectations on publication, barriers to publishing, and experience in presenting, publishing and clinical practice. A second survey was sent 12 months later to those respondents of the first survey who were amenable to follow-up. RESULTS: Overall, 46 of 59 (78%) presenters responded to the initial survey prior to their ASPO 2013 presentation. Of these, 34 agreed to participate in a longer-term follow-up of their presentation to publication experience. Of these 34, there were 17 who participated in the follow-up survey 1 year later. Just under half of the original respondents were residents (46%). All presenters (100%) planned to re-submit a revised manuscript if initially rejected. However, 35% of follow-up respondents did not make initial submission to a peer-reviewed journal. Results of a descriptive analysis suggest that more experienced researchers expect their submitted manuscript to be accepted for publication within a shorter time frame than those that have published fewer papers. Time was ranked as the greatest barrier to publication (60%) of those surveyed both in the initial prospective survey and for those who did not publish a paper in the follow-up survey (83%). CONCLUSION: This study suggests a strong desire and expectation of publishing ASPO presentations. Despite this expectation, past research and this data set suggest this expectation often does not materialize. "Time constraints" were the most commonly identified barrier to publication. To enhance dissemination of new findings from ASPO meetings, institutions and individuals should examine methods that facilitate and incentivize publication of findings in peer-reviewed publications.

Endolymphatic duct violation during retrosigmoid dissection of the internal auditory canal: a human temporal bone radiographic study.

OBJECTIVE/HYPOTHESIS: Successful hearing preservation after acoustic neuroma resection is sometimes complicated by delayed hearing deterioration. The goal of this study was to investigate the hypothesis that internal auditory canal (IAC) drilling during retrosigmoid acoustic neuroma removal may result in endolymphatic duct (ELD) injury, a potential cause of delayed hearing loss (HL) after hearing preservation surgery. STUDY DESIGN: Temporal bone anatomic and radiographic study and literature review. METHODS: Twenty-one human temporal bones were analyzed with high-resolution multislice computed tomography (HRMCT) and subjected to standard retrosigmoid IAC dissection with labyrinthine preservation and follow-up HRMCT for analyses of the ELD. A MEDLINE search was performed of studies documenting long-term hearing preservation outcomes after retrosigmoid dissection. RESULTS: Five of 21 (24%) bones were found to have violation of the ELD despite preservation of labyrinthine structures and the endolymphatic sac. These results correlate with the mean incidence of long-term hearing decline (26.6%). Reviews of human and animal studies indicate that injury to the ELD may create endolymphatic hydrops. CONCLUSIONS: The ELD is vulnerable to injury during IAC dissection even if labyrinthine structures at the lateral aspect of the IAC are preserved. These findings may be helpful in explaining and potentially preventing some cases of long-term hearing deterioration that may be a result of endolymphatic hydrops after ELD injury during acoustic tumor removal. Careful preoperative review of imaging studies using HRMCT may prove useful before retrosigmoid dissection.

Pediatric sleep surgery.

Adenotonsillectomy is the most common surgery performed for sleep disordered breathing with good outcomes. Children with obesity, craniofacial disorders, and neurologic impairment are at risk for persistent sleep apnea after adenotonsillectomy. Techniques exist to address obstructive lesions of the palate, tongue base, or craniofacial skeleton in children with persistent sleep apnea. Children with obstructive sleep apnea have a higher rate of peri-operative complications.

Sympathetic neuropathy and dysphagia following doxycycline sclerotherapy.

This case report demonstrates neurologic sequela following treatment with doxycycline sclerotherapy. A six-week-old child presented with respiratory distress from a macrocystic lymphatic malformation, extending from the skull base to the anterior mediastinum. Following doxycycline sclerotherapy, the airway symptoms resolved; however, the child developed silent aspiration and Horner's syndrome. Two months following treatment the patient resumed oral diet and at one year post-intervention there has been no recurrence of symptoms, with only mild ptosis remaining. While neuropathies following doxycycline sclerotherapy have been described, aspiration has never been documented. This case demonstrates a single patient's clinical course and resolution of their neuropathies.