Endoscopic ear surgery in children with down syndrome.

INTRODUCTION: Children with Down syndrome (DS) have a high incidence of chronic middle ear disease. Surgery to manage this disease is challenging due to the severity of illness and narrow ear canal dimensions. Endoscopic ear surgery is used to manage tympanic membrane and middle ear disease with the advantages of improved visualization and avoidance of post-auricular incisions. However, its application in children with DS has not been reported. We aim to compare the outcomes of endoscopic versus microscopic ear surgery in children with DS. METHODS: All patients with DS who underwent tympanoplasty without mastoidectomy between 2012 and 2018 were identified, and their charts retrospectively reviewed. Rate of residual perforation, hearing, surgical time, and surgical details were recorded. RESULTS: 37 surgeries in 26 patients were identified that met inclusion criteria. Two subgroups were analyzed. The first included 14 cases that were done using traditional microscopic visualization (MV). The second included 17 cases that had substantial or exclusive use of endoscopic visualization (EES). Due to a learning curve, the number of cases done endoscopically increased over time. The average age in MV was 13.9 years vs 11.0 in EES. The MV cases included 2 with cholesteatoma vs 4 in EES. In cases with adequate follow up, residual perforations were found in 1/13 MV, and 4/17 EES. All of the residual perforation cases in EES used acellular porcine submucosa grafts. None of the cases in MV used this material. Average air bone gap reduction was seen in both groups; 4.2 dB in MV, 9.8 dB in EES. Average surgical time was similar between groups; 124 min in MV, 115 min in EES. All cases in MV required a post-auricular incision and approach to the middle ear. Only four cases in EES required this approach. Six cases in EES did not require any incision outside of the ear canal for either graft harvest or middle ear approach. CONCLUSION: Endoscopic and microscopic ear surgery in children with DS have similar outcomes. There were no statistical differences in hearing results, surgical times, or residual tympanic membrane perforations, although the rate of perforations in the endoscopic group trended higher. Most endoscopic cases did not require conversion to a post-auricular approach. Endoscopic surgery allows some DS patients to avoid any incision outside of the ear canal.

Swallowing function after chemoradiation for advanced stage oropharyngeal cancer.

OBJECTIVE: Advanced-stage oropharyngeal cancer may be treated either surgically or nonsurgically. We reported previously functional outcomes after surgical resection with free-tissue transfer. In the present study, we evaluated swallowing function after combined chemoradiation for oropharyngeal cancer. STUDY DESIGN AND SETTING: Retrospective review of 30 patients treated at a tertiary academic center for Stage III/IV oropharyngeal cancer with sequential or concurrent chemoradiation from 1994 to 2003. RESULTS: Inclusion criteria were met by 27 of 30 (90%) patients. Most patients had base of tongue lesions (67%) and Stage IV disease (93%). Gastrostomy was carried out in 22 (82%) patients either before or during treatment. Three months after chemoradiation, 33% (9/27) were consuming all nutrition orally, 22% (6 of 27) were NPO, and 45% (12 of 27) had some oral intake but still required tube feeds. One year after treatment, 53% (10 of 19) had an exclusively oral diet whereas 47% still required tube feeds including 1 patient (5%) who was NPO. In patients without recurrence and follow-up length >1 year, 69% (9 of 13) were consuming all nutrition orally whereas 31% still required gastrostomy tube (G-tube) support. A higher rate of G-tube dependence was observed in patients treated for base of tongue lesions vs tonsil lesions (67% vs 25%, P = 0.049, chi(2) analysis). CONCLUSIONS: At this institution, the short-term (3-4 months) rate of G-tube dependence was similar after surgical and non-surgical treatment of oropharyngeal cancer. One year after chemoradiation, 31% of patients without recurrence still required tube feeds. SIGNIFICANCE: These results suggest that organ-preservation protocols do not reduce the prevalence of chronic dysphagia and G-tube dependence after management of oropharyngeal cancer. EBM RATING: C-4.