Contemporary Surgical Management of Craniofacial Fibrous Dysplasia Using Computer-Assisted Surgery and Intraoperative Navigation.

Craniofacial fibrous dysplasia (CFD) is a rare developmental disease of bone, which typically presents as a painless, expansile mass causing deformity of the craniofacial skeleton. In rare circumstances, compression of neurovascular structures may arise, causing symptoms such as pain, visual impairment, and hearing loss. Traditionally, CFD debulking has been performed with "freehand" techniques using preoperative imaging and anthropometric norms to determine the ideal amount of tissue removal. The advent of computer-assisted surgery, computer-aided design, and computer-aided manufacturing (CAD/CAM) has revolutionized the management of CFD. Surgeons can now fabricate patient-specific osteotomy/ostectomy guides, allowing for increased accuracy in bone removal and improved cosmetic outcomes. This series of 3 cases describe our institution's technique using patient-specific ostectomy "depth guides", which allow for maximum removal of fibro-osseous tissue while sparing deep and adjacent critical structures. These techniques can be widely applied to the craniofacial skeleton to assist in the surgical management of CFD.

Parental Knowledge of Obstructive Sleep Apnea Symptoms and Tonsillectomy in Children.

OBJECTIVE: Obstructive sleep apnea (OSA) is present in approximately 2% to 5% of children; however, only 15% of parents are reported to be knowledgeable about OSA in children. Sleep apnea in children can lead to cardiopulmonary disease, abnormal weight gain, failure to thrive, or learning difficulties. The purpose of our study is to assess parental knowledge of pediatric OSA to identify any knowledge gaps. STUDY DESIGN: Survey. SETTING: Three pediatric otolaryngology clinics associated with a tertiary care children's hospital in Buffalo, NY. METHODS: In June of 2021, parents of pediatric (0-18 years) otolaryngology patients completed a survey on their knowledge of OSA. Parents were asked to rank their concern about OSA and identify symptoms of OSA. Parental demographic data collected included gender, age, race, and educational level. Respondents were asked if their child had undergone a sleep study or tonsillectomy. RESULTS: Of the 246 parents included, 77 (31.4%) parents had a child who had a tonsillectomy, 40 (16.3%) had a child who had a sleep study done, and 25 (10.2%) had a child with both done. For recognizing the symptoms of pediatric OSA the mean was 6.3 (95% CI 5.8-6.8) out of 13 total. Symptoms least likely recognized were nocturnal enuresis and hyperactivity, 65 (27%) and 91 (37%) of parents correctly identifying these symptoms, respectively. Greater concern about OSA correlated with greater cumulative knowledge score (P < .001). Parents whose child had undergone a tonsillectomy were more likely to be concerned about OSA in children compared to non-tonsillectomy parents (P = .003), and sleep study parents were also more likely to be concerned about OSA than non-sleep study parents (P = .045). CONCLUSION: Parents who attended a pediatric otolaryngology clinic have knowledge gaps about pediatric sleep.

Proposed ultrasound algorithm to differentiate thyroglossal duct and dermoid cysts.

OBJECTIVE: 1) To assess reproducibility of the previously established SIST score. 2) To determine inter-observer agreement in using ultrasound (US) characteristics to differentiate thyroglossal duct cyst (TGDC) from dermoid cysts (DC) 3) Improve the method used to pre-operatively differentiate TGDC from DC. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care pediatric hospital. SUBJECTS AND METHODS: An electronic medical record was queried to identify children with midline neck masses who underwent pre-operative neck US and had a histopathologic diagnosis of either TGDC or DC. Two pediatric radiologists, blinded to the pathologic diagnosis, evaluated the US images and documented the presence of pre-determined characteristics of each mass. Potential differentiating factors were analyzed for their predictive power. The SIST (septations, irregular walls, solid components = TGDC) score was determined as well as inter-observer agreement. Using the characteristics that had significant predictive power, we used the data to develop an algorithm to improve predicting cyst type. RESULTS: Pathologically, there were 47 TGDC and 25 DC. The inter-observer agreement about the pathologic diagnosis between the two radiologists was substantial, K = 0.66. Overall, the SIST score predicted the correct diagnosis 67% of the time. Radiologist 1 and radiologist 2 were more accurate than the SIST score alone, making the correct diagnosis 96% and 86% of the time, respectively. In our study, we found that the most important US characteristics in differentiating TGDC and DC are: internal Septations, depth relative to Strap muscles, Shape and Solid parts (4 S algorithm). The SIST score criteria were individually shown to be significant and sensitive in recognizing DC, however, they were not specific and often misclassified TGDC as DC. We developed a new sequential filtering algorithm that more accurately differentiates cysts. This new algorithm uses step-wise filtering of characteristics, first for Septations, then for depth to Straps, then Shape of the cyst and lastly Solid parts (4 S algorithm). This algorithm correctly categorized cyst type in 100% of patients in our study. CONCLUSIONS: Pre-operatively differentiating TGDC and DC continues to be a challenge. Using our 4 S algorithm, we can more definitively differentiate TGDC from DC compared to the SIST score. All SIST score characteristics were significant and sensitive in detecting dermoid cysts, however, not very specific. The radiologists' judgment and accuracy was better than the SIST score. The 4 S algorithm uses sequential filtering of important characteristics: Septations, depth to Straps, Shape of cyst and lastly Solid parts to improve diagnostic accuracy.

A Comparison of Bipolar Electrocautery and Chemical Cautery for Control of Pediatric Recurrent Anterior Epistaxis.

OBJECTIVE: To compare the outcome of children with anterior epistaxis treated intraoperatively with either bipolar electrocautery or silver nitrate chemical cautery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care pediatric otolaryngology practice. SUBJECTS: Children aged 2 to 18 years treated with either intraoperative bipolar electrocautery or silver nitrate chemical cautery of the anterior nasal septum for recurrent anterior epistaxis. METHODS: Any reported bleeding event after surgery was recorded. The mean time from surgery to recurrent epistaxis was compared between groups. RESULTS: Fifty patients underwent bipolar electrocautery, while 60 patients underwent silver nitrate chemical cautery. Within 2 years, 1 (2%) patient in the bipolar electrocautery group and 13 (22%) patients in the silver nitrate chemical cautery group had recurrent epistaxis (P = .003). Two years after treatment, there was no difference between treatment groups. Overall, 4 patients (8%) had recurrent epistaxis postoperatively in the bipolar electrocautery group at a mean of 4.34 years after treatment, while 17 (28.3%) patients recurred after a mean of 1.53 years of treatment in the silver nitrate chemical cautery group (P = .01). CONCLUSION: Compared to those treated with chemical cautery, those treated with bipolar electrocautery had a longer nosebleed-free period and a lower incidence of recurrent epistaxis within 2 years of treatment. Beyond 2 years, the treatment methods are equivocal. Bipolar electrocautery may be a superior treatment in children who will not tolerate in-office chemical cautery, in those with a risk of severe bleeding, or when it can be combined with other operative procedures.

Medical and surgical management of congenital laryngomalacia: a case-control study.

OBJECTIVE: To compare the growth of infants with moderate to severe laryngomalacia who underwent supraglottoplasty to the growth of those treated with medical therapy alone. STUDY DESIGN: Case-control study of patients treated between 2008 and 2013. SETTING: Tertiary care pediatric otolaryngology practice. SUBJECTS AND METHODS: Fifty-one infants newly diagnosed with moderate to severe congenital laryngomalacia. Seventeen infants underwent supraglottoplasty and 34 matched controls had medical management, which included acid suppression therapy, speech and swallowing therapy, and/or high-calorie formula. The primary outcome measure was weight percentile recorded at the second clinic visit and at the last available follow-up. The secondary outcomes were the need for primary or revision supraglottoplasty, tracheostomy or gastrostromy, or the development of or persistence of failure to thrive. RESULTS: There was no difference in the mean weight percentile between the surgical and nonsurgical groups at the time of last follow-up (P = .89). The mean change in weight percentile during the study period was 32% (95% CI, 15%-48%) in the supraglottoplasty group and 31% (95% CI, 22%-40%) in the medical group (P = .97). Five of 5 (100%) patients with failure to thrive managed surgically and 10 of 10 (100%) managed medically were above the fifth percentile at the end of the follow-up period. One (3%) patient in the medical management group required tracheostomy and gastrostomy tube placement. CONCLUSIONS: Medical management and close observation of infants with moderate to severe congenital laryngomalacia may be a viable alternative to supraglottoplasty in appropriately selected infants.

Head and neck dog bites in children.

OBJECTIVES: 1) Demonstrate patterns of dog bite injury to the head and neck in children. 2) Identify treatment outcomes of dog bite injuries to the head and neck. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Children aged 0 to 19 years, treated for head and neck dog bites at our tertiary care children's hospital (1999-2007), were included. Demographics, dog breed and ownership, seasonal incidence, wound location, characteristics, management, and complications were recorded. RESULTS: Eighty-four children, aged 10 months to 19 years (mean, 6.19 years) underwent primary repair of head and neck dog bite injuries. The cheek (34%) and lips (21%) were involved most commonly. Average wound length was 7.15 cm. Dog bite incidence peaked during summer months. Infection occurred in 10.7 percent. Pulsed dye laser was used to improve cosmesis. CONCLUSIONS: Children are vulnerable to head and neck dog bite injuries. Wound healing is excellent despite a contaminated wound. Infections occur infrequently. Pulsed dye laser improves cosmesis.

Surgical management of drooling: clinical and caregiver satisfaction outcomes.

INTRODUCTION: Various surgical techniques are used to manage problematic drooling. These include: (1) re-routing of the submandibular ducts/excision of the sublingual glands (group 1), (2) excision of the submandibular glands/parotid duct ligation (group 2), and (3) ligation of the parotid and submandibular ducts (group 3). PURPOSE: To compare the long-term effectiveness of three surgical techniques and to evaluate long-term caregiver satisfaction. SETTING: Tertiary care children's hospital. STUDY DESIGN: 10 year retrospective chart review and telephone follow-up questionnaire. METHODS: Demographic data, drooling severity, medical management and surgical outcomes using objective severity ratings were evaluated. Satisfaction scores were obtained by phone interview. RESULTS: 33 patients, 19 male and 14 female, age 1.1-27.6 years (mean 9.4+/-4.9) underwent surgery. Six patients were in group 1, 14 in group 2 and 13 patients in group 3. There was no difference in age, sex or severity of drooling among groups. Mean follow-up was 4.5 years (range 1.1-10 years). Post-operative anti-cholinergic use was most common in group 3 (53%) compared to 21% in group 2 and 33% in group 1. Overall caregiver satisfaction for each group was 83% for group 1, 79% for group 2, and 30% for group 3. Gradual return of drooling occurred in 8 of 13 (61%) patients in group 3 and resulted in dissatisfied caregivers. CONCLUSIONS: Although recent literature advocates four-duct ligation, our long-term results do not appear favorable. Reasons for this failure and strategies for avoidance are discussed.

Revision adenoidectomy--a retrospective study.

BACKGROUND: Adenoid "re-growth" is a poorly understood phenomenon. While parents often express concerns regarding the potential for adenoid "re-growth", little information exists in the literature about its incidence and causation. PURPOSE: To establish the incidence and possible contributing factors leading to adenoid re-growth in children. DESIGN: Retrospective case series review. SETTING: Tertiary care children's hospital. METHODS: The charts of 106 patients who underwent revision adenoidectomy between 1995 and 2006 were reviewed. Thirty-four patients were excluded because the primary adenoidectomy was performed elsewhere or initially only a partial adenoidectomy was performed. In the remaining 72 patients, demographic data, clinical presentation, associated medical conditions and findings at surgery were studied. RESULTS: During the 11-year study period. 13,005 adenoidectomies or adenotonsillectomies were performed; 72/13,005 (0.55%) underwent revision adenoidectomy. The mean (+/-S.D.) age at presentation for primary adenoidectomy was 3.68+/-2.9 and 7.69+/-4.04 years for secondary ("revision") adenoidectomy with an average time interval of 4.3 years between surgeries. Age at initial adenoidectomy was not a significant factor in predicting revision adenoid surgery. 29/72 (40%) underwent a reflux work up including scintiscan with gastric emptying, 24h pH probe, or laryngoscopy. 28/29 (96%) were diagnosed with reflux. At least 15/72 (21%) were reported to have symptoms consistent with adenoid re-growth which were found to be caused by tubal tonsil hyperplasia. CONCLUSIONS: Revision adenoidectomy rarely needs to be performed. Tubal tonsillar hyperplasia, as opposed to re-growth of residual adenoid tissue previously removed, accounts for some cases. Extraesophageal reflux is a possible cause in some and requires further study.