Choosing Wisely Canada - pediatric otolaryngology recommendations.

The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology - Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don't routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don't order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don't place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don't routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don't prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don't prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don't administer perioperative antibiotics for elective tonsillectomy in children; (8) Don't perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don't perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

Bridging the gap: Using 3D printed polycaprolactone implants to reconstruct circumferential tracheal defects in rabbits.

OBJECTIVE: 1) To assess the feasibility of reconstructing 2-cm-long circumferential tracheal defects with a 3D printed polycaprolactone (PCL) implant in rabbits. 2) To evaluate endoscopic, histologic, and functional characteristics of a PCL tracheal implant over time. METHODS: Ten New Zealand rabbits were included in this study. A 2-cm-long 3D printed PCL tracheal implant was created. All rabbits underwent surgical excision of a 2-cm-long cm segment of cervical trachea, which was reconstructed with the implant. Rabbits were sacrificed at the following time points: 0, 4, 5, 6, and 7 weeks postoperatively. At these time points, a rigid bronchoscopy was performed, and blinded evaluators calculated the percentage of airway stenosis. The tracheas were then harvested and prepared for histologic analysis. RESULTS: All rabbits survived to their date of sacrifice except for one. Rabbits were euthanized between 0 to 54 days postoperatively with a median of 30 days. All rabbits developed significant granulation tissue with an average percentage stenosis of 92.3% ± 6.1%. On histology, granulation was present with extensive neovascularization and mixed inflammatory cells. There was re-epithelialization present on the luminal surface of the PCL implant near the anastomoses but absent at the center of the implant. CONCLUSION: This study demonstrates that our 2-cm-long 3D printed PCL tracheal implant can be used to reconstruct a tracheal defect of equivalent size in a New Zealand rabbit model in the short term. However, significant granulation tissue formation limits long-term survival. Further research is warranted to limit the granulation tissue overgrowth. LEVEL OF EVIDENCE: NA Laryngoscope, 2019.

Exploring polycaprolactone in tracheal surgery: A scoping review of in-vivo studies.

INTRODUCTION: Tracheal pathology can be life-threatening if not managed appropriately. There are still some surgical limitations today for certain pathologies, such as in severe tracheomalacia, or when long segments of trachea need to be resected. Poly(ε-caprolactone) (PCL) is a polymer that has recently gained popularity for its use in tracheal surgeries in animal models and in certain human pediatric cases in hopes of addressing these difficult situations. PCL can be 3D printed or manufactured through molds to create tracheal stents, splints, patches and even to reconstruct full circumferential tracheal defects. OBJECTIVE: To perform a scoping review, and explore insights into the applications of PCL for tracheal surgeries in-vivo. METHODS: A literature search in Embase, MEDLINE, and BIOSIS was performed to include all articles available prior to December 21, 2018 without any language restrictions. We included all original research that investigated the use of a PCL implant, stent, splint, scaffold, or graft in tracheal surgeries in-vivo. Assessment of all articles were performed by two independent authors prior to inclusion for analysis. RESULTS: A total of 27 articles were included in the study. All articles were original research studies, primarily consisting of interventional studies (92.4%), there was also 2 case reports (7.4%). Articles were published in the last decade, publications range from 2009 to 2019. The most common animal model used for the tracheal surgeries were the New Zealand rabbits (n = 19, 70%). Two studies (7%) also described the use PCL in a total of 4 human cases. To investigate the PCL reconstructed airways, histology and bronchoscopy were the most commonly implemented methods of analysis in 88.9% and 70.4% respectively. Airway analysis was also done using imaging modalities including CT scan (n = 9, 33.3%), MRI (n = 2, 7.4%), X-ray (n = 1, 3.7%). 17 (62.9%) of the studies used 3D printing processes to create their PCL implants. CONCLUSIONS: Overall, this review demonstrates the feasibility of PCL in tracheal reconstruction and tracheal stenting/splinting. It highlights common trends and the limitations of the literature thus far on this topic.

Rhinologic manifestations of Burkitt Lymphoma in a pediatric population: Case series and systematic review.

INTRODUCTION: Burkitt lymphoma (BL), an aggressive form of B-cell non-Hodgkin's lymphoma, arising from the nose and paranasal sinuses is relatively rare. It can present with various symptoms leading to potential misdiagnosis and delayed treatment. BL is fatal if left untreated, while early identification and treatment can improve prognosis. OBJECTIVES: 1) To review clinical presentations and sites of involvement of six cases of pediatric BL with rhinologic manifestations and compare these with the current literature. 2) To raise awareness on the variety of presentations of BL in this particular anatomic location. METHODS: A series of six cases of pediatric (0-18 years) BL with rhinologic manifestations is presented. Age, sex, ethnicity, symptoms, imaging, staging, treatment and outcome were recorded. A systematic review of literature was also conducted using PRISMA guidelines. The search strategy used keywords related to rhinologic manifestations of BL (nasal cavity, nasopharynx, paranasal sinus etc.; Burkitt etc.) and included studies published in English and French describing patients 0-18 years of age. RESULTS: 42 patients were included (six from case series and 36 from current literature). Most common presenting symptoms were: nasal obstruction (29%), facial swelling (24%), headache (21%) and proptosis (19%). Most frequent sites of presentation were: nasopharynx (40%), maxilla (40%) and sphenoid (33%). More than half (60%) had systemic involvement, of which the most common locations were: kidney (19%), pancreas (17%) and liver (17%). Mortality from BL in children from this study population was correlated with a longer duration of symptoms prior to presentation, as well as a misdiagnosis preceding the final diagnosis of BL. CONCLUSIONS: This study brings understanding to the numerous presentations of the same aggressive disease, promotes high clinical suspicion when evaluating common otolaryngologic symptoms and can guide healthcare providers in diagnosing pediatric BL with rhinologic manifestations.

Teaching communication skills to OTL-HNS residents: multisource feedback and simulated scenarios.

BACKGROUND: Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology - Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency. METHODS: For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulation-based clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts. RESULTS: Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across post-graduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner's mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p < 0.05) as assessed by OTL-HNS staff members and peers. No significant improvement across time was found for ratings by non-medical assessors. CONCLUSION: Implementing an educational program focused on communication skills using a multisource assessment in various contexts has shown to be potentially effective at our institution, and resulted for yearly improvement and consolidation of performance of OTL-HNS residents as judged by faculty and residents. The inclusion of a multisource assessment in the simulation curriculum is key to allow for the representation of different perspectives on communication skills, for both the assessment and the debriefing process. Future studies are needed to explore the possibility of fully integrating this educational program into residence training in order to support deliberate communication skills teaching.

A longitudinal simulation-based ethical-legal curriculum for otolaryngology residents.

OBJECTIVE: To develop, implement, and evaluate a longitudinal, simulation-based ethics and legal curriculum designed specifically for otolaryngology residents. METHODS: Otolaryngology residents were recruited to participate in a yearly half-day ethical-legal module, the curriculum of which spanned 4 years. Each module included: three simulated scenarios, small-group multisource feedback, and large-group debriefings. Scenarios involved encounters with standardized patients. Residents' ethical-legal knowledge was assessed pre- and postmodule with multiple-choice questions, and ethical reasoning was assessed by a variety of evaluators during the simulated scenario using a locally developed assessment tool. Participants completed an exit survey at the end of each module. RESULTS: Eighteen residents completed four modules from the academic years of 2008 to 2009 to 2011 to 2012. The first year was considered a pilot module, and data were collected for the following 3 years. Knowledge of legal issues improved significantly among residents (mean at pre = 3.40 and post = 4.60, P < 0.05). Residents' ethical reasoning skills also improved across years (mean 3.60/5 in 2009-2010, 3.76/5 in 2010-2011, and 4.33 in 2011-2012, P < 0.05). Survey results revealed a statistically significant self-perceived improvement in ethics reasoning skills (mean pre = 3.62, post = 4.86, P < 0.05). Participants reported that the curriculum was relevant to their practice (85%), that the debriefings were of high quality (83%), and that they would recommend this module to others (88%). CONCLUSION: To our knowledge, this is the first study exploring a longitudinal simulation-based ethical-legal curriculum tailored to otolaryngology-head and neck surgery residents. This educational program resulted in a both objective and subjective improvement in legal and ethics knowledge and skills. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2501-2509, 2017.

Concha bullosa mucocele: A case series and review of the literature.

BACKGROUND: Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinges on surrounding structures and can easily be mistaken for a neoplasm. OBJECTIVE: The objective of this study was to shed light on this rare entity and report its diagnostic features and treatment outcomes. METHODS: A case series conducted in a tertiary health care center. Demographic data, clinical presentation, imaging, cultures, and treatments were recorded. Operative video illustration and key images were obtained. A review of the literature was also performed. RESULTS: A total of five cases were reviewed, four of which were concha bullosa mucoceles and one was a mucopyocele. Three of the patients had some form of previous nasal trauma. Headache and nasal obstruction were the most common symptoms with a nasal mass finding on physical examination. Computed tomography was used in all the patients, and magnetic resonance imaging was used in four of the five patients. Four patients had coexistent chronic rhinosinusitis, and three had positive bacterial cultures. All these patients were treated endoscopically either with middle turbinate marsupialization or subtotal resection. No recurrence has been noted thus far. CONCLUSION: Concha bullosa mucocele is a rare diagnosis. Imaging characteristics are helpful in considering the diagnosis, although surgical intervention is often necessary to confirm the diagnosis and treat concha bullosa mucocele.

Lund-Mackay and modified Lund-Mackay score for sinus surgery in children with cystic fibrosis.

OBJECTIVE: Patients with cystic fibrosis (CF) frequently present with severe sinonasal disease often requiring radiologic imaging and surgical intervention. Few studies have focused on the relationship between radiologic scoring systems and the need for sinus surgery in this population. The objective of this study is to evaluate the Lund-Mackay (LM) and modified Lund-Mackay (m-LM) scoring systems in predicting the need for sinus surgery or revision surgery in patients with CF. METHODS: We performed a retrospective chart review of CF patients undergoing computed tomography (CT) sinus imaging at a tertiary care pediatric hospital from 1995 to 2008. Patient scans were scored using both the LM and m-LM systems and compared to the rate of sinus surgery or revision surgery. Receiver-operator characteristics curves (ROC) were used to analyze the radiological scoring systems. RESULTS: A total of 41 children with CF were included in the study. The mean LM score for patients undergoing surgery was 17.3 (±3.1) compared to 11.5 (±6.2) for those treated medically (p<0.01). For the m-LM, the mean score of patients undergoing surgery was 20.3 (±3.5) and 13.5 (±7.3) for those medically treated (p<0.01). Using a ROC curve with a threshold score of 13 for the LM, the sensitivity was 89.3% (95% CI of 72-98) and specificity of 69.2% (95% CI of 39-91). At an optimal score of 19, the m-LM system produced a sensitivity of 67.7% (95% CI of 48-84) and specificity of 84.6% (95% CI of 55-98). CONCLUSION: The modified Lund-Mackay score provides a high specificity while the Lund-Mackay score a high sensitivity for CF patients who required sinus surgery. The combination of both radiologic scoring systems can potentially predict the need for surgery in this population.

Synchronous airway lesions in children: an analysis of characteristics and comorbidities.

OBJECTIVES: To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy. METHODS: Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial). RESULTS: Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06-9.41; OR 3.0, 95% CI 1.05-8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84-6.52; OR 2.0, 95% CI 0.76-5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention. CONCLUSIONS: The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.

Effect of the F508del genotype on outcomes of endoscopic sinus surgery in children with cystic fibrosis.

OBJECTIVE: Numerous authors have sought to describe genotype-phenotype correlations in cystic fibrosis (CF), notably to pancreatic insufficiency and lung disease. However, few studies have focused on the association between the F508del genotype and response to sinus surgery. The objective of this study is to assess the effect of the F508del genotype on sinonasal disease severity and outcomes following functional endoscopic sinus surgery (FESS) in a pediatric population. METHODS: A retrospective chart review of 153 children with CF seen at a tertiary care pediatric hospital from 1995 to 2008 was performed. Patients were classified into one of three groups according to F508del genotype, either as homozygous, heterozygous or not carrying a F508del mutation. The sinonasal disease phenotype of the three groups was compared based on clinical and radiological findings, extent of endoscopic sinus surgery and rate of revision surgery. RESULTS: The relationship between the F508del genotype and pancreatic insufficiency was confirmed (p<0.05). There was no association between the F508del genotype and increased need for FESS (p=0.75). Moreover, no association was established between F508del homozygosity and presence of nasal polyps, Lund-Mackay score, extent of surgery or length of postoperative hospitalization. The rates of revision surgery did not differ significantly among the three genotypes analyzed (p=0.59). CONCLUSION: There is no clear association between the F508del genotype and an increased need for FESS, extent of surgery, or revision surgery. Given the phenotypic variability of sinonasal disease in patients with CF, a prospective study is needed to better understand outcomes following FESS and the contribution of gene modifiers to this effect.

Testing for pediatric obstructive sleep apnea when health care resources are rationed.

IMPORTANCE: Evaluation of pediatric obstructive sleep apnea in resource-limited health care systems necessitates testing modalities that are accurate and more cost-effective than polysomnography. OBJECTIVE: To trace the clinical pathway of children referred to our sleep laboratory for possible obstructive sleep apnea who were evaluated using nocturnal pulse oximetry and the McGill Oximetry Score. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of children 2 to 17 years old with suspected obstructive sleep apnea due to adenotonsillar hypertrophy, conducted at a Canadian pediatric tertiary care center. INTERVENTIONS: Nocturnal pulse oximetry studies scored using the McGill Oximetry Score. MAIN OUTCOMES AND MEASURES: For children who underwent adenotonsillectomy we determined the length of time from oximetry to surgery, postoperative length of stay, postoperative readmissions, and emergency department visits in the month following surgery and major surgical complications. We analyzed these outcomes by oximetry result. We compared the cost savings of our diagnostic approach with those of other diagnostic models. RESULTS: Among 362 children, the median age was 4.8 years (interquartile range, 3.3-6.7), and 61% were male. Two-hundred-sixty-six (73%) and 96 (27%), respectively, had inconclusive and abnormal oximetry results. Eighty of 96 of children with abnormal oximetry results (83%) and 81 of 266 children with inconclusive oximetry results (30%) underwent adenotonsillectomy. Thirty-three of 266 children (12%) underwent further evaluation with polysomnography; of 14 diagnosed as having OSA, 12 underwent adenotonsillectomy. Children with abnormal oximetry results were operated on soonest after testing and triaged based on oximetry results. No child with an inconclusive oximetry result required hospitalization for more than 1 night postoperatively; 14% of children (11 of 80) with an abnormal oximetry result required hospitalization for 2 or 3 nights (χ2 = 12.0; P = .001). Rates of readmissions and emergency department visits were low, irrespective of oximetry results (whether inconclusive or abnormal). We show that our oximetry-based diagnostic approach results in considerable cost savings compared with a polysomnography-for-all approach. CONCLUSIONS AND RELEVANCE: Oximetry studies evaluated with the McGill Oximetry Score expedite diagnosis and treatment of children with adenotonsillar hypertrophy referred for suspected sleep-disordered breathing. When resources for testing for sleep-disordered breathing are rationed or severely limited, our proposed diagnostic approach can help maximize cost-savings and allows sleep laboratories to focus resources on medically complex children requiring polysomnographic evaluation of suspected sleep disorders.

Asthma: the great imitator in foreign body aspiration?

OBJECTIVE: To determine the prevalence of underlying lower airway inflammatory conditions in children who underwent rigid bronchoscopy (RB) for a suspected foreign body aspiration (FBA) in the tracheobronchial tree and to identify the characteristics of patients who could benefit from a trial of antiasthma treatment prior to undergoing a diagnostic bronchoscopy. DESIGN: Retrospective chart review. SETTING: Children with suspected FBA in the tracheobronchial tree who underwent RB at the Montreal Children's Hospital (2001-2009). METHODS: Patient characteristics such as clinical, radiologic, and bronchoscopic findings on presentation, as well as prior use of inhaled bronchodilators or corticosteroids, were analyzed. A p value < .05 was considered significant. MAIN OUTCOME MEASURES: Use of inhaled bronchodilators or corticosteroids, signs, symptoms, and radiologic and bronchoscopic findings on presentation. RESULTS: Fifty-five children underwent an RB for suspected FBA. Foreign bodies were found in 36 subjects. Asthmatics were significantly more likely to have a negative bronchoscopy than nonasthmatics (80.0% vs 30.0%, p < .05). Otherwise, clinical and radiologic findings were not significantly different in these two groups. The median time between the suspected choking event and the first otolaryngology evaluation was 14 days in asthmatics (range 5 hours-90 days), whereas it was 16 hours in nonasthmatics (range 0.5 hours-120 days). CONCLUSION: A conservative approach cannot be justified in suspected asthmatic children with possible FBA, in whom the indications for diagnostic bronchoscopy must be tailored to each patient to ensure a timely diagnosis.

Series of congenital vallecular cysts: a rare yet potentially fatal cause of upper airway obstruction and failure to thrive in the newborn.

OBJECTIVES: Stridor is a relatively common symptom during the neonatal period. The most probable cause of inspiratory stridor and supralaryngeal airway obstruction in infancy is laryngomalacia. Laryngeal cysts are known to be found in association with supraglottic prolapse and are a rare yet potentially lethal cause of respiratory distress in the newborn. In the absence of more alarming presenting signs, the vallecular cyst, a form of laryngeal cyst, frequently defies diagnosis. We present a series of illustrative cases to raise awareness of vallecular cyst to help reduce the therapeutic delays that are currently encountered clinically. METHODS: A retrospective case series of four patients was reviewed. Each patient presented initially with stridor and additional signs of upper airway obstruction shortly after birth and was later diagnosed with vallecular cyst. RESULTS: The predominant presenting signs were stridor (four cases), signs of respiratory distress (three cases), failure to thrive (three cases), poor feeding (two cases), and cyanotic spells (one case). Age at presentation ranged from 16 days to 8 months. A definitive diagnosis was achieved by flexible laryngoscopy in all four cases. Coexistent laryngomalacia was found in three of the four cases. Primary outcomes at 1 month following marsupialization were complete remission in all four cases. CONCLUSIONS: The challenge in making an early diagnosis of vallecular cyst, especially when laryngomalacia is comorbid, has been reaffirmed in our case series. Diagnosis requires a high index of clinical suspicion in combination with careful inspection of the tongue base with direct examination and/or appropriate imaging modalities.

Lung involvement in juvenile onset recurrent respiratory papillomatosis: a systematic review of the literature.

OBJECTIVES: Determine the exact incidence of pulmonary involvement in recurrent respiratory papillomatosis (RRP); explore available treatments and their effectiveness; determine the characteristics of cases that progress to lung cancer. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Library databases between 1966 and 2007; reference lists of retrieved publication. STUDY SELECTION: Studies investigating recurrent respiratory papillomatosis with lung involvement. Age limited to 20 years of age to qualify for the diagnosis of juvenile-onset RRP. DATA EXTRACTION: Data pertaining to study design, population demographics, risk factors, site of involvement, investigation including the determination of the human papillomavirus type, treatment, and outcomes including the development of cancer. DATA SYNTHESIS: No randomized control trials were retrieved. Hundred and one studies met our inclusion criteria (23 cohorts, 4 case series, 72 case reports, 2 open trials) with 161 cases of lung involvement identified. From the cohort studies we could estimate the incidence of lung involvement in RRP at 3.3%. The incidence of cancer in cases with lung involvement was 16%. We could not draw conclusions regarding treatment effectiveness in lung involvement, as that was not evaluated except in case studies. It would nevertheless appear that Interferon is not effective and the use of intravenous Cidofovir needs to be better evaluated. CONCLUSION: Well-designed, hypothesis-driven randomized control trials and prospective cohort studies are warranted to improve our understanding of the mechanisms underlying the development of lung involvement in RRP, the risks associated with different HPV types, the efficacy of potential therapeutic options as well as the risk of progression to cancer.

Linking laryngopharyngeal reflux to otitis media with effusion: pepsinogen study of adenoid tissue and middle ear fluid.

HYPOTHESIS/OBJECTIVES: Laryngopharyngeal reflux (LPR) was recently implicated in the etiology of otitis media with effusion (OME). To study the hypothesis that gastric juice reaches the middle ear through the nasopharynx and eustachian tube, we evaluated the presence of pepsinogen in the adenoid tissues of children with otitis media with effusion (OME) and compared them with the tissues of a control group of children without OME. METHODS: In the study group, middle ear effusions (MEEs) and adenoidal tissue biopsies were obtained from patients undergoing simultaneous tympanostomy tube placement and adenoidectomy. In the control group, adenoid specimens were taken during adenoidectomy (+/- tonsillectomy) from children with no history of OME. The adenoid tissues were analyzed immunohistochemically to confirm the presence of pepsinogen. Normal gastric tissue was used as a positive control and lymphatic tissue as a negative control. Total pepsinogen levels of MEE were measured with enzyme-linked immunosorbent assay. RESULTS: Adenoid tissue of the OME group (n = 25) demonstrated significantly higher pepsinogen immunoreactivity when compared with the adenoid tissue of the control group (n = 29), specifically in staining of both the epithelia (p < .0001) and the subepithelia, (p < .001). The presence of pepsinogen was detected in 84% of MEEs from the OME group, at concentrations 1.86 to 12.5 times higher than that of serum. Pepsinogen messenger ribonucleic acid was not demonstrated in any of the adenoid tissues of the OME group. CONCLUSION: LPR plays an important role in the pathogenesis of OME as gastric reflux reaches the middle ear through the nasopharynx and eustachian tube to cause OME.

Complications of adenotonsillectomy revisited in a large pediatric case series.

OBJECTIVE: To document the most important postoperative adenotonsillectomy morbidities, with an emphasis on prolonged hospitalization and readmissions. DESIGN: Retrospective chart analysis. METHODS: We reviewed 2067 cases of adenotonsillectomies performed at our institution over a period of 6 years. RESULTS: Of these cases, 1927 patients had undergone tonsillectomy by electrocautery and adenoidectomy by suction-coagulator, of whom 9.3% required admission. The incidence of admissions owing to bleeding was 1.7%, whereas admissions owing to respiratory and gastrointestinal complications represented 3.7% and 5.2%, respectively. Compared with the literature and our institution's previous results, these morbidity values were found to be either comparable or significantly lower (p < .05). CONCLUSION: We attribute this improvement to our use of electrocautery-based techniques not only for tonsillectomy but also for adenoidectomy.

Left ventricular hypertrophy with outflow tract obstruction-a complication of dexamethasone treatment for subglottic stenosis.

To our knowledge, this is the 1st reported case of steroid-induced obstructive cardiomyopathy in a child being treated for subglottic stenosis. As well, although born at 27 weeks, our patient was over 4 kg and 4 months of age (44 weeks corrected gestational age). This appears to be a phenomenon chiefly involving premature babies in the neonatal period with no reports of this occurring in patients greater than 40 weeks corrected gestational age. Signs of cardiac hypertrophy include tachycardia, new cardiac murmur, increased oxygen requirements, decreased urine output, and decreased peripheral perfusion. Diagnosis and eventual recovery was confirmed with serial echocardiograms. Knowledge of this serious side effect of dexamethasone will allow otolaryngologists to intervene early and prevent a potentially deadly complication.