A SEER database study of malignant teratomas in the head and neck region.

OBJECTIVE: To review tumor and patient characteristics as well as survival of pediatric head and neck malignant teratomas (HNMT) in comparison to the adult population. DESIGN: This investigation was a retrospective cohort study. The Surveillance, Epidemiology, and End Results (SEER) database (SEER-18 Regs Custom registry, November 2018) was reviewed for all cases of head and neck malignant teratomas from 1975 to 2016. A log rank test was used to compare survival between infant, pediatric, and adult HNMT, and between head and neck and non-head and neck malignant teratomas. Infant, pediatric, and adult patients were defined as younger than one year old, younger than 18 years old, and older than 18 years old, respectively. RESULTS: Sixty-three malignant teratoma cases (1.96%) occurred in the head and neck region from 1975 to 2016, including 11 adult (17.46%) and 52 (82.54%) pediatric patients. 79.37% (50 patients) were diagnosed during infancy. The most common location was the soft tissue of the head and neck in pediatric patients (65.38%) and the thyroid gland in adults (54.54%). The 5-year survival was 45.83% (±7.19%) in infants and 46.00% (±7.05%) in pediatric patients. There were differences in 1-year and 5-year survival between pediatric HNMT and non-head and neck malignant teratomas, (76.01% versus 86.20%) (p = 0.022) and (46.00% versus 67.10%) (p < 0.001), respectively. There was no difference in 1-year and 5-year survival between pediatric patients and adults with HNMT, (76.01% versus 81.81%) (p = 0.618) and (46.00% versus 54.54%) (p = 0.560), respectively. CONCLUSION: HNMT occurred most frequently in patients under the age of 1. Prognosis of pediatric HNMT is poor in comparison to pediatric non-head and neck malignant teratomas. Repeat studies after accumulating more patients in the database would be beneficial to confirm our findings.

Development of video otoscopy quiz using a smartphone adaptable otoscope.

BACKGROUND: Otoscopy examination can be challenging. Traditional teaching uses still image illustrations. Newer attempts use video samples to simulate the otoscopy exam which is a dynamic process.Aims/Objective: To assess whether recorded otoscopy videos from a smartphone adaptable otoscope can be used to develop a video-based otoscopy quiz which may be used for instructing and familiarizing participants to normal anatomy and pathologic ear conditions. To use this quiz to assess current pediatric residents' competency of common otoscopy diagnosis. METHOD AND MATERIALS: This study was conducted in 2018. Video samples of ear pathology were collected at the Albany Medical Center using a smartphone adaptable otoscope- Cellscope. The videos were used to create a video otoscopy quiz (VOQ) without clinical vignettes. 45 pediatric residents from 3 academic institutions were evaluated with the quiz. RESULTS: The weighted mean for the VOQ was 66.90% (95%CI 58.89%-68.42%). The breakdown by questions are: myringosclerosis 72.88%, retraction pocket 80.65%, cholesteatoma 42.22%, hemotympanum 75.04%, tympanic membrane perforation 79.62%, cerumen impaction 95.46%, otitis externa 52.54%, otitis media with effusion 63.30%, acute otitis media 75.55%, normal ear 36.39%. CONCLUSION: We found that videos of otoscopy exams can be obtained with a smartphone adaptable otoscope and validated to develop a video-based quiz, which may be used to supplement otoscopic instruction. Following our testing process, we found pediatric residents are relatively well equipped to identify ear pathology on VOQ.

Therapeutic use of the HPV vaccine in Recurrent Respiratory Papillomatosis: A case report.

Recurrent Respiratory Papillomatosis (RRP) is a condition characterized by recurring squamous papillomas in the aerodigestive tract due to Human Papilloma Virus (HPV) infection. Treatment includes surgical debridement of the lesions often with adjuvant therapy. A newer adjuvant agent being tested is the HPV vaccine. The case report includes a child with RRP who underwent 10 surgeries in a year with an average inter-surgical interval (ISI) of 46 days. The patient then received the scheduled regimen of 3 doses of 9 valent HPV vaccine. Since beginning the vaccination, her average ISI increased to 113 days and as of writing of this paper only 1 surgery in the last 340 days. It is theorized that the increase in humoral response to the virus can slow the course of the disease, lengthen the ISI, and decrease morbidity. The results of this case report lends evidence to the use of the HPV vaccine as a therapeutic adjuvant therapy for RRP.

Tympanostomy tube placement in awake, unrestrained pediatric patients: A prospective, multicenter study.

OBJECTIVES: Tympanostomy tube (tube) placement is the most common pediatric otolaryngologic surgery in the United States. Most surgeries are performed in an operating-room setting under general anesthesia due to the lack of tolerable and reliable local anesthesia methods suitable for pediatric patients, and concerns regarding myringotomy procedures in a mobile child. This study evaluated the safety and efficacy of an iontophoresis system (IPS) to achieve local anesthesia in combination with a tube delivery system (TDS) for tube placement in pediatric patients in an office setting. METHODS: A prospective, single-arm study was conducted at 9 otolaryngology sites in the United States. Participants included pediatric patients aged 6 months to less than 22 years requiring tube placement. Patients were prepared for the procedure using behavioral support techniques and tube placement was attempted under local anesthesia using the IPS in conjunction with the TDS. No physical restraints were allowed and no anxiolytics, analgesics, or sedatives were permitted. Safety was assessed through the occurrence of adverse events and success rates for tube placement under local anesthesia were determined. Tolerability of the procedure was evaluated using the 5-point Wong-Baker FACES Pain Rating Scale and parental satisfaction was assessed using a postoperative survey. RESULTS: Seventy patients (127 ears) were enrolled in the study [mean (SD) age=7.0 (3.9) years]. No serious adverse events occurred in the 70 enrolled patients. Tube placement using the TDS was successful in 96.6% (114/118) of attempted ears. A single TDS was required in 105 ears, while more than 1 device was required in 9 ears. Of the 70 patients enrolled in study, 63 (90.0%) successfully received tubes in all indicated ears during their in-office visit. The mean (SD) change in pain score from pre-anesthesia to post-surgery was +0.9 (1.8). Favorable ratings for overall satisfaction with the in-office procedure were obtained from 96.9% (63/65) of respondents. Tube retention at 2 weeks was 99.1%. As only 15 patients were enrolled who were 3 years old or younger, the ability to generalize these results to younger patients is limited. CONCLUSIONS: In this study, use of the IPS and TDS technologies enabled safe, reliable, and tolerable placement of tubes in awake, unrestrained pediatric patients.

Tonsillectomy does not improve bedwetting: results of a prospective controlled trial.

PURPOSE: Sleep disordered breathing caused by tonsillar hypertrophy has been implicated as a cause of primary and secondary nocturnal enuresis in children. We prospectively studied the preoperative and postoperative rates of nocturnal and daytime incontinence in a group of children with tonsillar hypertrophy undergoing tonsillectomy compared to a matched control group undergoing surgery unrelated to the airway or urinary tract. MATERIALS AND METHODS: A total of 326 toilet trained children 3 to 15 years old were included, with 257 in the tonsillectomy group and 69 in the control group. Severity of tonsillar hypertrophy was graded preoperatively on a scale of 1 to 4. A voiding questionnaire regarding number of bedwetting and daytime incontinence episodes per week, voids per day, bowel movements per week, secondary or primary enuresis and family history was completed by parents preoperatively, and at 3 and 6 months postoperatively. RESULTS: Preoperatively the respective rates of nocturnal enuresis and daytime incontinence were 33% and 17% in the tonsillectomy group (p=0.89), and 35% and 14% in the control group (p=0.3). The respective cure rates for bedwetting at 3 and 6 months postoperatively were 40% and 50% in the tonsillectomy group (p=0.60), and 35% and 48% in the control group (p=0.61). Similarly no difference was seen in improvement or cure of daytime incontinence at 3 and 6 months postoperatively. CONCLUSIONS: We found no association between tonsillar hypertrophy and urinary incontinence before or after tonsillectomy.

Potential predisposition for nasal septal perforation with methotrexate use: report of 2 cases and literature review.

Methotrexate is a dihydrofolate reductase inhibitor with application both as a chemotherapeutic agent and as a disease-modifying antirheumatic drug. Although its ability to inhibit cellular proliferation is a desired effect in its role as an antineoplastic agent, this property may also hinder normal physiologic regeneration of the nasal epithelium. This effect may predispose patients to septal cartilage ischemia, necrosis and, eventually, perforation. We report 2 cases of septal perforations in the setting of prolonged methotrexate use and present a literature review. Patient 1 is an 8-year-old boy with juvenile rheumatoid arthritis managed with weekly methotrexate who developed a 4-mm septal perforation with an unremarkable biopsy. This was closed with a mucosal advancement flap without incident. Patient 2 is an 11-year-old boy with non-Hodgkin lymphoma treated with methotrexate. His examination was significant for a large perforation of the dorsocaudal septum. A biopsy was negative for malignancy in this patient. Repair has been deferred-initially for chemotherapy and currently for treatment relapse. We hypothesize that prolonged use of methotrexate alters the balance between physiologic desquamation and epithelial regeneration. This imbalance may promote septal ischemia and predispose patients to the development of septal perforations.

Laryngeal anatomic differences in pediatric patients with severe laryngomalacia.

OBJECTIVES: To compare the aryepiglottic (AE) length in pediatric patients who have severe laryngomalacia (SL) and are undergoing aryepiglottoplasty with the AE length of a convenience sample of control patients without laryngomalacia. DESIGN: Prospective case-control study. SETTING: A tertiary-care pediatric hospital. RESULTS: The mean AE fold length-glottic length ratio for patients with SL (0.380) was significantly lower than the mean ratio for controls (0.535) (P = .004 in 2-sample t test with unequal variance). For patients with SL, the aryepiglottoplasy procedure resulted in an average AE length increase-glottic length ratio of 0.330. Seven of the patients with SL were also diagnosed as having an underlying neurologic condition, and 18 had a diagnosis of gastroesophageal reflux disease. Two patients with SL required a tracheotomy for treatment of persistent airway obstruction. CONCLUSIONS: In this series, patients with SL had lower AE fold length-glottic length ratios and more frequent occurrence of neuromuscular tone abnormalities (especially gastroesophageal reflux) than controls. These 2 findings may be related in that low intrauterine tone might contribute to anatomic underdevelopment.

Bacterial biofilm presence in pediatric tracheotomy tubes.

OBJECTIVE: To determine whether bacterial biofilms are present on pediatric tracheotomy tubes. DESIGN: Prospective observational series. INTERVENTIONS: Eleven tracheotomy tubes removed during routine tracheotomy tube changes were analyzed for biofilm and live bacteria presence using confocal microscopy and vital stains. The external and internal surfaces of the tracheotomy tubes were studied in 3 locations: distal tip, midtracheotomy tube, and proximal opening. These data were correlated with tracheotomy site cultures and the reason for tracheotomy dependence. MAIN OUTCOME MEASURES: Microscopic images were analyzed for the presence of a biofilm (its morphological features and the presence of live and dead bacteria within the biofilm). RESULTS: Of 11 tracheotomy tubes, 10 had biofilm present on the internal surface of the distal tip. Externally, at the same location, 4 tubes had biofilms. On the internal surface of the midtracheotomy site, 8 had biofilm present, whereas only 1 had a biofilm on the internal surface of the proximal tracheotomy tube site. In the distal internal tracheotomy tube site, the biofilm was confluent in 5 tubes and patchy with evidence of microcolony formation in the remaining 5 tubes. Live bacteria were present in all biofilms. Control tracheotomy tubes did not have biofilms. All tracheotomy site cultures and disease states (chronic aspiration and bronchopulmonary dysplasia) were associated with tracheotomy tube biofilms. CONCLUSION: Bacterial biofilms containing live bacteria were demonstrated in most pediatric tracheotomy tubes, being most frequent and extensive on the internal surface of the distal tracheotomy tip.

Endoscopic posterior cricoid split and rib grafting in 10 children.

OBJECTIVE: To report our experience with endoscopic posterior cricoid split and rib graft insertion (EPCS/RG) in children with posterior glottic (PGS) and subglottic stenosis (SGS). DESIGN: Retrospective analysis of case series, with 1 to 2 year follow-up. SETTING: Tertiary-care pediatric referral center. PATIENTS: Ten consecutive patients undergoing EPCS/RG. INTERVENTION: EPCS/RG is a new procedure that expands the posterior glottic opening by dividing the posterior cricoid lamina endoscopically with a laser and inserting a rib cartilage graft through the laryngoscope. MAIN OUTCOME MEASURES: Laryngeal function and hospital stay. RESULTS: Successful decannulation in two of two patients with PGS and one of five patients with PGS and SGS without further surgery. Of the four not initially decannulated, two were decannulated with adjunctive procedures, and the other two can now tolerate tracheostomy capping for extended periods of time. We achieved improvement in exercise tolerance in three nontracheotomy-dependent patients. For those with established tracheotomies, median hospital stay was 3 days and intensive care unit care was unnecessary. There were no major complications or deterioration of voice or feeding. CONCLUSIONS: EPCS/RG appears to be safe and effective in the management of PGS in selected pediatric patients. This minimally invasive procedure has advantages over traditional open approaches and destructive endoscopic techniques (cordotomy and arytenoidectomy). The role of EPCS/RG alone in the face of severe grades of SGS appears to be limited.

Follicular dendritic cell tumor: an aggressive head and neck tumor.

OBJECTIVE: To characterize the clinicopathologic features of head and neck follicular dendritic cell (FDC) tumor and report the experience of this entity at our institution. STUDY DESIGN: Two case presentations are compared with a retrospective analysis of all published head and neck cases. SETTING: A tertiary academic medical center. RESULTS: Thirty four cases of FDC tumor of the head and neck cases have been published. Twenty five occurred in the cervical lymph nodes, 4 in the tonsils, 2 in the palate, 1 in the pharynx, 1 in the parapharyngeal region, and 1 in the thyroid gland. Patient ages ranged from 13 to 73 years (mean, 38), and there was a roughly equal number of men and women. Patients were treated with surgery (17), surgery and chemotherapy (8), and surgery and radiation (9). After the primary treatment, 12 patients had no evidence of disease, whereas 5 were incurable. Ten tumors recurred locally and 3 distally. Of these 13 patients who suffered recurrences, 4 had no evidence of disease after secondary treatment, 6 were alive with disease, and one was lost to follow up. Two patients died after recurrence. We add 2 unique cases to the 9 previously reported extranodal cases, 1 in the tonsil and 1 in the parotid gland. CONCLUSION: FDC tumor is a rare malignant neoplasm that can present in the head and neck region in both lymph nodes and extranodal sites. Because of their rarity, these tumors are probably underrecognized by both clinicians and pathologists. Distinct light microscopic, immunohistochemical, and ultrastructural features do exist, however, and are reviewed. Surgery has been the mainstay of treatment and should include diligent control of surgical margins. The role of adjuvant therapy remains controversial. Although originally considered to be a low-grade malignancy, our review suggests both high recurrence rates and metastatic potential. We believe that FDC tumor should be viewed and treated as a moderately aggressive head and neck tumor.