External auditory canal: Inferior, posterior-inferior, and anterior canal wall overhangs.

OBJECTIVES: To characterize anatomic variants of the external ear canal (EAC), specifically canal wall overhangs. EAC overhangs are problematic since they obstruct the view of the tympanic membrane (TM) and middle ear, possibly creating diagnostic and surgical difficulties. METHODS: We reviewed pre-operative temporal bone CTs from children with cholesteatoma, and no history of EAC erosion or surgery. We measured the anterior canal wall overhang (ACOH), inferior (ICOH), and posterior-inferior (PICOH). A smaller angle means more EAC overhang. Angles >180° counted as 180° since they are non-obstructing. Analysis was performed between angular measurements and clinical and demographic data. RESULTS: 86 patients (88 ears total) were studied. Mean age was 8.3 years. Only obstructing angles were analyzed statistically (<180°). The ICOH was most severe and occurred in 72/88 (81.8%) ears with a mean of 145.9 ±â€¯12.8SD° (range 102-171°). ACOH occurred in 60/88 (68.2%) ears with a mean of 148.3 ±â€¯10.9SD° (range 120-169°). PICOH occurred in 59/88 (67%) ears with a mean of 150.4 ±â€¯9.2SD° (range 124-169°). Overall, ICOH was significantly more severe than PICOH (P = 0.026). ICOH had more Severe (142-102°) overhangs (27/88, 30.7%) than ACOH (17/88, 19.3%) or PICOH (11/88, 12.5%), but these were not significantly different. Analysis of clinical data showed that as the ICOH overhang became more severe, there was a history of significantly more (p = 0.039, r = -0.209) tympanostomy tubes placed. CONCLUSIONS: The greatest prevalence and severity of EAC overhang was the ICOH with a mean angle of 145.9°, compared with 148.3° and 150.4° for the ACOH and PICOH, respectively. This anatomic study demonstrates that ICOH and PICOH are prevalent anatomic variants and may possibly cause similar difficulties in otoscopic diagnosis and surgical TM and middle ear exposure as the well-known ACOH.

Paravertebral Nerve Block for Donor Site Pain in Stage I Microtia Reconstruction: A Pilot Study.

Acute Interventional Perioperative Pain Service consultants have routinely placed paravertebral nerve block (PVB) catheters for the continuous release of ropivacaine following stage I microtia reconstruction with costal cartilage graft at our institution since 2010. A retrospective chart review from July 2006 was performed to compare the length of hospital stay, median pain score (0-10 scale), and opioid use of patients receiving PVB with those of historical controls. Statistical analysis included t, Mann-Whitney U, and Fisher's exact tests. A total of 15 stage I microtia surgeries were included, 10 with PVB and 5 without. Patients with and without PVB had high peak pain scores (8.4 vs 7.8), remained in the hospital for 3.5 and 3.8 days, and consumed 0.69 and 0.36 mg/kg morphine equivalents, respectively. These findings highlight the feasibility of PVB, but larger studies are needed to optimize pain relief in this population.

The role of tympanostomy tubes in surgery for acquired retraction pocket cholesteatoma.

OBJECTIVE: 1. To determine whether intraoperative tympanostomy tubes (TT) during surgery for acquired retraction pocket cholesteatoma (ARPC) can decrease recurrence of ARPC and retraction pockets (RP). 2. To determine the need for subsequent TT in children that did not initially receive TT. STUDY DESIGN: Retrospective review of children who underwent primary surgery for ARPC. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Audiometry, operative reports, office findings, and recurrence of ARPC and RP were analyzed. Univariate analysis with Fisher's exact test, Wilcoxon rank-sum and t test, as well as multivariate analysis with logistical regression, were used for statistical analyses. RESULTS: 21 patients had TT at initial surgery and 34 patients did not. The recurrence of ARPC was 24% for the TT Group versus 44% for the no TT group (p=0.09). The incidence of RP was 33% in the TT group versus 41% in the no TT groups (p=0.35). 35% of the no TT group subsequently required TT. Audiometric outcomes were not different between groups. TT placement did not significantly affect the odds of recurrent ARPC and RP (95% CI 0.12-1.83, p=0.28 for ARPC and 95% CI 0.30-4.60, p=0.82 for RP). However, the odds of recurrent ARPC and RP were significantly increased in children with stapes and malleus erosion by cholesteatoma. Children with stapes and malleus involvement had 5.28 and 11.8 times higher odds of recurrent ARPC compared to those without ossicular erosion (95% CI 1.09-25.6, p=0.04 stapes and 95% CI 1.58-88.3, p=0.02 malleus). Similarly, children with malleus involvement had an 18.6 times higher odds of recurrent RP (95% CI 1.62-214, p=0.02) compared to those who did not. Incus erosion was not a significant predictor for recurrent ARPC and RP. CONCLUSION: There was no statistical difference in recurrence or audiometric outcomes between patients who underwent TT versus those who did not during initial surgery for ARPC. However malleus and stapes erosion were significantly associated with recurrent ARPC and RP. These findings suggest that TT at initial ARPC surgery did not play a role in preventing recurrence, but malleus and incus erosion, was predictive of recurrent disease. A larger, prospective study of TT at initial surgery for ARPC is needed.

Coexistence of dermal sinus tract, dermoid cyst, and encephalocele in a patient presenting with nasal cellulitis.

Dermoid cysts, encephaloceles, and dermal sinus tracts represent abnormalities that develop during the process of embryogenesis. The elucidation of the precise timing of formation for these malformations has remained elusive at the molecular level of study. Yet, clinical experience has demonstrated that these malformations do not all occur in the same patient, suggesting a shared pathway that goes awry at distinct points for different patients, resulting in 1 of the 3 malformations. Herein the authors describe a case in which all 3 malformations were present in a single patient. This is the first description in the English literature of a sincipital encephalocele occurring with a dermoid cyst and a dermal sinus tract.

Anatomic variants on computed tomography in congenital aural atresia.

OBJECTIVE: To report the prevalence of anatomic variants on computed tomography (CT) in congenital aural atresia (CAA) and external auditory canal stenosis (EACS). Anatomic variants included inferiorly displaced/obstructing tegmen mastoideum, malleus-incus complex (MIC) directly lateral to stapes, facial nerve obstruction of oval window (OW) or middle ear, and incudostapedial joint (ISJ) angle. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: An anatomic analysis of 130 CT scans (98 children, 32 bilateral) of CAA/EACS, performed by a blinded neuroradiologist. Both Jahrsdoerfer's and new/modified anatomic considerations were graded in 32 atresiaplasty and 66 nonsurgical patients. Surgical data were analyzed for anatomic correlations related to surgical findings. RESULTS: Prevalence of anatomic variants was as follows: 13% of the ears had mild inferior displacement of tegmen, 4% had a significantly obstructing tegmen, and 24% had MIC directly lateral to stapes. The facial nerve obstructed access to OW in 41% and middle ear in 21%. Six atresiaplasty patients were reported to have a large MIC obstructing stapes access with increased intraoperative difficulty in viewing and assessing the integrity and mobility of the ISJ and stapes. Five of these 6 (83%) were noted on CT scan. The mean ISJ angle was 101° (range, 51°-155°). CONCLUSION: A large obstructing MIC increases difficulty of atresiaplasty. Awareness of the presence of these anatomic variants is an aid in teaching temporal bone anatomy and may possibly influence the decision regarding atresiaplasty.

Congenital cholesteatoma: predictors for residual disease and hearing outcomes.

OBJECTIVE: To determine predictive factors for residual disease and hearing outcomes of surgery for congenital cholesteatoma (CC). DESIGN: Retrospective record review of surgery for CC from January 1, 1998, through December 31, 2010. The initial extent of CC was staged using the system as defined by Potsic et al. SETTING: Tertiary care children's hospital. PATIENTS: Eighty-one children (82 ears) underwent a total of 230 operations for CC. The mean (SD) age was 5.3 (2.9) years, and the mean follow-up was 4.3 years. INTERVENTION: Initial and subsequent operations for CC and audiologic evaluations. MAIN OUTCOME MEASURES: Statistical analyses were performed to determine factors associated with increased residual disease for CC and poorer hearing outcomes. RESULTS: Higher initial stage of disease, erosion of ossicles, and removal of ossicles were significantly associated with increased likelihood of residual CC (46%, 50%, and 51%, respectively; P < .001). More extensive disease at initial surgery was associated with poorer final hearing outcomes (P < .05). Other significant findings included CC medial to the malleus (41.5%) or incus (54.3%), abutting the incus (51.3%) or stapes (63%), or enveloping the stapes (50%); all patients had increased residual disease (all P < .05). Excellent audiometric results (air-bone gap of ≤20 decibel hearing level) were obtained in 63 (77%) of the 82 ears. CONCLUSIONS: More extensive initial disease, ossicular erosion, and the need for ossicular removal were associated with residual disease. On the basis of our data, the best chance for completely removing CC at initial surgery involves removing involved ossicles if they are eroded, if the CC is abutting or enveloping the incus or stapes, if the CC is medial to the malleus or incus, or if the matrix of the CC is violated. These results may help guide surgeons to achieve the best results for their patients.

Congenital external auditory canal stenosis and partial atretic plate.

OBJECTIVES: To report outcomes of surgery for severe congenital external auditory canal (EAC) stenosis with or without partial atretic plate (PAP). DESIGN: Retrospective review. SUBJECTS: Thirteen patients (18 ears) had surgery for severe EAC stenosis with (n=10, 56%) or without PAP (n=8, 44%). Indications included severe stenosis with hearing loss, cerumen impactions, and/or canal cholesteatoma. Mean age=7.8 years (range 0.4-19.9 years). Mean follow up=5.2 years (range 0.4-10.0 years). SETTING: Tertiary care children's hospital. INTERVENTIONS: Nineteen endaural canaloplasties were performed in 17 ears (2 revisions). There was one post-auricular approach. Fifteen tympanoplasties were performed in 13 ears (2 revisions). PAP was reconstructed with drilling to enlarge the bony annulus and fascia grafting to enlarge the tympanic membrane in 10 (56%) ears. OUTCOME MEASURES: Patency of EACs; otologic findings; pure tone averages (PTA); complications. RESULTS: All (100%) EACs had improved patency (>or=4mm). Findings included canal cholesteatoma (2/18, 11%), ossicular fixation (4/18, 22%), stapes abnormality (2/18, 11%), and incudostapedial discontinuity from cholesteatoma (1/18, 6%). Mean preoperative PTA=38.7 dB HL (range 60-20 dB HL). Mean post-operative PTA=23.6 dB HL (range 50-6.7 dB HL). Audiologic results were significantly better for cases without PAP (p<.01) and without ossicular fixation (p<.01). There were seven minor and no major complications. CONCLUSIONS: Endaural canaloplasty is safe and effective for providing patent EACs and hearing improvement for severe congenital EAC stenosis. However, since hearing outcomes were worse for cases with PAP and ossicular fixation, alternatives such as hearing aids or BAHA may be considered.

Combined atresiaplasty and tragal reconstruction for microtia and congenital aural atresia: thesis for the American Laryngological, Rhinological, and Otological Society.

OBJECTIVE: To describe a new technique for combining atresiaplasty with tragal reconstruction by performing the tragal reconstruction with cartilage grafting at the same time as the atresiaplasty for patients with microtia and congenital aural atresia. Hearing and canaloplasty outcomes for this combined technique are reported. PATIENTS: Patients with aural atresia (n = 19) with (n = 16) or without (n = 3) microtia, and a Jahrsdoerfer grade of 6 or higher. Mean age was 8.3 years. Atresiaplasty was performed in 20 ears, with the new combined technique in 15 ears (75%). METHODS/INTERVENTIONS: During the meatoplasty portion of atresiaplasty, the tragus was reconstructed with a cartilage graft and an anteriorly pedicled skin flap. OUTCOME MEASURES: Hearing results, complications including canal stenosis, infections, sensorineural hearing loss, and facial nerve injuries. RESULTS: The mean postatresiaplasty pure tone average (PTA) and air bone gap (ABG) were 37.5 and 29.4 dB, respectively. Eleven (55%) of the ears had an ABG of < or =30 dB, and 10 (50%) had speech reception thresholds (SRT) of < or =30 dB. Six ears (30%) had postoperative infections. Revision surgery was performed in four ears (20%) for canal/meatal stenosis, and in six (30%) for conductive hearing loss. Bone Anchored Hearing Aid was performed in six patients (30%). There was no sensorineural hearing loss or facial nerve injury. CONCLUSIONS: The new combined tragal reconstruction and atresiaplasty technique yielded satisfactory hearing, canal/meatal patency, and cosmetic results, with acceptable rates of complications. This combined tragal reconstruction and atresiaplasty technique is a valuable option in the armamentarium of microtia and atresia surgeons.

Outcomes studies of epiglottic and base of tongue prolapse in children.

OBJECTIVES: The purpose of this study was to compare previously reported flexible fiberoptic laryngoscopy (FFL) findings of a grading system for children with epiglottic and base of tongue (EBT) prolapse with findings at follow-up FFL. Surgical outcomes and tracheotomy decannulation are also reported. STUDY DESIGN: : Retrospective medical record review. METHODS: Fourteen children with EBT prolapse had transnasal FFL in the supine position on at least two occasions. Findings were graded for initial versus most recent FFL. The previously published EBT prolapse grading system was reapplied. Mean age was 8.7 years at the last evaluation. Mean interval between initial and most recent FFL was 1.9 years. RESULTS: At follow-up FFL, six (43%) children had the same grade of EBT prolapse, five (36%) had a milder grade, and three (21%) had a more severe grade. Five (36%) children were decannulated, and nine (64%) children remain tracheotomy dependant. Of nine children who had surgery, four (44%) were decannulated. Eight (89%) of nine children who were not decannulated have a history of developmental delay (P < .03). Twelve (86%) children had gastroesophageal reflux disease, and six (43%) had abnormal swallowing function. CONCLUSIONS: The grading system was successfully reapplied to compare initial with follow-up findings in a cohort of children with EBT prolapse. Gastroesophageal reflux disease and swallowing dysfunction are common in this population. Judicious surgery may have some efficacy for EBT prolapse in selected patients. Many children with EBT prolapse still require tracheotomy, especially those with developmental delay.

Flexible fiberoptic laryngoscopy in children: effect of sitting versus supine position.

Currently no standard exists as to the exact technique of flexible fiberoptic laryngoscopy (FFL) for children. Our objective was to determine the effects of examination in the sitting versus supine position on upper airway findings during FFL in children using a standardized technique and a grading system. In this prospective study, each child acted as his or her own control. Thirty children underwent FFL at a tertiary care children's hospital (mean age 4.5 years). FFL was performed during spontaneous ventilation in both positions, using a standardized sedation technique administered by a single paediatric anaesthesiologist. The findings of inspiratory prolapse of the base of tongue, epiglottis, aryepiglottic folds and arytenoids, and presence of retractions were graded. The results indicated no differences in laryngeal findings between the two positions in 19 (63%) out of 30 children. Differences were observed in 11 (37%) children (p<0.01), but were of small magnitude (one grade) in 10 (91%) of 11 children. Only one child (9%) with severe hypotonia had a difference of two grades. For children with positional differences, 6 (55%) had more obstruction in the supine position, while 5 (45%) had more obstruction in the sitting position. We conclude that although sitting versus supine position statistically significantly affects upper airway findings during FFL in children, examination in either position is usually acceptable. Examination in both positions may detect small differences in approximately one third of children, but we believe this would usually not alter management. Investigators are encouraged to adopt standardized techniques for FFL and grading systems that will allow meaningful comparisons between patients, techniques, and centers.

Synchronous airway lesions and esophagitis in young patients undergoing adenoidectomy.

OBJECTIVE: To determine the prevalence of synchronous airway lesions and esophagitis in children younger than 18 months undergoing adenoidectomy for adenoid hypertrophy and upper airway obstruction. DESIGN: Retrospective review spanning 4.5 years. SETTING: Tertiary care children's hospital. PATIENTS: All children younger than 18 months who underwent adenoidectomy for upper airway obstruction by 2 pediatric otolaryngologists. EXCLUSION CRITERIA: craniofacial dysmorphism and congenital syndromes. INTERVENTIONS: Simultaneous interventions during adenoidectomy included flexible nasopharyngolaryngoscopy (n = 32), direct laryngoscopy (n = 31), rigid tracheobronchoscopy (n = 30), and esophagoscopy with biopsy (n = 32). MAIN OUTCOME MEASURES: Prevalence of synchronous airway lesions and histologic esophagitis. RESULTS: Thirty-five children younger than 18 months underwent adenoidectomy for airway obstruction (2 also had simultaneous tonsillectomy). Synchronous airway lesions were found in 19 (59%) of 32 patients who underwent airway endoscopy, including laryngeal edema (n = 9), laryngomalacia (n = 8), tracheal vascular compression (n = 4), subglottic stenosis (n = 4), midmembranous vocal fold lesions (n = 3), bronchial stenosis (n = 1), and true vocal fold immobility (n = 1). Among 32 patients who underwent esophageal biopsy, histologic evidence of gastroesophageal reflux disease was found in 10 patients (31%), and eosinophilic esophagitis was found in 4 patients (13%). Overall prevalence of any synchronous finding (airway and/or esophagus) was 27 (77%) of 35. CONCLUSIONS: Synchronous airway lesions and esophagitis (both gastroesophageal reflux disease and eosinophilic esophagitis) were prevalent among children younger than 18 months undergoing adenoidectomy for adenoid hypertrophy and upper airway obstruction. The presence of these findings argues for consideration of endoscopy during adenoidectomy for very young children.

Bone anchored hearing aid in children--prevention of complications.

To report results with the bone anchored hearing aid (BAHA) in children. Retrospective medical record review. Tertiary care children's hospital. Fourteen children with microtia/aural atresia underwent BAHA surgery. Mean age was 5.8 years. Data were collected concerning age, diagnoses, surgery, success of implantation, hearing, complications use of BAHA, speech reception thresholds (SRT), complications BAHA surgeries and revisions. Fifteen implants were placed by the author in 13 children. Eleven of 13 (84.6%) children are successfully using BAHAs (one bilateral) with a mean post operative SRT of 18.5dB (range 14-25dB). Mean interval between first and second stages was 7.3 months (n=12). Three unilateral implants were placed by a different surgeon in a child with severe hemifacial microsomia who developed complications treated by the author. Complications included poor healing requiring removal of three implants in one child, recurrent cellulitis of flap requiring revision (n=4), loss of implant (n=2), tearing of flap with dermatome due to tenting by healing screw (n=1), thin skull necessitating multiple drilling sites (n=1). BAHA surgery has a high success rate in children. The following recommendations may decrease complications: (1) 6-month period between stages in children with thin skulls, (2) thin flap with scalpel when it is tented by healing screw or infiltrate flap with local anesthetic to balloon it prior to using the dermatome for second stage cases, and (3) create extremely thin flap to prevent cellulitis.

Lack of association between esophageal biopsy, bronchoalveolar lavage, and endoscopy findings in hoarse children.

OBJECTIVE: To determine the prevalence of esophagitis (based on esophageal biopsy results) and aspiration (based on bronchoalveolar lavage [BAL]) in children with hoarseness. DESIGN: Retrospective medical chart review spanning 24 months of 127 consecutive children (mean age, 6.9 years; range, 1.8-17 years) who presented with hoarseness to 2 attending otolaryngologists. SETTING: Tertiary care children's hospital.Intervention All subjects underwent direct laryngoscopy, rigid bronchoscopy with BAL, and rigid or flexible esophagoscopy with biopsy. MAIN OUTCOME MEASURES: The BAL result was considered positive if the number of lipid-laden macrophages was "moderate" or "large," and the esophageal biopsy result was considered positive if any 2 of the following 3 histologic criteria were present: basal cell hyperplasia, increased papillary height, and intraepithelial inflammatory infiltrate. Comparisons between subjective endoscopic findings and objective test results were made using the t test and contingency table analysis, where appropriate. RESULTS: Of the 127 children, 104 (82%) had vocal nodules; 53 (43%) had endoscopically visualized laryngitis; 36 (28%) had tracheobronchial inflammatory changes; 60 (47%) had abnormal esophagoscopy findings; 47 (37%) had a positive BAL result; and 38 (30%) had a positive esophageal biopsy result. There was no significant correlation between BAL and esophageal biopsy results (P = .11). The odds of having positive BAL or esophageal biopsy results were unaffected by the presence of vocal nodules; endoscopically visualized inflammation of the larynx, trachea, or esophagus; or symptoms or previous clinical history of gastroesophageal reflux disease. CONCLUSION: Positive esophageal biopsy and BAL results are prevalent among children with hoarseness, regardless of subjective upper aerodigestive tract endoscopic findings.

Endoscopic KTP laser excision of severe tracheotomy-associated suprastomal collapse.

OBJECTIVE: The purpose of this study was to investigate the feasibility, safety, and clinical utility of potassium-titanium-phosphate (KTP) laser bronchoscopy for excision of severe, obstructing tracheotomy-associated suprastomal collapse. METHODS: A retrospective review was performed of six children at a tertiary care children's hospital with severe tracheotomy-associated collapse of the suprastomal anterior tracheal wall cartilage, precluding decannulation. All subjects had undergone KTP laser endoscopic excision of the collapsed segment of suprastomal tracheal cartilage. Medical records were assessed for: (1) endoscopic demonstration of relief of suprastomal collapse, and (2) successful tracheotomy decannulation. RESULTS: All six patients had endoscopic evidence of relief of suprastomal airway obstruction after KTP laser therapy. Five of six (83%) subsequently underwent successful decannulation. There was one case of minimal thermal airway injury associated with a laser fire during use of the KTP laser, the effects of which were fortunately transient. CONCLUSIONS: KTP laser bronchoscopic excision of severe tracheotomy-associated suprastomal collapse: (1) is a feasible technique; (2) results in relief of suprastomal obstruction with subsequent successful decannulation in selected patients; and (3) avoids the need for more extensive open neck procedures. However, risks of KTP laser therapy are not negligible and strategies must be in place to minimize the occurrence of complications.

Mandibular distraction for micrognathia and severe upper airway obstruction.

OBJECTIVE: To determine whether the use of mandibular distraction osteogenesis (DOG) can help to avoid tracheotomy or achieve decannulation in patients with mandibular hypoplasia and severe upper airway obstruction. DESIGN: Retrospective medical record review (spanning a 27-month period). SETTING: Tertiary care children's hospital. SUBJECTS: Group A (n=8) was composed of infants with Pierre Robin sequence and no tracheotomy (mean age, 2.5 months); group B (n=6), older nontracheotomized micrognathic children with obstructive sleep apnea (OSA) (mean age, 69 months); and group C (n=12), tracheotomized children with complex congenital syndromes (mean age, 33 months). INTERVENTION: Bilateral mandibular DOG with endoscopic (n=24) and/or radiographic (n=17) airway evaluation (mean follow-up, 16 months [range, 2-42 months]). OUTCOME MEASURES: Group A, tracheotomy avoidance; group B, resolution of OSA (clinically or on polysomnography); and group C, decannulation. RESULTS: Group A, 7 patients (88%) successfully avoided tracheotomy; group B, 5 patients (83%) had resolution of OSA; and group C, 2 patients (17%) underwent decannulation. CONCLUSIONS: Mandibular DOG (1) allows tracheotomy avoidance in infants with isolated Pierre Robin sequence and (2) relieves OSA in older micrognathic children without tracheotomy. However, mandibular DOG does not frequently lead to decannulation in tracheotomized patients with complex congenital syndromes.