Effect of adenoid size on the post-adenoidectomy hypernasality in children with a normal palate.

PURPOSE: Adenoidectomy, either alone or with tonsillectomy, is a common surgical procedure in the field of pediatric otorhinolaryngology. Resonance function may be altered postoperatively in the form of hypernasality, which is usually transient. This study aimed to investigate the effect of adenoid size on post-adenoidectomy hypernasality in children with a normal palate. METHODS: Seventy-one children with different degrees of adenoid hypertrophy were included in this prospective observational study. Endoscopic assessment of the adenoid size and preoperative and postoperative evaluation of speech (at 1 and 3 months) with auditory perceptual assessment (APA) and nasometry were performed. RESULTS: APA showed preoperative hyponasality in 59.1% of children and was found to be significantly related to the adenoid size, with more hyponasality in grades 3 and 4. One month postoperatively, hypernasality was detected in 26.7% of patients and was found to be related to the preoperative adenoid size with higher hypernasality in grades 3 and 4. Three months postoperatively, all patients had gained normal nasality except one (1.4%) who was subjected to a longer follow-up period. Nasometric assessment showed significant differences at the three visits (pre, 1, and 3 months postoperatively), with a negative correlation between the grade of adenoid size and nasalance scores preoperatively and a significant positive correlation between them at 1 month postoperatively. However, no significant correlation was detected at 3 months postoperatively. CONCLUSION: Transient hypernasality may develop in some patients after adenoidectomy, especially in children with a larger preoperative adenoid size. However, transient hypernasality generally resolves spontaneously within 3 months.

Furlow Palatoplasty and Tonsillectomy for Treating Patients With Submucous Cleft Palate and Tonsillar Hypertrophy: A One-Stage Procedure.

BACKGROUND: Children with cleft palate are more liable to have obstructive sleep apnea than children with normal palate due to narrow airways. Tonsillar hypertrophy is a common cause of pediatric obstructive sleep apnea; hence, it is not surprising to be encountered during cleft palate repair. The aim of this study was to evaluate the feasibility of tonsillectomy and Furlow palatoplasty performed as a 1-stage operation in patients presenting with submucous cleft palate (SMCP) and tonsillar hypertrophy. MATERIALS AND METHODS: Eleven pediatric patients with SMCP and hypertrophied tonsils were included in this case series study. Furlow palatoplasty and tonsillectomy were performed for the patients in 1 sitting. The evaluation of velopharyngeal function was done preoperatively and postoperatively via auditory-perceptual-assessment, nasometry, and flexible nasopharyngoscopy. In addition, the Epworth sleepiness scale for children/adolescents was administered to the parents to assess daytime sleepiness of their children. RESULTS: The speech improved postoperatively. Auditory-perceptual-assessment showed significant reductions in hypernasal speech, nasal air escape, and weak pressure consonants. In addition, nasometry revealed significantly decreased nasalance scores for nasal and oral sentences. A postoperative increased velar movement was observed with a significant improvement in velopharyngeal closure. The preoperative Epworth sleepiness scale for children/adolescents assessment revealed excessive daytime sleepiness in 8 patients, with significant improvement of scores postoperatively. CONCLUSIONS: Removal of hypertrophied tonsils during the repair of SMCP with Furlow palatoplasty did not negatively affect speech outcome or velar movement postoperatively. It is logical to perform both procedures simultaneously in 1 sitting to avoid postoperative sleep-related breathing disorder, which may necessitate a second stage operation.

Persistent Obstructive Sleep Apnea in Children with Down Syndrome After Adenotonsillectomy: Drug Induced Sleep Endoscopy-Directed Treatment.

ABSTRACT: Children with down syndrome (DS) are more liable to develop obstructive sleep apnea (OSA) which is usually treated with adenotonsillectomy. However, OSA may persist in many of those patients after the procedure. The aim of this study was to assess the efficacy of drug-induced sleep endoscopy (DISE)-directed treatment in management of DS children with persistent OSA after adenotonsillectomy. Sixteen DS children with persistent OSA after adenotonsillectomy were evaluated. DISE was done in the operating theatre to identify the site of obstruction, and surgical intervention was performed according to the finding. Polysomnographic study was used pre- and post-operatively to measure the outcome. DISE revealed obstruction in different sites of the airway. DISE-directed treatment was done according to the site of obstruction. Polysomnographic study showed postoperative significant changes for all parameters. The authors achieved improvement of overall apnea-hypopnea index which was normalized in seven patients (44%). In conclusion, DISE-directed treatment is an effective procedure for persistent OSA in DS children who underwent adenotonsillectomy. However, residual obstruction in those children may be due to many characteristic features that cause narrowing of the airway.

Acute Invasive Fungal Rhinosinusitis and Coronavirus Disease 2019.

ABSTRACT: Acute invasive fungal rhinosinusitis (mucormycosis) is a rare, highly fatal disease. This opportunistic fungal infection causes angioinvasion and ischemic tissue necrosis. It mainly affects immunocompromised patients. Since the coronavirus disease 2019 (COVID-19) outbreak, many case reports have described the rhino-orbital-cerebral mucormycosis associated with COVID-19. However, the underlying predisposing factors are unknown. Several factors, other than diabetes, which is the most well-known contributing factor, may be involved in causing this severe fungal infection in COVID-19 patients. These factors may include steroid therapy, which is being used in severely dyspneic patients, the use of broad-spectrum antibiotics that may cause fungal flare-ups, and hospitalization with possible nosocomial infections. In addition, increased serum ferritin levels, possible endothelial damage, and pancreatic islets affection among COVID-19 patients may be implicated. Head and neck surgeons should be aware of the increasing prevalence of craniofacial mucormycosis among COVID-19 patients, as early diagnosis and prompt treatment are essential to improve the outcomes.

Subjective Smell Assessment as An Office-based Rapid Procedure In COVID-19 Era.

ABSTRACT: A recent history of smell disorder may be a potential predictor for COVID-19. The authors used a subjective olfaction score that was demonstrated on a hard paper-bar. The authors examined 480 patients who were attending the outpatient clinic. Ninety-seven patients (20.2%) demonstrated variable degrees of recent smell disorder. For those patients, lab testing including nasopharyngeal swab for real-time polymerase chain reaction (RT-PCR) was performed. Eighty-eight of them (90.7%) have been confirmed to be COVID-19 positive. Although psychophysical testing is more reliable, subjective assessment of smell is a rapid procedure and can be used as an office-based method for patients' screening in COVID-19 era. Smell disorder could be an alarming sign for COVID-19 even with absent characteristic symptoms.

Concomitant adenotonsillectomy and cleft palate repair in one sitting.

PURPOSE: When adenotonsillar hypertrophy (ATH) is encountered in children during cleft palate (CP) repair, the decision for adenotonsillectomy is challenging. The aim of this study was to evaluate the effectiveness of adenotonsillectomy done during CP repair for children with ATH on speech and breathing. METHODS: Nine children with CP and ATH underwent adenotonsillectomy prior to palatoplasty in same sitting. The age of patients ranged between 1.5 and 3.5 years with a mean age of 2.3 years at the time of operation. Auditory perceptual assessment (APA), nasometric assessment, and velopharyngeal function evaluation were performed when the children reached the age of 4 years. RESULTS: No children developed obstructive breathing episodes postoperatively as witnessed by parents. APA showed normal nasality in six patients and mild hypernasality in three patients. Nasalance scores for both nasal and oral sentences were found to be comparable with that of normal children of the same age. Velopharyngeal closure was seen competent in four patients, borderline competent in three patients, and borderline incompetent in two patients. CONCLUSION: Performing adenotonsillectomy during CP repair does not deleteriously affect the speech and it prevents the occurrence of postoperative obstructive breathing episodes that may be caused by the hypertrophied tonsils and/or adenoid.

Adenoid hypertrophy causing obstructive sleep apnea in children after pharyngeal flap surgery.

PURPOSE: Pharyngeal flap surgery used for treatment of velopharyngeal insufficiency (VPI) may be followed by obstructive sleep apnea (OSA) especially if the patient has developed adenoid hypertrophy. However, adenoidectomy may adversely affect speech in these patients. The aim of this study was to assess the effectiveness of transnasal endoscopic power-assisted adenoidectomy in relieving OSA in patients with adenoid hypertrophy who underwent pharyngeal flap surgery, and the impact of the procedure on their speech. METHODS: Transnasal endoscopic power-assisted adenoidectomy for nine children presenting with adenoid hypertrophy was performed. The patients had previously undergone pharyngeal flap surgery for treatment of VPI. Flexible nasopharyngoscopy was used in the diagnosis of adenoid hypertrophy. Pre- and postoperative polysomnography with measurement of apnea-hypopnea index (AHI) was done. Additionally, auditory perceptual assessment of speech (APA) and nasalance scores was measured pre- and postoperatively. RESULTS: All patients were shown to have OSA by polysomnography, and a larger adenoid size was significantly associated with a higher AHI. We achieved a significant improvement in AHI after adenoidectomy. However, six patients still demonstrated OSA, albeit with a reduced severity. Speech was not adversely affected postoperatively as the APA and nasalance scores showed non-significant changes. CONCLUSION: Adenoid hypertrophy may be encountered in children who undergo pharyngeal flap surgery, which may cause OSA. Transnasal endoscopic power-assisted adenoidectomy is a safe and effective method for treatment of OSA in those patients without prejudicing the pharyngeal flap, and it has no adverse effect on speech.

The Impact of Velopharyngeal Surgery on the Polysomnographic Parameters After Cleft Palate Repair.

Velopharyngeal surgical procedures may have adverse effect on the airway of the patients with velopharyngeal insufficiency (VPI). The aim of this study was to evaluate the polysomnographic parameters (PSG) in patients who underwent corrective surgery for treatment of VPI. The study included 39 patients who underwent 1 of 3 velopharyngeal surgical techniques; Furlow palatoplasty (12 patients), pharyngeal flap (18 patients), and sphincter pharyngoplasty (9 patients). The patients were subjected to PSG, and they were considered to have obstructive sleep apnea (OSA) with apnea-hypoapnea index (AHI) >1.Comparison of PSG parameters of patients showed insignificant difference regarding the total sleep time, sleep efficiency, arousal index, desaturation index, and minimum oxygen saturation. Significant difference was detected regarding peak end-tidal CO2 and AHI. Pharyngeal flap was detected as the most surgical technique that worsened the PSG parameters with OSA in 78% of patients, followed by sphincter pharyngoplasty with OSA in 56% of patients. Furlow palatoplasty was detected as the least impacting technique on the airway in 25% of patients who demonstrated OSA. In conclusion, velopharyngeal surgery has a variable impact on the PSG; pharyngeal flap has the most worsening effect followed by sphincter pharyngoplasty, while Furlow palatoplasty has the least adverse effect.

Closure of Oroantral Fistula With Buccal Fat Pad Flap and Endoscopic Drainage of the Maxillary Sinus.

Oroantral fistula (OAF) is a pathologic communication between the oral cavity and the maxillary sinus. It is usually associated with maxillary sinusitis, where drainage of sinus infection is a mandatory step during closure of the fistula. The flap used for closure of OAF should be tension free, broadly based and well vascularized. The aim of this study was to assess the effectiveness of closure of OAF using buccal fat pad (BFP) flap with concomitant endoscopic middle meatal antrostomy for maxillary sinus drainage. Nineteen patients with chronic OAF were included in the study. Closure was performed using BFP with endoscopic middle meatal antrostomy. Preoperative and postoperative assessments were carried out. Patients were followed up for at least 1 year postoperatively. Complete closure of all OAFs was achieved with no recurrence or dehiscence. In conclusion, closure of OAF with BFP flap and concomitant endoscopic drainage of the maxillary sinus through the middle meatus is an effective, easy, and simple method. It has a high success rate with no effect on the vestibular depth or mouth opening.

Lateralization of the Pharyngeal Flap for Treatment of Lateral Velopharyngeal Gap.

Pharyngeal flap is usually used for treatment of velopharyngeal insufficiency (VPI); it is bridged between the posterior pharyngeal wall and the soft palate traversing the central part of the velopharyngeal port. The aim of this study was to assess the efficacy of lateralization of the pharyngeal flap for treatment of VPI in patients with lateral velopharyngeal gap. Fifteen patients with VPI due to lateral velopharyngeal gap were subjected to closure of the gap by pharyngeal flap that was lateralized to fill the gap. Preoperative and postoperative assessment of velopharyngeal functions including flexible nasopharyngoscopy, auditory perceptual assessment (APA), and nasometric assessment were performed. Postoperatively, flexible nasopharyngoscopy showed complete velopharyngeal closure in all the patients, with significant improvement of speech parameters as measured by APA. Also, nasalance score showed significant improvement for oral and nasal sentences that was measured by nasometry. Lateralization of the pharyngeal flap for treatment of VPI in patients with lateral velopharyngeal gap is an effective method; it improves the velopharyngeal closure and the speech of the patients.

Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by formation of large cervical osteophytes that may compress the posterior wall of the aerodigestive tract. It is a rare cause of dysphagia in the elderly. The aim of this study was to investigate the various otolaryngologic manifestations of DISH. Eleven elderly patients with DISH were included in the study. All patients presented with dysphagia that was graded on the swallowing screening tool (EAT-10), and the diagnosis of DISH was based on computed tomographic criteria. The patients were subjected to otolaryngologic examination and flexible laryngoscopy. Polysomnography was used for patients with excessive daytime sleepiness for detection of obstructive sleep apnea (OSA). In addition to dysphagia of varying severity, OSA was found in nine patients, change of voice in six, globus sensation in seven, aspiration in three, and cervical pain in seven. Flexible laryngoscopy showed bulging of the posterior pharyngeal wall in all patients. DISH may be an unrecognized contributory factor to both dysphagia and OSA in the elderly. Change of voice, aspiration, globus sensation, and cervical pain are other otolaryngologic manifestations that may be encountered symptoms of the disease. An otolaryngologist should be aware of the disease that may be overlooked, and computed tomography is a confirmatory diagnostic method.

Eosinophilic granuloma of the temporal bone in children.

Eosinophilic granuloma (EG) is a bony destructive disease that frequently occurs in children; it is a subtype of Langerhans cell histiocytosis. The aims of this study were to detect the presenting features of temporal bone lesions in children and to evaluate the efficacy of surgery combined with radiotherapy in treatment of the disease. A retrospective study on 12 children with EG of the temporal bone was done. Computed tomography and hearing assessment were performed for all patients. All patients were treated with cortical mastoidectomy followed by postoperative radiotherapy. Follow-up was carried out for at least 2 years. The patients' presenting symptoms were external ear canal mass in 10 patients (83.3%), postauricular swelling in 8 patients (66.7%), and persistent otorrhea in 4 patients (33.3%). Ten patients (83.3%) showed conductive hearing loss, whereas 2 patients (16.7%) showed mixed hearing loss on the affected side. Computed tomography showed osteolytic defects without sclerotic margins filled with soft tissue masses involving the mastoid bone. Histopathologic examination showed eosinophils and Langerhans cells that were immune reactive for CD1 antigen and S-100 protein. Postoperative follow-up showed complete cure of the disease in 10 children (83.3%), with recurrence detected in 2 patients (16.7%) who needed second surgical intervention. We concluded that temporal bone EG in children may present with features that mimic the features of chronic suppurative otitis media. However, computed tomography and histopathologic examination are diagnostic. Cortical mastoidectomy together with postoperative radiotherapy is an achievable treatment in most cases.

Congenital aural atresia.

Congenital aural atresia is a spectrum of ear deformities present at birth that involves some degree of failure of the development of the external auditory canal. This malformation may be associated with other congenital anomalies; it occurs as a result of abnormal development of the first and second branchial arches and the first branchial cleft and most often occurs sporadically, although the disease may be manifested in different syndromes. Congenital aural atresia is considered one of the most difficult and challenging surgeries for the otologic surgeon. The goals of atresia surgery are to restore functional hearing, preferably without the requirement of a hearing aid, and to reconstruct a patent, infection-free external auditory canal. The repair is usually done at the age of 6 years, so children with bilateral atresia may need hearing amplification in the first few weeks of life until the age at surgery. To optimize the surgical outcome, careful audiological and radiological evaluation of the patient should be performed preoperatively. Also, postoperative frequent packing and regular follow-up are mandatory to avoid restenosis and infection of the newly created canal. With careful intraoperative dissection and regular follow-up, complications of surgery can be avoided.

Congenital cholesteatoma of the infratemporal fossa with congenital aural atresia and mastoiditis: a case report.

BACKGROUND: Congenital cholesteatoma may be expected in abnormally developed ear, it may cause bony erosion of the middle ear cleft and extend to the infratemporal fossa. We present the first case of congenital cholesteatoma of the infratemporal fossa in a patient with congenital aural atresia that has been complicated with acute mastoiditis. CASE PRESENTATION: A sixteen year old Egyptian male patient presented with congenital cholesteatoma of the infratemporal fossa with congenital aural atresia complicated with acute mastoiditis. Two weeks earlier, the patient suffered pain necessitating hospital admission, magnetic resonance imaging revealed a soft tissue mass in the right infratemporal fossa. On presentation to our institute, Computerized tomography was done as a routine, it proved the diagnosis of mastoiditis, pure tone audiometry showed an air-bone gap of 60 dB. Cortical mastoidectomy was done for treatment of mastoiditis, removal of congenital cholesteatoma was carried out with reconstruction of external auditory canal. Follow-up of the patient for 2 years and 3 months showed a patent, infection free external auditory canal with an air-bone gap has been reduced to 35db. One year after the operation; MRI was done and it showed no residual or recurrent cholesteatoma. CONCLUSIONS: Congenital cholesteatoma of the infratemporal fossa in cases of congenital aural atresia can be managed safely even if it was associated with mastoiditis. It is an original case report of interest to the speciality of otolaryngology.

Endoscopic nasopharyngeal exploration at the end of conventional curettage adenoidectomy.

Adenoid hypertrophy (AH) is a common cause of airway obstruction in children and its recurrence after conventional curettage adenoidectomy is not rare. The purpose of this study is to assess the efficacy of endoscopic nasopharyngeal exploration at the end of curettage adenoidectomy on decreasing the incidence of adenoid re-hypertrophy. Three hundred and fifty children diagnosed as having AH, underwent conventional curettage adenoidectomy by a single surgeon. The cases were randomly divided into two equal groups A and B, group B were further subjected to nasopharyngeal exploration by the nasal endoscope after removal of their adenoids with cauterization of any visible residuals, while group A were not subjected to this endoscopic maneuver. Follow-up was carried out for at least 2 years; flexible nasopharyngoscopy was used for detection of recurrent AH. Cases that were not subjected to endoscopic nasopharyngeal exploration (group A) showed a high recurrence rate (6.6%), while explored cases (group B) showed a low incidence of recurrence (1.18%). Most recurrence of group A (6%) was detected within the first year of the follow-up period which may indicate re-growth of residual adenoidal tissues that were missed during conventional curettage adenoidectomy. Endoscopic nasopharyngeal exploration at the end of conventional curettage adenoidectomy is a useful method in decreasing the incidence of recurrent AH.

Repair of choanal atresia and oro-nasal fistula in one sitting.

A seven month-old girl with bilateral choanal atresia presented to our institution with oro-nasal fistula secondary to a previous atresia repair. Examination revealed obstruction of both choanae and the presence of a fistula located in the hard palate. Endoscopic repair of the atresia and a two-layer closure of the fistula were carried out in one sitting. Follow-up of the patient for 6 months showed patent choanae and a healed palatal fistula.

Asymptomatic cardiopulmonary changes caused by adenoid hypertrophy.

Adenoid hypertrophy is the most common cause of pediatric upper airway obstruction, and it can lead to cardiopulmonary complications such as pulmonary hypertension, cor pulmonale, and even heart failure. The aim of this study was to detect the asymptomatic cardiopulmonary changes that could happen in children with adenoid hypertrophy.Eighty children with adenoid hypertrophy were included in this study. Chest x-ray was used to assess the cardiothoracic ratio, whereas echocardiography was used for measuring the pulmonary arterial pressures, right ventricular diastolic filling parameters, and right ventricular end-diastolic diameters. All patients underwent adenoidectomy with or without tonsillectomy, and they were subjected again to echocardiographic assessment 6 months after the operation. No patient showed an increase in the cardiothoracic ratio on x-ray. Preoperative echocardiography showed an increase in pulmonary artery pressure (22.7 [SD, 3.8] mm Hg), a decrease in right ventricular diastolic filling parameters (E/A = 1.03 [SD, 0.17]), and an increase in right ventricular end-diastolic diameters (1.89 [SD, 0.19] cm). Postoperatively, pulmonary artery pressure decreased to 17.2 [SD, 2.1] mm Hg, right ventricular diastolic filling (E/A) increased to 1.25 [SD, 0.11], and right ventricular end-diastolic diameters decreased to 1.68 [SD, 0.12] cm. The comparison between preoperative and postoperative results for each individual parameter was statistically significant. Clinically asymptomatic cardiopulmonary changes due to adenoid hypertrophy are not rare. Early diagnosis and treatment of upper airway obstruction can prevent these serious complications. Echocardiographic examination should be recommended for these patients as a part of preoperative preparation to avoid anesthetic complications.

Epidermoid cyst of the external auditory canal in children: diagnosis and management.

Epidermoid cyst of the external auditory canal (EAC) is rarely encountered in the clinical practice, but when it occurs, it may cause obstruction of the meatus that necessitates surgical excision. The aims of this study were to present 9 pediatric patients with epidermoid cysts of the EAC and to evaluate the outcome of the surgical technique that has been used in excision. Surgical removal of the cyst was carried out through a simple transmeatal approach, a medially based rectangular skin flap was elevated and the cyst was completely removed. No complications or recurrence have been reported. Epidermoid cyst should be listed in the differential diagnosis of EAC masses; it appears on computed tomography as a cystic mass in the outer cartilaginous part of EAC that is usually limited to the soft tissue with no bone erosion. It can be removed easily through simple transmeatal approach with high success rate and no morbidity.