Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal.

OBJECTIVE: Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies. METHODS: We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated. RESULTS: Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%. CONCLUSION: Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications. LEVEL OF EVIDENCE: Level 3 Case-series Laryngoscope, 2024.

Endoscopic Transnasal Management of Meningoceles and Encephaloceles in Children: A Systematic Review.

OBJECTIVE: To review surgical techniques used in the endoscopic transnasal repair of pediatric basal meningoencephaloceles and compare perioperative outcomes in children <2 and ≥2 years old. DATA SOURCES: MEDLINE, EMBASE, and CENTRAL. REVIEW METHODS: Data sources were searched from inception to August 22, 2022, using search terms relevant to endoscopic transnasal meningoencephalocele repair in children. Reviews and Meta-analyses were excluded. Primary outcomes were the incidence of intraoperative and postoperative complications, including cerebrospinal fluid leak, recurrence, and reintervention. Quality assessments were performed using Newcastle-Ottawa Scale, ROBIN-I, and NIH. RESULTS: Overall, 217 patients across 61 studies were identified. The median age at surgery was 4 years (0-18 years). Fifty percent were female; 31% were <2 years. Most defects were meningoencephaloceles (56%), located transethmoidal (80%), and of congenital origin (83%). Seventy-five percent of repairs were multilayered. Children ≥2 years underwent multilayer repairs more frequently than those <2 years (P = 0.004). Children <2 years more frequently experienced postoperative cerebrospinal fluid leaks (P = 0.02), meningoencephalocele recurrence (P < 0.0001), and surgical reintervention (P = 0.005). Following multilayer repair, children <2 years were more likely to experience recurrence (P = 0.0001) and reintervention (P = 0.006). CONCLUSION: Younger children with basal meningoencephaloceles appear to be at greater risk of postoperative complications following endoscopic endonasal repair, although the quality of available evidence is weakened by incomplete reporting. In the absence of preoperative cerebrospinal fluid leak or meningitis, it may be preferable to delay surgery as access is more conducive to successful repair in older children.

Clinician treatment choices for post-traumatic stress disorder: ambassadors survey of psychiatrists in 39 European countries.

BACKGROUND: Considering the recently growing number of potentially traumatic events in Europe, the European Psychiatric Association undertook a study to investigate clinicians' treatment choices for post-traumatic stress disorder (PTSD). METHODS: The case-based analysis included 611 participants, who correctly classified the vignette as a case of PTSD, from Central/ Eastern Europe (CEE) (n = 279), Southern Europe (SE) (n = 92), Northern Europe (NE) (n = 92), and Western Europe (WE) (N = 148). RESULTS: About 82% woulduse antidepressants (sertraline being the most preferred one). Benzodiazepines and antipsychotics were significantly more frequently recommended by participants from CEE (33 and 4%, respectively), compared to participants from NE (11 and 0%) and SE (9% and 3%). About 52% of clinicians recommended trauma-focused cognitive behavior therapy and 35% psychoeducation, irrespective of their origin. In the latent class analysis, we identified four distinct "profiles" of clinicians. In Class 1 (N = 367), psychiatrists would less often recommend any antidepressants. In Class 2 (N = 51), clinicians would recommend trazodone and prolonged exposure therapy. In Class 3 (N = 65), they propose mirtazapine and eye movement desensitization reprocessing therapy. In Class 4 (N = 128), clinicians propose different types of medications and cognitive processing therapy. About 50.1% of participants in each region stated they do not adhere to recognized treatment guidelines. CONCLUSIONS: Clinicians' decisions for PTSD are broadly similar among European psychiatrists, but regional differences suggest the need for more dialogue and education to harmonize practice across Europe and promote the use of guidelines.

Public knowledge of button battery ingestions: A social media based cross-sectional analysis.

INTRODUCTION: Button battery (BB) ingestion injuries are a devastating and preventable event within the pediatric population. Efforts to reduce the prevalence of esophageal button battery ingestion injuries include primary preventative measures. It is integral to assess the public's baseline knowledge about BB injuries to tailor future primary prevention efforts. METHODS: This is a crowdsourcing survey-based study. Participants were notified through our institution's Twitter and Instagram accounts. RESULTS: There were 930 completed survey responses from May to June 2022. The survey found that 87% (791/910) knew that swallowing a BB could cause injury and 71% knew that it could cause death (642/905). Eight-five percent of respondents did not know what signs and symptoms to look for after BB ingestion, only 30% (99/340) of healthcare professionals felt they would know. Only 10.1% (94/930) of participants knew to give children over 12 months old honey after suspected BB ingestion. Thirty-four percent (311/930) knew that complications could still occur even after BB were removed. Seventy-seven percent (719/930) knew that a dead BB could cause injury but only 17% knew the correct way to dispose of a dead button battery (158/930). Only 8% (72/930) of participants were knew that wrapping dead BB in tape could potentially prevent injury. CONCLUSION: The current study reveals gaps in the public's understanding of BB injury including: the presentation of BB injuries; the delayed harm of BB impactions; management and mitigation strategies, and BB disposal methods. This survey provided imperative insights to help guide future education and primary prevention initiatives.

Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach.

OBJECTIVE: To evaluate factors that influence the rate of cholesteatoma recurrence (growth of new retraction cholesteatoma) in children. METHODS: Review of children with primary acquired or congenital cholesteatoma. Severity was classified by extent and EAONO-JOS stage, and surgery by SAMEO-ATO. Primary outcome measure was 5-year recurrence rate using Kaplan-Meier or Cox regression analysis. RESULTS: Median age was 10.7 years for 408 cholesteatomas from which 64 recurred. Median follow up was 4.6 years (0-13.5 years) with 5-year recurrence rate of 16% and 10-year of 29%. Congenital cholesteatoma (n = 51) had 15% 5-year recurrence. Of 216 pars tensa cholesteatomas, 5-year recurrence was similar at 14%, whereas recurrence from 100 pars flaccida cholesteatomas was more common at 23% (log-rank, p = 0.001). Sub-division of EAONO-JOS Stage 2 showed more recurrence in those with than without mastoid cholesteatoma (22.1% versus 10%), with more in Stage 3 (31.9%; p = 0.0003). Surgery without mastoidectomy, including totally endoscopic ear surgery, had 11% 5-year recurrence. Canal wall-up tympanomastoidectomy (CWU) and canal wall-down/mastoid obliteration both had 23% 5-year recurrence. Multivariate analysis showed increased recurrence for EAONO-JOS Stage 3 (HR 5.1; CI: 1.4-18.5) at risk syndromes (HR 2.88; 1.1-7.5) and age < 7 years (HR 1.9; 1.1-3.3), but not for surgical category or other factors. CONCLUSION: Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. When controlling for these factors, surgical approach does not have a significant effect on this outcome. Other objectives, such as lower post-operative morbidity and better hearing outcome, may prove to be more appropriate parameters for selecting optimal surgical approach in children.

Wearable Technology: A Wellbeing Option for Serving Police Officers and Staff? A Comparison of Results of a Pilot Study with Firearms Officers and a Group of Mixed Officers and Staff.

The high-stress nature of policing contributes to deterioration of officer health and wellbeing as well as high levels of absenteeism and attrition. Wearable technology (WT) has been identified as a potential tool that can help in improving officer health and wellbeing. This pilot study aimed to give initial insight into acceptability and engagement with WT amongst officers. The study also aimed to uncover any notable areas for exploration in future research within the domain of officer health and wellbeing. Two groups were observed, firearms officers and a mixed group of officers. Participants wore the WT for an extended period, completed a variety of health and wellbeing questionnaires and discussed their experience in focus groups. Firearms officers and mixed group officers displayed similar sleep efficiency, but firearms officers have worse sleep consistency and sleep performance. Firearms officers appear to have higher HRV and a slightly lower resting heart rate. Both groups display reasonable acceptance of the use of WT, speaking favorably during the focus groups of how monitoring the data had improved their quality of life in terms of their understanding of sleep, wellbeing and how they had consequently completed lifestyle modification. WT offers some promise in managing officer health and wellbeing; studies with larger sample sizes are needed to confirm this.

Use of a Caprine Model for Simulation and Training of Endoscopic Ear surgery.

BACKGROUND: The objective of this study was to evaluate the utility of a caprine model in endoscopic ear surgical education using the index procedures of tympanoplasty and ossiculoplasty. Specifically, this study assessed the face and content validity of the caprine model, and the potential impact of anatomical differences on trainee understanding of human middle ear anatomy. METHODS: Twelve otolaryngology trainees attended a 3-hour endoscopic ear surgery course utilizing the caprine model in which they completed canalplasty, tympanoplasty, and ossiculoplasty. Prior to the course, the trainees completed a self-reported needs assessment and knowledge assessment of human middle ear anatomy. Following the course, the trainees repeated the knowledge assessment and completed evaluation and validation questionnaires. Five-point Likert scores were used for the needs assessment and validation questionnaire. RESULTS: Of the 12 trainees, 9 participated in the study. All domains of the learner needs assessment showed an average improvement of 1 point on the post-course evaluation with 6 of 9 domains being significantly improved using the Wilcoxon signed-rank test (P< .05). The model achieved validation in the domains of face, content, and global content validity with an average Likert score > 4. Knowledge assessment scores increased by 7% (P=.23) after the course compared to before. CONCLUSION: The caprine model offers an effective surgical simulation model for endoscopic ear surgery training with good face and content validity. We find it to be readily available and affordable. We currently use it routinely to give otolaryngology residents the experience of endoscopic ear surgery before operating on patients.

Endoscopic Repair of Round Window Cochleocele.

OBJECTIVE: To describe the novel presentation, implications, and endoscopic management of a congenital round window cochleocele. PATIENT: A 16-month old girl with profound hearing loss from bilateral incomplete partition type 1 (IP1) anomaly of the cochlea plus left-sided cochlear nerve aplasia and cochleocele. INTERVENTION: Anomalies were identified with computed tomographic scanning and magnetic resonance imaging during cochlear implant candidacy assessment. While under general anesthesia for right-sided cochlear implantation, the cochleocele was removed and packed with temporalis fascia using transcanal endoscopic ear surgery. The endoscope was held by an assistant while the surgeon packed the round window using a two-handed technique to counter the gush of cerebrospinal fluid. RESULTS: The child made an uneventful recovery with no cerebrospinal fluid leak or meningitis. CONCLUSIONS: Cochleocele can protrude through the round window of a cochlea with incomplete partition type 1 anomaly. An increased risk of meningitis secondary to acute otitis media is expected given the known risk from cochleocele arising through a stapes footplate fistula. Care should be taken to check for the presence of a cochleocele in hearing loss from congenital malformations involving the basal turn of the cochlea on imaging and also at the time of cochlear implant surgery. Repair should be considered at the first opportunity to prevent meningitis. If early cochlear implant surgery is not feasible or appropriate (as, for example, with cochlear nerve aplasia), transcanal endoscopic ear surgery provides good access for a low-morbidity approach.

Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review.

CONTEXT: Children presenting to health care facilities with button battery (BB) impaction. OBJECTIVES: To describe characteristics of children with vascular complications after BB impaction, as well as associated outcomes. DATA SOURCES: National Capital Poison Center registry and PubMed database from inception to December 2021. STUDY SELECTION: All reports describing children aged <18 years with vascular, esophageal, or airway complications after BB ingestion. DATA EXTRACTION: We extracted characteristics including date of publication, age and sex of child, battery type and size, duration and location of impaction, complications, subsequent interventions, and interval between battery removal and death. RESULTS: A total of 361 cases involved severe complications or death after BB ingestion (321 cases from the National Capital Poison Center registry database, 40 additional cases from PubMed). Nineteen percent (69 of 361) were fatal and 14% (51 of 361) involved vascular injuries. Three-quarters (75%) of vascular complications were aorto-esophageal fistulae and 82% of vascular injuries were not survivable. Fatal vascular cases had significantly longer median impaction time (96 hours versus 144 hours, P <.05) and a wider range of presenting features than survivors. LIMITATIONS: The total number of cases with vascular complications was small, data reported varied between cases, and no data were available on overall exposure. Long-term morbidity data were not available for the survivors. CONCLUSIONS: Prolonged BB impaction is a risk factor for vascular complications and death. A high index of suspicion is required for children representing with hematemesis after BB impaction, with prompt transfer to a tertiary center because vascular surgical intervention may offer a chance of survival.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review.

Importance: Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions. Objective: To review airway injuries, including long-term sequelae, after BB ingestion in children. Evidence Review: For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis. Conclusions and Relevance: Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Button battery taping prevents oesophageal injury.

AIM: Most button battery (BB) ingestions in children are unwitnessed leading to prolonged exposures and severe complications. One third of ingestions occur from free BB, that are stored or awaiting disposal. Recommendations have been made to cover the terminals of discarded BB with adhesive tape; however, it is unclear if this practice prevents injury. Our aim was to determine if tape could prevent oesophageal injury in a cadaveric porcine model. METHODS: Electrical, masking, packing and duct tape were compared. One BB was left untaped. Taped BBs were placed in a cadaveric porcine oesophagus controlled for temperature and humidification. Specimens were assessed at 0, 0.5, and hourly for 6 h by visual inspection, temperature and pH. BB voltage was measured before and after testing. All tests were repeated in triplicate. RESULTS: Oesophageal specimens demonstrated burn prevention in the packing and duct tape trials. Burns were seen in 2/3 trials with electrical tape and 3/3 trials with masking tape. pH remained neutral throughout the study for all packing and duct tape specimens. pH remained neutral initially for masking tape but increased rapidly to 12 by 2 h. There was no change in battery voltage for the packing tape and duct tape trials. There was a 16.3% reduction in voltage for masking tape which was similar to controls. CONCLUSIONS: Taping BB with packing tape and duct tape prevented oesophageal burns. This may provide a novel method of burn prevention for loose BB intended for disposal.

Cholesteatoma in Children with Sotos Syndrome.

BACKGROUND: Sotos syndrome is a rare genetic disorder characterized by neurodevelopmental delay and excessive childhood growth including macrocephaly. In this study, we present our experience of children with Sotos syndrome and cholesteatoma. METHODS: Retrospective case note review and cross-referencing with hospital picture archive and communication systems or cases identified from a prospective database of consecutive cholesteatoma surgeries. RESULTS: A total of 400 children underwent surgery for acquired cholesteatoma and 5 (1%) had Sotos syndrome (1 bilaterally). In comparison, 42(11%) had cleft palate which is around 10 times more common than Sotos syndrome, 5 (1%) had Down syndrome, and 3 (1%) had Turner syndrome. The median age at primary surgery was 8 years old (3.5-10.9 years), 124 children with Sotos syndrome were identified in picture archive and communication systems (4% with cholesteatoma) of which temporal bone imaging was available in 86 (70%) at the median age of 9 years (0-17.2), and 33/86 (38%) had normal ears bilaterally on all imaging. Changes consistent with fluid or inflammation were present in 9/30 (30%) computed tomography and 24/72 (33%) magnetic resonance imaging scans. Development of mastoid pneumatization was impaired in 20/30 (67%) computed tomography and 8/72 (11%) magnetic resonance imaging scans. At 5 years, children with Sotos syndrome (33%) had greater recidivism than those with cleft palate (15%) (Kaplan-Meier log-rank analysis, P=.001) CONCLUSION: Children with Sotos syndrome appear to be at increased risk of developing acquired cholesteatoma. Impaired temporal bone pneumatization is a common incidental finding in Sotos syndrome in keeping with this risk. Further study of this previously unreported association may improve the understanding of pathogenetic mechanisms in cholesteatoma.

Hearing Instability in Children with Congenital Cytomegalovirus: Evidence and Neural Consequences.

OBJECTIVE/HYPOTHESIS: Sensorineural hearing loss (SNHL) is a common sequela of congenital cytomegalovirus (cCMV), potentially exacerbating neurocognitive delay. The objectives of this study were to assess: (1) age at which SNHL in children with cCMV; (2) stimulability of the auditory system in children with cCMV following cochlear implantation (CI); and (3) whether features of magnetic resonance imaging (MRI) potentially are predictive of hearing outcomes. METHODS: In this retrospective study of a prospectively acquired cohort, 123 children with cCMV who were referred for hearing loss at a single tertiary referral hospital over 20 years were compared with an unmatched comparative group of 90 children with GJB2-related deafness. Outcome measures were results of newborn hearing screening (NHS), behavioral audiograms, and, in a subgroup of cochlear implant (CI) users, responses from the auditory nerve and brainstem evoked by CI at initial activation, as well as lesional volume of FLAIR-hyperintense signal alterations on MRI. RESULTS: All but 3 of 123 children with cCMV had confirmed and persistent SNHL. At birth, 113 children with cCMV underwent NHS, 31 (27%) passed in both ears and 23 (20%) passed in one ear (no NHS data in 10 children). At the first audiologic assessment, 32 of 123 (26%) had normal hearing bilaterally; 35 of 123 (28%) had unilateral SNHL; and 57 of 123 (46%) had bilateral SNHL. More than half (67 of 123, 54%) experienced hearing deterioration in at least one ear. Survival analyses suggested that 60% of children who developed SNHL did so by 2.5 years and 80% by 5 years. In the children who passed NHS in one or both ears, 50% developed hearing loss by 3.5 years in the ear, which passed unilaterally (n = 23 ears), and 50% by 5 years in bilateral passes (n = 62 ears). Hearing loss was significant enough in all but one child with isolated high-frequency loss for rehabilitation to be indicated. Hearing thresholds in individual ears were in the CI range in 83% (102 of 123), although duration of deafness was sufficient to preclude implantation at our center in 13 children with unilateral SNHL. Hearing aids were indicated in 16% (20 of 123). Responses from the auditory nerve and brainstem to initial CI stimulation were similar in children with cCMV-related SNHL compared with GJB2-related SNHL. Characteristic white matter changes on MRI were seen in all children with cCMV-related SNHL (n = 91), but the lesion volume in each cortical hemisphere did not predict degree of SNHL. CONCLUSIONS: cCMV-related SNHL is often not detected by NHS but occurs with high prevalence in early childhood. Electrophysiological measures suggest equivalent stimulability of the auditory nerve and brainstem with CI in children with cCMV and GJB2-related SNHL. Hyperintense white matter lesions on FLAIR MRI are consistently present in children with cCMV-related SNHL but cannot be used to predict its time course or degree. Combined, the data show early and rapid deterioration of hearing in children with cCMV-related SNHL with potential for good CI outcomes if SNHL is identified and managed without delay. Findings support universal newborn screening for cCMV followed by careful audiological monitoring. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:S1-S24, 2022.