Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections.

OBJECTIVES: To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. STUDY DESIGN: We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. RESULTS: Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/µL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). CONCLUSIONS: In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Combination mTOR and SHP2 inhibitor treatment of lymphatic malformation endothelial cells.

Mammalian target of rapamycin (mTOR) inhibitors are clinically effective at treating some complex lymphatic malformations (LM). The mTOR inhibitor rapamycin blocks the phosphoinositide 3-kinase (PI3K) pathway, which is commonly mutated in this condition. Although rapamycin is effective at controlling symptoms of LM, treatment courses are long, not all LMs respond to treatment, and many patients relapse after treatment has stopped. Concurrent rat sarcoma virus (RAS) pathway abnormalities have been identified in LM, which may limit the effectiveness of rapamycin. Protein tyrosine phosphatase-2 (SHP2) controls the RAS pathway upstream, and SHP2 inhibitors are being investigated for treatment of various tumors. The objective of this study was to determine the impact of SHP2 inhibition in combination with rapamycin on LM growth in vitro. Using primary patient cells isolated from a surgically resected LM, we found that combination treatment with rapamycin and the SHP2 inhibitor SHP099 caused a synergistic reduction in cell growth, migration and lymphangiogenesis. These results suggest that combination treatment targeting the PI3K and RAS signaling pathways may result in effective treatment of LMs of the head and neck.

FCRL4 Is an Fc Receptor for Systemic IgA, but Not Mucosal Secretory IgA.

Fc receptor-like (FCRL) 4 is an immunoregulatory receptor expressed on a subpopulation of human memory B cells of mucosa-associated lymphoid tissue. Fc receptor function of FCRL4 was demonstrated by binding of IgA to FCRL4 following heat aggregation of the Ig. In this study, we demonstrate that FCRL4 recognizes J chain-linked systemic IgA in the absence of heat aggregation. We further demonstrate that mucosal secretory IgA is not recognized by FCRL4 and that systemic IgA binding can be competitively inhibited by recombinant secretory component protein. Finally, we provide evidence that primary FCRL4-bearing human memory B cells are constitutively bound to IgA. Our study provides a mechanism for the negative regulatory activity of FCRL4 on AgR-mediated B cell activation.

The Impact of Hospital Surgical Volume on Healthcare Utilization Outcomes After Pediatric Thyroidectomy.

BACKGROUND: A positive relationship between an individual surgeon's operative volume and clinical outcomes after pediatric and adult thyroidectomy is well-established. The impact of a hospital's pediatric operative volume on surgical outcomes and healthcare utilization, however, are infrequently reported. We investigated associations between hospital volume and healthcare utilization outcomes following pediatric thyroidectomy in Canada's largest province, Ontario. METHODS: Retrospective analysis of administrative and health-related population-level data from 1993 to 2017. A cohort of 1908 pediatric (<18 years) index thyroidectomies was established. Hospital volume was defined per-case as thyroidectomies performed in the preceding year. Healthcare utilization outcomes: length of stay (LOS), same day surgery (SDS), readmission, and emergency department (ED) visits were measured. Multivariate analysis adjusted for patient-level, disease and hospital-level co-variates. RESULTS: Hospitals with the lowest volume of pediatric thyroidectomies, accounted for 30% of thyroidectomies province-wide and performed 0-1 thyroidectomies/year. The highest-volume hospitals performed 19-60 cases/year. LOS was 0.64 days longer in the highest, versus the lowest quartile. SDS was 83% less likely at the highest, versus the lowest quartile. Hospital volume was not associated with rate of readmission or ED visits. Increased ED visits were, however, associated with male sex, increased material deprivation, and rurality. CONCLUSIONS: Increased hospital pediatric surgical volume was associated with increased LOS and lower likelihood of SDS. This may reflect patient complexity at such centers. In this cohort, low-volume hospitals were not associated with poorer healthcare utilization outcomes. Further study of groups disproportionately accessing the ED post-operatively may help direct resources to these populations.

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.

BalanCI: Head-Referenced Cochlear Implant Stimulation Improves Balance in Children with Bilateral Cochleovestibular Loss.

INTRODUCTION: To determine the impact of a head-referenced cochlear implant (CI) stimulation system, BalanCI, on balance and postural control in children with bilateral cochleovestibular loss (BCVL) who use bilateral CI. METHODS: Prospective, blinded case-control study. Balance and postural control testing occurred in two settings: (1) quiet clinical setting and (2) immersive realistic virtual environment (Challenging Environment Assessment Laboratory [CEAL], Toronto Rehabilitation Institute). Postural control was assessed in 16 and balance in 10 children with BCVL who use bilateral CI, along with 10 typically developing children. Children with neuromotor, cognitive, or visual deficits that would prevent them from performing the tests were excluded. Children wore the BalanCI, which is a head-mounted device that couples with their CIs through the audio port and provides head-referenced spatial information delivered via the intracochlear electrode array. Postural control was measured by center of pressure (COP) and time to fall using the WiiTM (Nintendo, WA, USA) Balance Board for feet and the BalanCI for head, during the administration of the Modified Clinical Test of Sensory Interaction in Balance (CTSIB-M). The COP of the head and feet were assessed for change by deviation, measured as root mean square around the COP (COP-RMS), rate of deviation (COP-RMS/duration), and rate of path length change from center (COP-velocity). Balance was assessed by the Bruininks-Oseretsky Test of Motor Proficiency 2, balance subtest (BOT-2), specifically, BOT-2 score as well as time to fall/fault. RESULTS: In the virtual environment, children demonstrated more stable balance when using BalanCI as measured by an improvement in BOT-2 scores. In a quiet clinical setting, the use of BalanCI led to improved postural control as demonstrated by significant reductions in COP-RMS and COP-velocity. With the use of BalanCI, the number of falls/faults was significantly reduced and time to fall increased. CONCLUSIONS: BalanCI is a simple and effective means of improving postural control and balance in children with BCVL who use bilateral CI. BalanCI could potentially improve the safety of these children, reduce the effort they expend maintaining balance and allow them to take part in more complex balance tasks where sensory information may be limited and/or noisy.

Obstructive sleep apnea in children aged 3 years and younger: Rate and risk factors.

OBJECTIVE: Undiagnosed and untreated obstructive sleep apnea (OSA) can predispose children to neurobehavioural consequences. However, there is a lack of data identifying rate of, and risk factors for, OSA in very young healthy children. The objective of this study was to determine the rate of OSA and identify risk factors associated with the presence and severity of OSA in children aged 3 years and younger. METHODS: This was a retrospective chart review of healthy children between 1 and 3 years old who had a baseline polysomnogram (PSG) between January 2012 and June 2017. Patient demographics, referral history, and PSG data were recorded. RESULTS: One hundred and thirteen children were referred for a PSG, of which 66 (58%) were diagnosed with OSA and 47 (42%) did not have OSA. In the OSA group, 13 (20%) were mild and 53 (80%) were moderate-severe. Nasal congestion (P=0.001), adenoid hypertrophy (P=<0.001), and tonsillar hypertrophy (P=0.04) reported at the time of referral were more common in the OSA group compared to the no-OSA group. Binary logistic regression analysis showed that referral from an otolaryngologist (odds ratio=2.6, 95% confidence interval=1.1 to 6.0) were associated with moderate-severe OSA. CONCLUSION: A high rate of OSA was found among children aged 3 years and younger. Children referred by an otolaryngologist are more likely to be diagnosed with moderate-severe OSA. Children aged 3 years and younger with symptoms of OSA should be considered high-risk for OSA and be prioritized for early PSG and management.

Separating the contributions of olivocochlear and middle ear muscle reflexes in modulation of distortion product otoacoustic emission levels.

OBJECTIVES: Mediated by the medial olivocochlear system (MOCS), distortion product otoacoustic emission (DPOAE) levels are reduced by presentation of contralateral acoustic stimuli. Such acoustic signals can also evoke a middle ear muscle reflex (MEMR) that also attenuates recorded DPOAE levels. Our aim is to clearly differentiate these two inhibitory mechanisms and to analyze each separately, perhaps allowing the development of novel tests of hearing function. METHODS: DPOAE were recorded in real time from chinchillas with normal auditory brainstem response thresholds and middle ear function. Amplitude reduction and its onset latency caused by contralateral presentation of intermittent narrow-band noise (NBN) were measured. Stapedius and tensor tympani muscle tendons were divided without disturbing the ossicular chain, and DPOAE testing was repeated. RESULTS: Peak reduction of (2f1 - f2) DPOAE levels occurred when the center frequency of contralateral NBN approximated the primary tone f2, indicating an f2-frequency-specific response. For a 4.5-kHz centered NBN, DPOAE (f2 = 4.4 kHz) inhibition was 0.1 dB (p < 0.001). This response remained present after tendon division, consistent with an MOCS origin. Low-frequency NBN (center frequency: 0.5 kHz) reduced otoacoustic emission levels (0.1 dB, p < 0.001) across a wide range of DPOAE frequencies. This low-frequency response was abolished by division of the middle ear muscle tendons, clearly indicating MEMR involvement. CONCLUSIONS: Following middle ear muscle tendon division, DPOAE inhibition by contralateral stimuli approximating the primary tone f2 persists, whereas responses evoked by lower contralateral frequencies are abolished. This distinguishes the different roles of the MOCS (f2 frequency specific) and MEMR (low frequency only) in contralateral modulation of DPOAE. This analysis helps clarify the pathways involved in an objective test that might have clinical benefit in the testing of neonates.

Suspension Microesophagoscopy for Endoscopic Suture Closure of Pediatric Tracheoesophageal Fistula.

A 15-year-old male with previous open tracheoesophageal fistula (TEF) repair presented with a large, short recurrent TEF. The TEF was denuded with cautery on the tracheal side and the patient was intubated with a cuffed endotracheal tube. Suspension microesophagoscopy allowed excellent exposure of the TEF from the esophageal side, which was cauterized. Four sutures were placed endoscopically from the esophageal side, and the TEF remained closed 6 months postoperatively. Laryngoscope, 2024.

Respiratory distress in a neonate: Inflation of a third branchial anomaly with positive airway pressure.

Positive airway pressure from noninvasive ventilation is an essential tool for many pediatric patients with respiratory distress. We present a case of an unknown third branchial anomaly that was diagnosed following inflation with continuous positive airway pressure (CPAP), which exacerbated the infant's respiratory distress.

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.

Oral Sucrose in Infants Undergoing Flexible Nasolaryngoscopy: A Blinded Randomized Pilot Study.

INTRODUCTION: Flexible nasolaryngoscopy (FNL) is a common, uncomfortable procedure performed to assess the upper airway in infants. Oral sucrose is used during various painful procedures in infants but has not been used during FNL. Our objective was to understand the impact of oral sucrose on discomfort in infants undergoing FNL. METHODS: Infants (<12-months-old) undergoing FNL in the otolaryngology clinic were randomized to treatment (0.5 mL 24% oral sucrose) or standard management (no sucrose). Sucrose was administered <2 min prior to FNL performed by a single endoscopist. Outcome measures included: EVENDOL pain scale and cry duration and visit duration. Infant discomfort was measured by a second observer who was blinded to treatment group. RESULTS: Forty-seven infants were included, 23 were treated with sucrose and 24 with standard management. The median (IQR) age was 3.0 (2-5.7) months. There were no significant differences in age, weight, or sex across groups. The median (IQR) duration of FNL was 35.2 (26.5-58.4) and 36.4 (28.9-51.8) seconds for treatment and standard management groups, respectively. Mean (SD) EVENDOL scores were significantly lower in the sucrose group [4.9 (2.0)] than standard group (6.7 [2.1]) (p = 0.003). Mean cry duration after FNL was significantly shorter in the sucrose group (29.9 [20.4] seconds) than the standard group (52.7.0 [40.6] seconds) (p = 0.02). Median (IQR) visit duration did not differ across groups (1.1 [0.9-1.3] vs. 1.1 [0.7-1.4] h [p = 0.15]). CONCLUSION: Oral sucrose given before FNL reduced EVENDOL scores and cry duration after FNL and did not prolong clinic visits in this randomized pilot study. LEVEL OF EVIDENCE: 2 Laryngoscope, 2024.

Percutaneous tracheostomy in the pediatric population: A systematic review.

OBJECTIVE: Percutaneous tracheostomy is routinely performed in adult patients but is seldomly used in the pediatric population due to concerns regarding safety and limited available evidence. This study aims to consolidate the current literature on percutaneous tracheostomy in the pediatric population. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, EMBASE, CINAHL, and Web of Science were searched for studies on pediatric percutaneous tracheostomy (age ≤18). The Joanna Briggs Institute and ROBINS-I tools were used for quality appraisal. RESULTS: Twenty-one articles were included resulting in 143 patients. Patient age ranged from 2 days to 17 years, with the largest subpopulation of patients (n = 57, 40 %) being adolescents (age between 12 and 17 years old). Main indications for percutaneous tracheostomy included prolonged ventilation (n = 6), respiratory insufficiency (n = 5), and upper airway obstruction (n = 5). One-third (n = 47) of percutaneous tracheostomies were completed at the bedside in an intensive care unit. Select studies reported on surgical time and time from intubation to tracheostomy with a mean of 13.8 (SD = 7.8) minutes (n = 27) and 8.9 (SD = 2.8) days (n = 35), respectively. Major postoperative complications included tracheoesophageal fistula (n = 4, 2.8 %) and pneumothorax (n = 3, 2.1 %). There were four conversions to open tracheostomy. CONCLUSION: Percutaneous tracheostomy had a similar risk of complications to open surgical tracheostomy in children and adolescents and can be performed at the bedside in a select group of patients if necessary. However, we feel that consideration must be given to the varying anatomical considerations in children and adolescents compared with adults, and therefore suggest that this procedure be reserved for adolescent patients with a thin body habitus and clearly demarcated and palpable anatomical landmarks who require a tracheostomy. When performed, we strongly support using endoscopic guidance and a surgeon who has the ability to convert to an open tracheostomy if required.

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.

Pediatric Esophageal Foreign Bodies: The Role of Socioeconomic Status in Ingestion Patterns.

OBJECTIVE: Pediatric esophageal foreign bodies (EFBs) are common and can result in serious complications. Little is known about the influence of socioeconomic status (SES) on EFB ingestion in children. The goal was to study SES as a risk factor for dangerous foreign body ingestion and in-hospital complications in children. METHODS: This was a retrospective cohort study of children presenting to a tertiary care pediatric hospital with an esophageal foreign body from 2010 to 2021. SES was assessed for each patient by linking their postal code to the Ontario Marginalization Index to determine a quintile score across four dimensions of deprivation: residential instability, material deprivation, dependency, and ethnic concentration. Dangerous EFBs were defined as magnets, batteries, sharp objects, or bones. In-hospital complications included: intensive care unit admission, prolonged length of stay, and postoperative sequelae. RESULTS: A total of 680 patients were included. Dangerous EFB ingestion was higher for children with increased residential instability (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.6) and increased material deprivation (OR, 2.2; CI, 1.9-2.8), which was similarly true for odds of complications. Odds of dangerous EFB ingestion were higher in older children (OR, 1.1; CI, 1.0-1.1) and odds of complications were higher in children with comorbidities (OR, 1.1; CI, 1.0-1.3). CONCLUSION: Higher levels of housing instability and material deprivation are associated with dangerous EFB ingestion and complications related to EFB ingestion. These findings emphasize the role that SES plays on child health outcomes and the need for initiatives to mitigate these disparities. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2945-2953, 2024.

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.

Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study.

OBJECTIVE: To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections. DESIGN: Multi-centre observational cohort study using data from 2009 to 2018 clinical records. SETTING: Canadian children's hospitals (7) and community hospitals (3). PATIENTS: Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections. INTERVENTIONS: Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation. MAIN OUTCOME MEASURES: Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates. RESULTS: Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018. CONCLUSIONS: Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

Myer-Cotton Grade of Subglottic Stenosis Depends on Style of Endotracheal Tube Used.

OBJECTIVES: Determine percentage of subglottic stenosis using current endotracheal tube (ETT) cross-sectional areas as actual, compared with previously published ETT cross-sectional areas as expected, and determine if style of ETT could result in a change in percentage of stenosis or Myer-Cotton grade. STUDY TYPE: Cross-sectional study. DESIGN: Prospective analysis. METHODS: Eight styles of uncuffed pediatric ETT from four manufacturers ranging from 2.0 to 6.0 inner diameter (ID) were evaluated. ID and outer diameter (OD) measurements were obtained from each company's specification sheets. Cross-sectional area was calculated for each ETT using the formula (Area = πr2 ). The cross-sectional areas of each current ETT (actual) were compared with those of previously published ETTs (expected) based on age, and the degree of stenosis was calculated using the formula [1- (Area actual /Area expected )] × 100%. Ranges of percentage for each style of ETT were calculated. RESULTS: There was an increase in range of OD and area with increasing size of ETT ID, with the largest range in OD being 0.8 mm, and the largest range in area being 10.55 mm2 . The median interquartile range (IQR), range of percentage stenoses was 11 (5%), ranging from 0% to 21%. Seven of 28 (25%) ranges were found to span two Myer-Cotton grades. CONCLUSIONS: The Myer-Cotton grade of subglottic stenosis depends on the style of ETT used. Using updated values from currently available ETTs aims to keep this grading system valid with respect to surgical approach and outcomes following surgery. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2808-2812, 2023.

Olfaction and Gustation in Children With Primary Ciliary Dyskinesia.

Objective: Primary ciliary dyskinesia (PCD) is a rare autosomal recessive disorder whereby abnormal cilia cause a wide array of respiratory tract manifestations including chronic rhinosinusitis. The purpose of this study was to determine whether olfaction and gustation are impaired in children with PCD. Study Design: Cross-sectional study. Setting: Tertiary pediatric academic hospital. Methods: Children with confirmed PCD based on having at least 1 of 3 approved diagnostic criteria as per The American Thoracic Society guidelines were recruited from The PCD Clinic in our tertiary care pediatric hospital. Odor identification ability was tested using the Universal Sniff (U-Sniff) test and taste threshold was measured using an electrogustometer. The main outcome of this study is to determine the incidence of olfactory dysfunction in children with PCD and investigate if there is an associated gustatory dysfunction. Results: Twenty-five children participated (14 male, 11 female), The median age was 10.8 years (range: 4.1-17.9 years). Only 4/25 (16%) complained of olfactory dysfunction prior to testing. None of the patients complained of dysgeusia. However, 48% (12/25) scored less than 7 on the U-Sniff, signifying hyposmia or anosmia. In contrast, scores obtained by electrogustometry were in the normal range. There was no correlation between performance on the U-Sniff and electrogustometry testing. Conclusion: Olfactory impairment in children with PCD is common but underrecognized by patients. This is not associated with abnormal gustation. Among other, this places children with PCD at an increased risk with respect to smelling a fire or detecting spoiled or poisonous food.