Risk factors for perioperative airway difficulty and evaluation of intubation approaches among patients with benign goiter.

OBJECTIVE: The objective was to determine patient and gland characteristics associated with difficult intubation in patients undergoing thyroidectomy for goiter and to assess different methods of intubation in these patients. METHODS: This study was an IRB-approved, retrospective chart review of 112 consecutive patients undergoing hemithyroidectomy or total thyroidectomy for thyroid goiter from 2009-2012 at an academic tertiary care facility in Bronx, New York. Patient demographics, thyroid gland characteristics (gland weight and nodule size), presence of preoperative symptoms (dyspnea, dysphagia, and hoarseness), and radiographical findings (tracheal compression, tracheal deviation, and substernal extension of the thyroid gland) were recorded. Anesthesia records were reviewed for method of intubation, as well as success or failure of intubation attempts. RESULTS: Nineteen patients (17.0%) were men and 93 (83.0%) were women. The age of the patients included in the study ranged from 14 to 86 years with a mean ± SD age of 53.5 ± 14.7 years. Difficult intubation was noted with 13 (11.6%) patients. Only patient age was significantly associated with difficult intubation. The mean age of patients with airway difficulty was 60.7 ± 3.7 years compared to 52.1 ± 1.5 years in those who did not experience airway difficulty (P = .04). No other reviewed risk factors were found to be significantly associated with difficult intubation. Fiberoptic intubation (FOI) was used in 38 patients and difficult intubation occurred in 18.4% (7/38). Direct laryngoscopy with transoral intubation (LTOI) was used in 58 patients, in whom 3.4% (2/58) experienced a difficult intubation. FOI was aborted 6 times and LTOI was subsequently successful in each of these cases. CONCLUSIONS: Our results suggest that benign nodular goiter disease does not pose significant challenges to intubation in our patient cohort. The technique of intubation deviated from the initial plan several times in the FOI group, whereas LTOI was ultimately successful in every case. Our data suggest that the role of fiberoptic intubation for patients with large goiters should be further refined.

Failure factors in pediatric deep neck space abscess surgical management.

INTRODUCTION: Deep neck space infections (DNSI) in pediatric otolaryngology are a common occurrence in the inpatient setting. A subset of DNSI patients will fail medical and surgical management. It is difficult to predict which patients will fail. There are no studies that effectively evaluate variables associated with readmission and reoperation for DNSI abscesses. The purpose of this study was to evaluate the specific perioperative decisions that may lead to combined therapy failure and necessitate reoperation. METHODS: A case-control study was performed at a single center academic tertiary care hospital. Patients <18 years old treated from January 2015 to April 2020 with a surgically treated DNSI were reviewed. The single incision and drainage group (SOp) and reoperation group (ReOp) were evaluated with reoperation performed within a 30-day period. Intravenous antibiotic administration timing, drain management and type (gauze or latex), diagnostic, and postoperative factors were evaluated. RESULTS: The SOp group consisted of 275 patients and the ReOp group of 21 patients. The average preoperative intravenous antibiotic time showed no statistical difference (p = 0.884) and no increased risk for reoperation (p = 0.470; OR = 0.993). Timing of drain removal showed a significant difference (p < 0.005; 41.1 SOp vs 46.5 h ReOp). Abscess location (p = 0.855) and complications rate did not vary (p = 0.450). Gauze drains were used in 131 (44.3%), latex in 80 (27%), and no drain in 84 (28.4%) with no difference regarding reoperation (p = 0.124). Length of stay was longer in the ReOp group (8 vs 4 days; p < 0.001). The average measured dimension for each group did not significantly vary (p = 0.633). CONCLUSIONS: The duration of antibiotics in the preoperative period showed no statistical role in the need for reoperation in DNSI abscess patients. Drain type and duration also had a potentially clinically relevant association with the need for reoperation. Extensive unknown abscess pockets or inadequate technique may be the main contributors to the need for reoperation.

Laryngopyocoele: an unusual cause of a sore throat.

Laryngopyocoeles are rare entities that present as airway obstruction or as neck masses. We present a unique case of a laryngopyocoele in a young patient with a sore throat. A 22-year-old man presented to the emergency department with a sore throat of 1-week duration. He had no other upper respiratory symptoms. His vitals were as follows: heart rate, 91; respiratory rate, 16; blood pressure, 119/60; and temperature, 36.8 (98.3°F). There were no signs of respiratory distress or airway involvement. The findings from his physical examination were normal except for tenderness on palpation of his larynx. A soft tissue neck x-ray was suggestive of epiglottitis. Fiberoptic laryngoscopy revealed a nonerythematous, edematous epiglottis and edema of the left arytenoid and aryepiglottic fold with slight bulging into the airway. A contrast neck computed tomography revealed a nonenhancing fluid collection at the level of the left arytenoid cartilage. The diagnosis of a laryngopyocoele was made. The patient was admitted to the intensive care unit for airway monitoring and treated conservatively with intravenous antibiotics. The collection did not resolve by day 4, and the patient was taken to the operating room for incision and drainage of the laryngopyocoele. The patient made an uneventful recovery.

A Quality Improvement Plan for Implementing an Innovative Organization System for Pediatric Airway Patients.

Risks of pediatric tracheostomy are well known. The objectives of this quality improvement study were to organize tracheostomy supplies into a comprehensive care kit and demonstrate that the kits improved nursing and parental comfort in providing tracheostomy care routinely and emergently. Kits were assembled using roll-up toiletry style bags and organized in a uniform fashion with necessary supplies. Nurses and parents were surveyed using a 5-point Likert-type. Feedback was overall very positive; the kits were found to ease the transition of caring for a child with a new tracheostomy from hospital to home. This intervention can easily be adapted at other pediatric institutions.

Diagnosis and management of congenital floor of mouth masses: A systematic review.

OBJECTIVES: Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants. METHODS: A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined. RESULTS: 85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%. CONCLUSION: Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

The impact of the COVID-19 pandemic on fellowship training: A national survey of pediatric otolaryngology fellowship directors.

OBJECTIVES: To gain a better understanding of the effects the COVID-19 pandemic has had on current and future pediatric otolaryngology fellowship training, as well as how the application process was impacted this past year. METHODS: An anonymous web-based survey consisting of 24 questions was sent to all fellowship directors. The survey questions were designed to gain a better understanding of the effects of the current COVID-19 pandemic on the surgical and clinical experience of current, to characterize the types of supplemental educational experiences that fellowship directors had incorporated into the curriculum to compensate for the decreased surgical and clinical workload, and highlight differences based on geographic location. RESULTS: Overall, 22 of 36 fellowship directors responded to our survey, for a total response rate of 61%. The Midwest had the highest response rate at 72.7%, followed by the Northeast (71.4%), the West (50%), and the South (50%). The vast majority of fellowship directors (77.2%) reported the COVID-19 pandemic had a "significant impact" on overall pediatric otolaryngology fellowship training. 86.3% of fellowship directors reported that their programs were still performing some surgical operations, but with decreased overall volume. Interestingly, 13.6% of fellowship directors reported that their fellows had been pulled to medicine or ICU services to assist with the COVID-19 pandemic. Of these programs that had a fellow pulled to the ICU or medicine service, 2 out of 3 were located in the Northeast, with the remaining fellow being from a program in the South. CONCLUSION: Overall, pediatric otolaryngology fellowship directors reported the COVID-19 pandemic has had a significant impact on the overall fellowship experience within the field of pediatric otolaryngology, with the majority feeling that both their fellows surgical and clinical experience have been significantly impacted.

Pediatric Thyroidectomy.

Objectives/Hypothesis To evaluate hospital course and associated complications among pediatric patients undergoing thyroidectomy. Study Design and Setting Retrospective database review of the Kids' Inpatient Database (2009, 2012). Methods The Kids' Inpatient Database was evaluated for thyroidectomy patients for the years 2009 and 2012. Surgical procedure, patient demographics, length of stay, hospital charges (in US dollars), and surgical complications were evaluated. Results Of an estimated 1099 nationwide partial thyroidectomies and 1654 total thyroidectomies, females accounted for 73.5% and 79.1% of patients, respectively. Children <1 year of age had significantly longer hospital courses ( P < .0001), and patients 1 to 5 years of age had a significantly greater length of stay than individuals 6 to 20 years of age (7.8 vs 2.1 days, P < .001). The most common complications overall included hypocalcemia, respiratory complications, vocal cord paresis/paralysis, postoperative infection, and bleeding. Vocal cord paralysis was noted in 1.7% of pediatric thyroidectomy patients. The presence of these complications among total thyroidectomy patients significantly increased one's length of stay and hospital charges. A neck dissection was reported in 22.9% of malignant thyroidectomy patients. Conclusion Nearly 20% of children who underwent total thyroidectomy experienced postoperative hypocalcemia, positing a need for the development of postoperative calcium replacement algorithms to minimize the sequelae of hypocalcemia. A greater incidence of respiratory and infectious complications among younger patients (<6 years) suggests a need for closer monitoring, possibly encompassing routine postoperative intensive care unit utilization, in an attempt to minimize these sequelae.

Association of Gender With Financial Relationships Between Industry and Academic Otolaryngologists.

Importance: Gender disparities continue to exist in the medical profession, including potential disparities in industry-supported financial contributions. Although there are potential drawbacks to industry relationships, such industry ties have the potential to promote scholarly discourse and increase understanding and accessibility of novel technologies and drugs. Objectives: To evaluate whether gender disparities exist in relationships between pharmaceutical and/or medical device industries and academic otolaryngologists. Design, Setting, and Participants: An analysis of bibliometric data and industry funding of academic otolaryngologists. Main Outcomes and Measures: Industry payments as reported within the CMS Open Payment Database. Methods: Online faculty listings were used to determine academic rank, fellowship training, and gender of full-time faculty otolaryngologists in the 100 civilian training programs in the United States. Industry contributions to these individuals were evaluated using the CMS Open Payment Database, which was created by the Physician Payments Sunshine Act in response to increasing public and regulatory interest in industry relationships and aimed to increase the transparency of such relationships. The Scopus database was used to determine bibliometric indices and publication experience (in years) for all academic otolaryngologists. Results: Of 1514 academic otolaryngologists included in this analysis, 1202 (79.4%) were men and 312 (20.6%) were women. In 2014, industry contributed a total of $4.9 million to academic otolaryngologists. $4.3 million (88.5%) of that went to men, in a population in which 79.4% are male. Male otolaryngologists received greater median contributions than did female otolaryngologists (median [interquartile range (IQR)], $211 [$86-$1245] vs $133 [$51-$316]). Median contributions were greater to men than women at assistant and associate professor academic ranks (median [IQR], $168 [$77-$492] vs $114 [$55-$290] and $240 [$87-$1314] vs $166 [$58-$328], respectively). Overall, a greater proportion of men received industry contributions than women (68.0% vs 56.1%,). By subspecialty, men had greater median contribution levels among otologists and rhinologists (median [IQR], $609 [$166-$6015] vs $153 [$56-$336] and $1134 [$286-$5276] vs $425 [$188-$721], respectively). Conclusions and Relevance: A greater proportion of male vs female academic otolaryngologists receive contributions from industry. These differences persist after controlling for academic rank and experience. The gender disparities we have identified may be owing to men publishing earlier in their careers, with women often surpassing men later in their academic lives, or as a result of previously described gender disparities in scholarly impact and academic advancement.

How radiologic/clinicopathologic features relate to compressive symptoms in benign thyroid disease.

OBJECTIVES/HYPOTHESIS: To identify compressive symptomatology in a patient cohort with benign thyroid disease who underwent thyroidectomy. To determine radiographic/clinicopathologic features related to and predictive of a compressive outcome. STUDY DESIGN: Retrospective cohort study. METHODS: Medical records of 232 patients with benign thyroid disease on fine needle aspiration who underwent thyroidectomy from 2009 to 2012 at an academic medical center were reviewed. Data collection and analyses involved subjects' demographics, compressive symptoms, preoperative airway encroachment, intubation complications, specimen weight, and final pathologic diagnosis. RESULTS: Subjects were ages 14 to 86 years (mean: 52.4 years). Ninety-six subjects (41.4%) reported compressive symptomatology of dysphagia (n =74; 32%), dyspnea (n = 39; 17%), and hoarseness (n = 24; 10%). Ninety-seven (42.2%) had preoperative airway encroachment. Dyspnea was significantly related to tracheal compression, tracheal deviation, and substernal extension. Dysphagia was related to tracheal compression and tracheal deviation. Compressive symptoms and preoperative airway encroachment were not related to intubation complications. Final pathologic diagnosis was not related to compressive symptoms, whereas specimen weight was significantly related to dyspnea and dysphagia. Final pathology revealed 74 subjects (32%) with malignant lesions. Malignant and benign nodular subject groups differed significantly in substernal extension, gland weight, tracheal deviation, and dyspnea. Logit modeling for dyspnea was significant for tracheal compression as a predictor for the likelihood of dyspnea. CONCLUSION: Dyspnea was closely related to preoperative airway encroachment and most indicative of a clinically relevant thyroid in our cohort with benign thyroid disease. Tracheal compression was found to have predictive value for the likelihood of a dyspneic outcome. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:993-997, 2017.

The role of larygotracheal reconstruction in the management of recurrent croup in patients with subglottic stenosis.

OBJECTIVES: To determine the role of laryngotracheal reconstruction for recurrent croup and evaluate surgical outcomes in this cohort of patients. METHODS: Retrospective chart review at a tertiary care pediatric hospital. RESULTS: Six patients who underwent laryngotracheal reconstruction (LTR) for recurrent croup with underlying subglottic stenosis were identified through a search of our IRB-approved airway database. At the time of diagnostic bronchoscopy, all 6 patients had grade 2 subglottic stenosis. All patients were treated for reflux and underwent esophageal biopsies at the time of diagnostic bronchoscopy; 1 patient had eosinophilic esophagitis which was treated. All patients had a history of at least 3 episodes of croup in a 1 year period requiring multiple hospital admissions. Average age at the time of LTR was 39 months (range 13-69); 5 patients underwent anterior graft only and 1 patient underwent anterior and posterior grafts. Patients were intubated for an average of 5 (range 3-8) days and hospitalized for an average of 12 (range 7-20) days post-operatively. One patient experienced narcotic withdrawal post-operatively, but there were no other post-operative complications. All patients underwent follow-up airway endoscopy within 4 weeks and none required any further dilation procedures. Average post-operative follow-up was 24 months (range 10-48) and none of the patients experienced any further episodes of croup. CONCLUSIONS: Single stage LTR is a safe and effective treatment for recurrent croup in the setting of underlying subglottic stenosis, and should be considered in patients who are refractory to medical management.

Stridor and apnea as the initial presentation of primary hypoparathyroidism.

We present a previously undescribed case of stridor and apnea as the initial presentation of primary hypoparathyroidism. A neonate presenting with these symptoms was initially diagnosed with laryngopharyngeal reflux and laryngomalacia. After failing medical management, she underwent supraglottoplasty with improvement of stridor, but persistent apneic events. Further work-up showed severe hypocalcemia due to hypoparathyroidism. Subsequent genetic testing revealed a diagnosis of Bartter Syndrome Type V, a rare cause of primary hypoparathyroidism. Although uncommon, hypocalcemic tetany can present as apneic episodes in the setting of unrecognized primary hypoparathyroidism. Electrolyte abnormalities should be explored in neonates with recurrent apnea of unknown etiology.

Perioperative considerations and complications in pediatric parathyroidectomy.

OBJECTIVES/HYPOTHESIS: To evaluate perioperative considerations and post-operative complications associated with parathyroidectomy in the pediatric population. METHODS: The Kids' Inpatient Database 21 (KID) was searched for patients who underwent parathyroidectomy in 2009 and 2012. Patient demographics, hospital stay, associated charges, and post-operative adverse sequelae were evaluated in all patients and included patient comorbidity and additional procedure requirement analysis. RESULTS: There were 182 patients extrapolating to 262 parathyroidectomies over the two years analyzed. Although a minority of patients were male (45.4%), these patients had greater rates of complications, length of stay, and hospital charges. Importantly, minorities and younger patients (≤15y) also had more complicated post-operative courses. The lengths of stay for patients experiencing post-operative altered mental status (18.7d), post-operative infection (15.5d), respiratory complications (19d), and cardiac complications (13d) were significantly increased compared to individuals without major complications (3.4d) (p < 0.001). Patients with pre-existing chronic kidney disease, dialysis-dependence, and bone sequelae (most commonly from hungry bone syndrome) also had significantly lengthier stays and greater associated costs. CONCLUSION: Findings from this analysis can be included in a comprehensive pre-operative informed consent process between physicians and patients discussing perioperative considerations and potential complications of parathyroidectomy. Males, younger children, and patients with preexisting renal conditions experienced lengthier and more complicated hospital stays, suggesting the need for closer monitoring of these cohorts.

Open airway surgery for subglottic hemangioma in the era of propranolol: Is it still indicated?

OBJECTIVES: With the emergence of propranolol as the primary treatment for hemangiomas the indications for surgical intervention have been greatly reduced. There remains a role for surgical management in those patients who fail medical therapy, particularly for hemangiomas involving the airway. Detailed is our experience with subglottic hemangiomas, including three patients who failed propranolol treatment and were successfully treated with surgical excision and single stage laryngotracheoplasty (LTP) with thyroid ala graft. METHODS: Retrospective case series (level of evidence: 4). RESULTS: Six patients were treated with propranolol for subglottic hemangiomas over a 6 year period (2008-2014). Three patients responded to propranolol therapy and required no adjunctive surgical procedures. Three patients failed propranolol treatment, and required open resection of their subglottic hemangiomas and thyroid ala graft placement. Indications for resection were complete lack of response to propranolol in one patient, and initial response to propranolol with subsequent regrowth in the other two patients. All three patients were treated with submucosal extirpation of their hemangioma and single stage LTP; hemangioma was confirmed in all cases by positive GLUT-1 staining. All three surgical patients were successfully extubated post-operatively and none had hemangioma regrowth. CONCLUSIONS: Fifty percent of patients in our series did not have long-term response to propranolol for subglottic hemangioma, highlighting the importance of close follow-up. When identified early, subglottic hemangiomas refractory to propranolol treatment can be successfully addressed with single stage LTP and tracheotomy can be avoided.

Securing stent during multi-stage laryngotracheoplasty--an evolved technique.

BACKGROUND: Multi-stage laryngotracheoplasty (LTP) typically requires a stent be secured to the airway for 2-6 weeks. Our technique has evolved over time to securing the stent to the strap muscles and tying a series of knots long enough to leave the suture tail protruding through the skin incision, which simplifies stent removal. METHODS: Retrospective chart review. RESULTS: Twenty-four patients underwent multi-stage LTP at our institution from 2007 to 2013. Eight patients were excluded from the study because they either did not have a stent placed (n=4), or they had a t-tube placed which was not sutured in place (n=4). Of the remaining 16 patients, 62.5% (n=10) had their stent secured via sutures which were buried below the skin, and 37.5% (n=6) via a long suture tail which was left protruding through the end of the skin incision. An incision was required for stent removal 100% of buried sutures patients, and 33% of exposed suture patients (p=0.0009). Average operative time for stent removal was 60min in the buried sutures group, and 25min in the exposed sutures group (p=0.0075). CONCLUSIONS: Securing stents via an exposed suture technique decreases the need for making a skin incision during the second stage of the operation, and significantly decreases the operative time of the second stage.

Comparative outcomes of severe obstructive sleep apnea in pediatric patients with Trisomy 21.

OBJECTIVES: To analyze the outcomes of severe obstructive sleep apnea (OSA) in pediatric patients with Trisomy 21 compared with non-syndromic patients. METHODS: A retrospective chart review was performed for patients with a diagnosis of severe obstructive sleep apnea, (defined as, Apnea-Hypopnea index (AHI) of ≥ 10) in a tertiary children's hospital. Data were analyzed for subjective and objective outcomes along with perioperative care and health care utilization. Patients with Trisomy 21 were compared with non-syndromic patients. RESULTS: A total of 230 patients with severe OSA were included in the study. Eighteen of these patients had Trisomy 21. Adenotonsillectomy was the most common surgical intervention in both groups. There was no statistical difference in the preoperative AHI between groups. Post treatment AHI in the Trisomy 21 group changed from an average of 26.6 to an average of 11.6 as compared with 24.5 to 3.6 in the non-syndromic group. The average perioperative hospital stay was 3.8 days in Trisomy 21 group compared to 1.7 days for the non-syndromic group (p < 0.001, Mann-Whitney U test). Complete resolution was seen in 35% of the Trisomy 21 group versus 75% in the non-syndromic group. CONCLUSIONS: A majority of Trisomy 21 patients with severe OSA had residual symptoms following surgical intervention. There is also an increased risk of post-operative airway intervention and increased length of hospital stay in these patients.

Tracheal rupture in complicated delivery: a case report and review of the literature.

A case of distal tracheal rupture is described, literature review reveals two previously reported cases of neonatal distal tracheal rupture, as well as 14 cases of anterior subglottic rupture. All patients had shoulder dystocia, and 59% had associated brachial plexus injury. Delayed diagnosis (>3 days) was common in the distal tracheal group (66%), compared to 0% in the anterior subglottic group. The 2 distal tracheal rupture patients were initially managed conservatively, but ultimately required open repair. Distal tracheal rupture is exceedingly rare and more difficult to diagnose and manage than the more common anterior subglottic rupture.

Management of complex glottic stenosis in children with recurrent respiratory papillomatosis.

OBJECTIVES: To describe our management of complex glottic stenosis in tracheotomy dependent children with severe recurrent respiratory papillomatosis. METHODS: Retrospective chart review at a tertiary care children's hospital. RESULTS: Three children with complex glottic stenosis secondary to severe recurrent respiratory papillomatosis were treated at our institution since 2011. Two patients had complete stenosis, and the third had near-complete stenosis. Two patients were managed using balloon dilation alone, and the third also underwent laryngotracheal reconstruction with posterior costal cartilage grafting. Two patients have been successfully decannulated and the third has been tolerating continuous tracheotomy capping for greater than twelve months. All three patients underwent aggressive debridement of papillomatosis and balloon dilation every 4-6 weeks until their burden of disease was controlled. In two patients, the glottic airway was patent, and the third continued to have complete restenosis between procedures and required laryngotracheoplasty with multiple post-operative dilation procedures to establish an adequate glottic airway. CONCLUSIONS: Severe laryngeal stenosis is a well-described complication of recurrent respiratory papillomatosis, but its management is not well-defined. Aggressive management of papillomatosis with frequent debridement is critical in successfully managing laryngeal stenosis. Balloon dilation alone may be surprisingly effective in these patients, and laryngotracheoplasty can be used as an adjunct procedure in those patients who fail balloon dilation. Given the quality of life issues and concerns regarding distal spread of disease with tracheotomies in these patients, we feel that aggressive management and early decannulation is in the patient's best interest.

Hemispheric dominance and cell phone use.

IMPORTANCE: A thorough understanding of why we hold a cell phone to a particular ear may be of importance when studying the impact of cell phone safety. OBJECTIVE: To determine if there is an obvious association between sidedness of cell phone use and auditory hemispheric dominance (AHD) or language hemispheric dominance (LHD). It is known that 70% to 95% of the population are right-handed, and of these, 96% have left-brain LHD. We have observed that most people use their cell phones in their right ear. DESIGN: An Internet survey was e-mailed to individuals through surveymonkey.com. The survey used a modified Edinburgh Handedness Inventory protocol. Sample questions surveyed which hand was used to write with, whether the right or left ear was used for phone conversations, as well as whether a brain tumor was present. SETTING: General community. PARTICIPANTS: An Internet survey was randomly e-mailed to 5000 individuals selected from an otology online group, patients undergoing Wada testing and functional magnetic resonance imaging, as well as persons on the university listserv, of which 717 surveys were completed. MAIN OUTCOME AND MEASURE: Determination of hemispheric dominance based on preferred ear for cell phone use. RESULTS: A total of 717 surveys were returned. Ninety percent of the respondents were right handed, and 9% were left handed. Sixty-eight percent of the right-handed people used the cell phone in their right ear, 25% in the left ear, and 7% had no preference. Seventy-two of the left-handed respondents used their left ear, 23% used their right ear, and 5% had no preference. Cell phone use averaged 540 minutes per month over the past 9 years. CONCLUSIONS AND RELEVANCE: An association exists between hand dominance laterality of cell phone use (73%) and our ability to predict hemispheric dominance. Most right-handed people have left-brain LHD and use their cell phone in their right ear. Similarly, most left-handed people use their cell phone in their left ear. Our study suggests that AHD may differ from LHD owing to the difference in handedness and cell phone ear use. Literature suggests a possible relationship between cell phone use and cancer. The fact that few tumors were identified in this population does not rule out an association.

Endotracheal nitinol stents: lessons from the learning curve.

OBJECTIVE: To reflect on lessons learned placing endotracheal nitinol stents in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: All children who underwent nitinol cervical tracheal stenting were included. Records were carefully reviewed for intraoperative and postoperative complications, management choices, outcomes, and factors that influenced results. RESULTS: Between 1999 and 2011, 7 children underwent 13 stent placements. Median follow-up was 5 years (range, 1-12 years). Six patients underwent stenting as a salvage procedure following open attempts at airway reconstruction. Four patients remain decannulated with their stent in place (median follow-up 7 years). The fifth patient had his stent removed endoscopically after 50 days because it became apparent that his obstruction was primarily laryngeal. The sixth child had his stent removed via a tracheal fissure after 14 months because of recalcitrant subglottic inflammation at the superior stent border. The seventh patient was decannulated for over 2 years but ultimately required tracheotomy replacement because of stenosis with the stent lumen. Complications included stent migration (23%), restenosis (29%), edema (29%), and granulation (57%). CONCLUSION: Endotracheal nitinol stents provide a realistic opportunity for decannulation in children for whom other options have failed but should be reserved only as a salvage procedure in severely complicated airways. Our experience has taught valuable lessons about stent indications, sizing, characteristics, and deployment, as well as means to avoid and manage their complications.

Pectus excavatum in children with laryngomalacia.

BACKGROUND: Laryngomalacia is the most common congenital laryngeal anomaly and is associated with several disorders including gastric reflux, sleep apnea, hypotonia and failure to thrive. Pectus excavatum (PE) is the most common chest wall deformity affecting 1-300/1000 individuals. Though many authors presume a relationship between PE and laryngomalacia, there is no published data to establish this association. GOAL: To test the hypothesis that patients referred to our pediatric otolaryngology clinic for evaluation of laryngomalacia exhibit higher rates of PE than the general population. METHODS: Retrospective review of prospectively enrolled children who presented with laryngomalacia (January 2008-June 2012) to a tertiary care, hospital based, pediatric otolaryngology practice. Each chart was examined for a concurrent diagnosis of pectus deformity. RESULTS: Of the 137 laryngomalacia patients, 9 (6.6%) had documented PE. This represents a significantly increased rate of PE when compared to children without laryngomalacia (p = 0.001). Four of the 9 children with PE underwent supraglottoplasty for laryngomalacia, a significantly greater proportion than the 9/128 of the children with isolated laryngomalacia who underwent supraglottoplasty (p = 0.004). CONCLUSIONS: This study suggests an association between laryngomalacia and PE. Pediatric otolaryngologists should be cognizant of this relationship, though further studies are needed to elucidate the nature of this association.