Otolaryngologic Disease in Down syndrome.

As the most common human chromosomal abnormality, Trisomy 21 is a condition that many otolaryngologists and likely all pediatric otolaryngologists will encounter during their careers. There are several considerations regarding airway obstruction, otologic conditions, anesthetic implications, and endocrine disorders that will impact the treatment of these patients. Further, there is increasing literature supporting the use of early instrumental assessment of swallowing, drug-induced sleep endoscopy at the time of first surgical intervention for sleep apnea, consideration of concurrent upper and lower airway evaluation, and early otologic management including potential surgical hearing rehabilitation.

Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study.

OBJECTIVE: Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH). METHODS: Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA. RESULTS: The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not. CONCLUSION: Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication. LEVEL OF EVIDENCE: 4.

Tracheal pressure generated by high-flow nasal cannula in 3D-Printed pediatric airway models.

OBJECTIVE: Heated and humidified high flow nasal cannula (HFNC) is an increasingly used form of noninvasive respiratory support with the potential to generate significant tracheal pressure. The aim of this study was to quantify the pressure generated by HFNC within the trachea in anatomically correct, pediatric airway models. METHODS: 3D-printed upper airway models of a preterm neonate, term neonate, toddler, and small child were connected to a spontaneous breathing computerized lung model at age-appropriate ventilation settings. Two commercially available HFNC systems were applied to each airway model at increasing flows and the positive end-expiratory pressure (PEEP) was recorded at the level of the trachea. RESULTS: Increasing HFNC flow produced a quadratically curved increase in tracheal pressure in closed-mouth models. The maximum flow tested in each model generated a tracheal pressure of 7 cm H2O in the preterm neonate, 10 cm H2O in the term neonate, 9 cm H2O in the toddler, and 24 cm H2O in the small child. Tracheal pressure decreased by at least 50% in open-mouth models. CONCLUSIONS: HFNC was found to demonstrate a predictable flow-pressure relationship that achieved sufficient distending pressure to consider treatment of pediatric obstructive sleep apnea and tracheomalacia in the closed-mouth models tested.

A grisly event in the Kenai Peninsula.

We report an unusual manifestation of penetrating facial trauma. It was suffered by a recreational fly fisherman who was hiking away from a casting spot when he fell and was impaled by a section of his graphite flyrod. The circumstances of his injury, its clinical manifestations, and its imaging findings are discussed. Emergency physicians and radiologists should be aware of the computed tomography appearance of impaled foreign bodies and their capability to penetrate deeply to reach critical vascular and neurologic structures. The role of imaging in penetrating trauma to the face and skull base for guiding appropriate intervention is emphasized.

Scoping review: Awareness of neurotoxicity from anesthesia in children in otolaryngology literature.

OBJECTIVE: Review otolaryngology literature for awareness of neurotoxicity from general anesthesia in children. Recently, there has been increasing focus in anesthesia literature on the long-term effects of general anesthesia on neurodevelopment. Multiple animal models have demonstrated evidence of neurotoxicity from both inhalational and intravenous anesthetics. Cohort studies also have revealed modestly increased risk of adverse neurodevelopmental outcomes in children exposed to a single episode of general anesthesia prior to 3 to 4 years of age, with stronger evidence for multiple exposures in this age range. Otolaryngologists may subject children to general anesthesia via procedures or tests, including computed tomography, magnetic resonance imaging, and auditory brainstem response. DATA SOURCES: PubMed, Embase, Scopus, and Web of Science Review. METHODS: A scoping review using the above databases was performed limited to January 2005 through December 2015. Articles were screened and reviewed based on predefined inclusion and exclusion criteria. RESULTS: Initial search generated 3,909 articles. After 72 full text articles were reviewed, only seven articles mentioned neurotoxicity as a risk of general anesthesia in pediatric patients. CONCLUSION: Despite the high volume of pediatric otolaryngologic procedures performed annually, there remains limited awareness in our literature discussing neurotoxicity as an outcome. Prospective data from anesthesia literature is still pending; therefore, specific recommendations cannot be made at this time. Otolaryngologists should be aware of the concerns and work toward defining elective procedures, combining surgical procedures with other procedures or imaging, and reassessing the timing and frequency of various interventions under general anesthesia in young children. Laryngoscope, 127:1930-1937, 2017.

Systematic review for surgical treatment of adult and adolescent laryngotracheal stenosis.

OBJECTIVES/HYPOTHESIS: To determine if open surgical treatment options for adult and adolescent laryngotracheal stenosis are more successful than endoscopic procedures. STUDY DESIGN: Systematic review. METHODS: Embase and MEDLINE were searched for publications on adult and adolescent patients (>13 years old) with laryngotracheal stenosis. Cause of stenosis (intubation, idiopathic, or trauma) and treatments (open laryngotracheal resection with anastomosis, open laryngotracheal reconstruction with expansion grafting, or endoscopic procedures) were included. Primary outcomes are decreased additional surgery performed and success of decannulation, if previously tracheostomy. RESULTS: There were 297 abstracts reviewed, 104 articles selected for full-text review, and 39 articles, with 834 pooled patients, included in the analysis. Patients who had an open procedure (resection with anastomosis or reconstruction with expansion grafting) had significantly different outcomes rates; 32% versus 38% (P <.001) received additional surgery and 89%and 83% (P <.001) were decannulated, respectively. For patients who had endoscopic repair, 44% received additional surgery, and 63% were decannulated. Patients with idiopathic stenosis were more likely to receive additional surgery than those with traumatic (54% vs. 25%) and intubation/tracheostomy etiologies (54% vs. 35%). Etiology of stenosis did affect decannulation rates, patients with intubation/tracheostomy etiology had decannulation rates of 88%, compared to traumatic etiologies (78%, P <.001) and idiopathic stenosis (63%, P <.001). Risk of bias did not impact study results and was assessed using a validated instrument, Methodological Index for Non-randomized Studies criteria. CONCLUSIONS: Patients with adult laryngotracheal stenosis who undergo laryngotracheal resection with anastomosis receive less surgery compared to those who undergo endoscopic treatment or laryngotracheal reconstruction with augmentation/grafting. Patients with idiopathic stenosis are less likely to receive further surgery compared to those from trauma or intubation/tracheostomy, but have the lowest rate of decannulation. LEVEL OF EVIDENCE: NA Laryngoscope, 127:191-198, 2017.

Update on mandibular distraction osteogenesis.

PURPOSE OF REVIEW: Mandibular distraction osteogenesis has become one of the most powerful reconstructive tools for addressing congenital lower jaw deformities. This review will focus on clinical and basic science contributions to the literature in the last year, which have shown innovations in mandibular distraction osteogenesis techniques and advances in outcomes. RECENT FINDINGS: The longest phase of distraction is consolidation, when newly formed bone must fully heal. If consolidation could be accelerated, the length of time required for fixation would be less and complications associated with fixation devices would decline. In the last year, animal studies were conducted reporting the application of growth factors directly to distraction gaps to accelerate bone formation. Additional research in animal models showed success with the addition of bone marrow-derived mesenchymal stem cells to the distraction gap. Distraction devices are being piloted with automated, continuous formats compared with current devices that require manual activation. The use of surgical planning software programs to determine the location of osteotomies was another focus of current studies. SUMMARY: Rates of activation can be accelerated with the addition of stem cells and growth factors to distraction sites, as could time to full consolidation. The addition of mesenchymal stem cells and deferoxamine and the use of low-intensity ultrasound during distraction are three of the most promising approaches reported in recent studies with potential for future translation from animal models. Computer-assisted presurgical planning offers added accuracy and potential time savings. Newer distraction devices using computer automation are still in preliminary phases, but show promise.

Skull base defect in a patient with ozena undergoing dacryocystorhinostomy.

Ozena, which is often used interchangeably with atrophic rhinitis or empty nose syndrome, is a progressive and chronically debilitating nasal disease that results in atrophy of the nasal mucosa, nasal crusting, fetor, and destruction of submucosal structures. Although the etiology is not completely understood, infection with Klebsiella ozaenae is widely believed to contribute to the destructive changes. We present a case of a patient with ozena secondary to K. ozaenae with extensive destruction of bony structures of the nasal cavity undergoing elective dacryocystorhinostomy. An extensively thinned skull base secondary to the disease process resulted in an unforeseen complication in which the skull base was entered leading to a cerebrospinal fluid leak. Patients with known history of ozena or atrophic rhinitis often have extensive destruction of the lateral nasal wall and skull base secondary to progression of disease. Submucosal destruction of these bony structures mandates the need for extreme caution when planning on performing endoscopic intervention at or near the skull base. If physical examination or nasal endoscopy is suspicious for atrophic rhinitis or a patient has a known history of infection with K. ozaenae, we recommend preoperative imaging for surgical planning with careful attention to skull base anatomy.

Community-acquired methicillin-resistant Staphylococcus aureus in nasal vestibular abscess.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is a recognized entity that is increasingly responsible for skin and soft tissue infections. However, it is not the usual pathogen isolated in nasal vestibular abscess. METHODS: We present a series of 13 consecutive patients presenting to a tertiary care center with nasal vestibular abscess over a 2.5-year period. RESULTS: All abscesses were cultured and 100% (13/13) grew S. aureus. Of the S. aureus isolates, 92% (12/13) were MRSA. Antibiotic susceptibilities of the MRSA isolates were as follows: 100% were susceptible to rifampin, trimethoprim-sulfamethoxazole, and tetracycline, 75% to clindamycin, 58% to fluoroquinolones, and 17% to erythromycin. CONCLUSION: MRSA is an important pathogen in the community. It is therefore critical to appreciate its potential predominance in nasal vestibular abscess. Clinicians should obtain cultures, modify antibiotic therapy as warranted, and initiate empiric therapy to include MRSA coverage for nasal vestibular abscess.