Heated humidified high-flow nasal cannula: a new conservative approach for neonatal nasal stenosis.

PURPOSE: The aim of this study is to evaluate the efficacy of heated humidified high flow nasal cannula (HFNC) therapy as a conservative treatment option for newborns suffering from nasal stenosis, a condition that often leads to respiratory distress and feeding difficulties. Given the increasing utilization of HFNC in various upper and lower respiratory tract indications, characterized by its flow-based mechanism and minimal mucosal damage, we seek to investigate its potential benefits in this specific patient population. METHODS: A retrospective chart review of newborns with congenital nasal stenosis treated with HFNC for respiratory distress or feeding difficulties in a pediatric tertiary center between 2014 and 2022. Data were collected for demographic characteristics, clinical presentation and ventilatory requirements, pre and post HFNC application. RESULTS: Six infants with nasal stenosis were included in the study cohort. Five were diagnosed with congenital pyriform aperture stenosis, three of whom had additional midnasal stenosis. One patient had nasal synechiae. Two patients had failed surgical treatment and all patients failed conservative treatment prior to HFNC treatment. Following HFNC use, improvement was noted in oxygen saturations, heart and respiratory rates, meal volumes and weight. None of the patients required any additional sinonasal surgical treatment. No complications were observed. CONCLUSIONS: In this case series, we present the first documented use of HFNC treatment for nasal stenosis, showing favorable results. Further studies with a larger cohort, wider range of conditions and extended follow-up periods are needed to establish the risks and benefits of HFNC for neonatal nasal stenosis.

Management of first branchial anomalies in children: 20 years of experience.

PURPOSE: Branchial cleft anomalies (BCAs) are common pediatric head and neck lesions; however, only 1-4% involve the first branchial cleft. The rare occurrence of first BCAs, their presentation at a young age, and the possible facial nerve involvement make diagnosis and treatment challenging. METHODS: A retrospective chart review was conducted for children diagnosed with their first BCA between 2000 and 2020. Data on demographics, presenting symptoms, physical findings, imaging features, previous surgery, and treatment outcomes were collected and analyzed. RESULTS: The cohort included 17 patients with a median age of 5 years at presentation. Seven (41%) had undergone previous surgical intervention before definitive surgery. Eight were classified as Work Type II anomalies, and nine as Work Type I. Sixteen patients (94%) underwent definitive surgical excision at a median age of 6.9. A parotid approach was used in 10 (62%), with dissection of the mass from the facial nerve, and a retro-auricular or end-aural approach was used in 6 (38%). Complete excision was achieved in 14/16 patients (88%). Three patients had transient facial nerve paresis postoperatively. Recurrence was noted in 3/16 patients (18%). Enhancement in imaging was positively correlated with post-operative complications (R = 0.463, P = 0.018). CONCLUSIONS: First, BCA poses a diagnostic and surgical challenge; thus, definitive surgical treatment is often delayed. The surgical approach should be tailored to the type of anomaly (Work type I or II) and possible facial nerve involvement. Risk factors for post-operative complications are a history of recurrent infections and previous surgical interventions. The presence of contrast enhancement in preoperative imaging should alert surgeons to perioperative challenges and the risk of post-operative complications.

Novel prognostic factors for successful treatment of pediatric chronic rhinosinusitis using the sinus and nasal quality of life survey (SN-5H).

INTRODUCTION: Chronic rhinosinusitis (CRS) is strongly associated with significant impairment of quality of life (QoL) in children. The SN-5 questionnaire is an important assessment tool for pediatric CRS. This study aimed to evaluate potential prognostic factors for treatment of pediatric CRS within the Hebrew version of the SN-5 questionnaire. METHODS: A prospective study in pediatric otolaryngology unit. Patients were treated either surgically or pharmacologically. Following informed consent, parents of pediatric CRS patients completed the translated and validated Hebrew version (SN-5H) prior to treatment and after three months. We analyzed the results of both treatment arms according to success (achieving minimal clinically important difference; MCID). RESULTS: 102 children aged 5-12 years and their caregivers participated (74 CRS patients and 28 controls without CRS). SN-5H items scores were significantly higher in CRS patients compared to controls (p < 0.001). Baseline activity scores were higher, while baseline emotional scores were lower in MCID( +) CRS patients, compared to MCID(-) CRS patients (p < 0.05). High emotional stress and low activity scores at baseline were associated with poorer odds to achieve MCID. CONCLUSIONS: The SN-5H questionnaire is invaluable tool for assessing pediatric CRS patients. Psychosocial aspects of CRS significantly affect QoL and should be addressed in the office pre-treatment. The SN-5H can aid in highlighting patients in need for further reassurance and psychosocial support to manage expectations, and to improve QoL.

Predictors of residual disease following pediatric thyroglossal duct cyst excision.

OBJECTIVES: Residual thyroglossal duct cyst (TGDC) following surgical excision is not uncommon. This study aimed to search for risk factors for residual disease that either required revision surgery or were resolved with only conservative treatment and follow up. METHODS: A retrospective study of consecutive children who underwent surgical excision for thyroglossal duct cysts between 2008 and 2021 at Schneider Children's Medical Center of Israel, a tertiary referral center in Israel. RESULTS: Out of 102 children, 54 (53 %) had an uneventful recovery, 32 (31 %) had post-operative complications which were managed without revision surgery, and 16 (16 %) underwent revision surgery. A comparison of the three groups showed that children who had early post-operative complications (up to one month) were more likely to respond to conservative treatment (57 %). In contrast children with late complications had a higher probability (59 %) of undergoing revision surgery. The presence of a pre-operative cutaneous fistula was significantly associated with revision surgery (p = 0.012). In addition, children with no prior history of neck infection were more likely to have an uneventful recovery (p = 0.005). CONCLUSIONS: TGDC disease has a wide range of clinical presentations both before and after surgery. A significant percentage of children with persistent post-operative symptoms may resolve without revision surgery. The presence of a pre-operative cutaneous fistula and late post-operative complications are the main risk factors for revision surgery.

Intranasal foreign bodies: A 10-year analysis of a large cohort, in a tertiary medical center.

BACKGROUND: Nasal foreign bodies (NFB) are commonly seen in pediatric patients seeking medical attention in the emergency department (ED). We aim to describe the occurrence, clinical presentation and management, of these cases, and to assess various risk factors for complications. METHODS: A retrospective analysis of a computerized patient directory of 562 children admitted to the emergency department during a 10-year period, with NFB, in a tertiary pediatric hospital. RESULTS: Upon admittance, most of the children (82%) were asymptomatic. Among the symptomatic children (18%), the primary symptoms were nasal discharge (10%), epistaxis (8%) and pain (4%). Younger children (under 4 years) were more likely to insert organic materials, compared to older children. Younger children were also admitted sooner to the emergency department and were more likely to present with nasal discharge. The overall complication rate was 5%. None of the children had aspirated the foreign body. Complications included infection (2%), necrosis (0.7%), septal perforation (0.5%), deep mucosal laceration (1.5%) and loss of foreign body (1.9%). Significantly higher rates of symptoms and complications were associated with button batteries. Increased risk for complications were observed according to type of foreign body, multiple attempts to remove it, posterior insertion and left-side insertion. CONCLUSIONS: Nasal foreign bodies in children are common. Mostly, patients are asymptomatic, therefore a high index of suspicion is required, for quick diagnosis and safe removal, without complications.

Intraoperative Ultrasonographic Assessment of Vocal Cord motion under sedation, following paediatric thyroidectomy in the Era of COVID-19: A double-blinded preliminary study.

INTRODUCTION: Unilateral vocal cord paralysis (UVCP) is a known complication of thyroid surgery, due to iatrogenic recurrent laryngeal nerve injury, with reported rates of 2%-5% in children. The gold standard for assessing vocal cord function in flexible nasendoscopy (FNE) examination, which is considered high-risk for contraction of the COVID-19 virus. Intraoperative ultrasonographic assessment (IUA) of vocal cord function is a non-invasive and relatively simple procedure performed in a supine position, performed during spontaneous breathing, following reversed anaesthesia, while the patient is still sedated. OBJECTIVES: To evaluate the validity of IUA modality in children undergoing thyroidectomy and to compare it to the standard FNE. DESIGN: A prospective double-blind study covering 24 months (March 2019-March 2021). Twenty thyroid lobectomies were performed, during 15 surgeries. Vocal cord function was assessed three times: Pre-operatively by FNE, intraoperative (IUA) following extubation, and a second FNE on the first post-operative day. SETTINGS: A tertiary paediatric hospital. RESULTS: The overall accuracy of IUA results in our study was 92%. IUA sensitivity, specificity, positive and negative predictive values were 100%, 89%, 33% and 100%, respectively. Patient's age demonstrated borderline significance (p = .08). The resident's experience was associated with a better correlation between IUA and FNE results (p < .05). CONCLUSIONS: IUA of vocal cord motion has a high accuracy rate for detection of iatrogenic vocal cord paralysis, similar to FNE. It is easily learned by residents, well-tolerated by children, and it provides a safe and valid alternative modality while ensuring the safety of the medical staff in treating patients, especially in times of COVID-19 pandemic.

[COCHLEAR IMPLANTS IN SINGLE-SIDED DEAFNESS].

INTRODUCTION: In normal hearing, the brain receives bilateral auditory input from both ears. In individuals with only one functioning ear listening in noisy environments and sound localization may become difficult. Historically, the impact of unilateral hearing loss in children had typically been minimized by clinicians, as it was assumed that one normal hearing ear provided sufficient auditory input for speech development and normal hearing experience. Data supporting the negative effects of unilateral deafness has been accumulating during the last decades. The effects of unilateral deafness extend beyond spatial hearing to language development, slower rates of educational progress, problems in social interaction and in cognitively demanding tasks. Until recently, treatments for single sided deafness were limited to routing signals from the deaf ear to the contralateral hearing ear either through conventional CROS aids or through bone anchored technologies. These technologies simply transfer sounds to the single functioning ear which allow sound awareness from the deaf side and minor improvement in hearing in noisy environments and localization. The cochlear implant is a surgically implanted electronic device that contains an array of electrodes which is placed into the cochlea, and stimulates the cochlear nerve. The cochlear implant bypasses the injured parts of the inner ear. Currently it is the only treatment to restore binaural hearing. This review aims to discuss the different aspects, the benefits and disadvantages of cochlear implantation in children with single sided deafness.

Hearing loss patterns after cochlear implantation via the round window in an animal model.

PURPOSE: The mechanism and the type of hearing loss induced by cochlear implants are mostly unknown. Therefore, this study evaluated the impact and type of hearing loss induced by each stage of cochlear implantation surgery in an animal model. STUDY DESIGN: Original basic research animal study. SETTING: The study was conducted in a tertiary, university-affiliated medical center in accordance with the guidelines of the Institutional Animal Care and Use Committee. SUBJECTS AND METHODS: Cochlear implant electrode array was inserted via the round window membrane in 17 ears of 9 adult-size fat sand rats. In 7 ears of 5 additional animals round window incision only was performed, followed by patching with a small piece of periosteum (control). Hearing thresholds to air (AC) and bone conduction (BC), clicks, 1 kHz and 6 kHz tone bursts were measured by auditory brainstem evoked potential, before, during each stage of surgery and one week post-operatively. In addition, inner ear histology was performed. RESULTS: The degree of hearing loss increased significantly from baseline throughout the stages of cochlear implantation surgery and up to one week after (p<0.0001). In both operated groups, the greatest deterioration was noted after round window incision. Overall, threshold shift to air-conduction clicks, reached 61 dB SPL and the bone conduction threshold deteriorated by 19 dB SPL only. Similar losses were found for 1-kHz and 6-kHz frequencies. The hearing loss was not associated with significant changes in inner ear histology. CONCLUSIONS: Hearing loss following cochlear implantation in normal hearing animals is progressive and of mixed type, but mainly conductive. Changes in the inner-ear mechanism are most likely responsible for the conductive hearing loss.

Inlay "butterfly" cartilage tympanoplasty.

OBJECTIVES: The aim of this study was to analyze the outcome of inlay "butterfly" cartilage tympanoplasty. METHODS: The files of 42 patients (24 were male, 18 were female) who underwent primary or revision inlay butterfly cartilage tympanoplasty in 2005 to 2011 at a tertiary medical center were reviewed. Patients were regularly observed by otoscopy and audiometry. RESULTS: The mean patient age was 27 years (range, 14-75 years), and the mean duration of follow-up was 24 months (range, 3-36 months). The postoperative period was uneventful. The technical (anatomical) success rate was 92% at 1 year. There was a significant decrease in the mean air-bone gap in 32 patients (preoperatively, 49.6 dB; postoperatively, 26.2 dB; P = .006). Results were suboptimal in 3 patients with persistent small perforations of the operated ear. CONCLUSION: Inlay butterfly cartilage tympanoplasty appears to be effective in terms of defect closure and improved hearing, comparable with temporalis fascia graft tympanoplasty. Follow-up is necessary for at least 1 year when some perforation may reappear.

Insular thyroid carcinoma: a retrospective clinicopathologic study.

BACKGROUND: Poorly differentiated carcinoma is a rare epithelial tumor that falls between well-differentiated thyroid carcinoma and anaplastic thyroid carcinoma in terms of morphologic appearance and biologic behavior. An insular variant was characterized in 1983. Further study of this neoplasm is warranted owing to its high aggressiveness, propensity to local recurrence and distant metastases, and high associated mortality. Since insular thyroid carcinoma may have varied presentations, treatment should be individualized. PURPOSE: To describe the experience of a major tertiary medical center with insular thyroid carcinoma over a 7-year period. MATERIAL AND METHODS: The study sample consisted of 17 patients with poorly differentiated thyroid cancer, insular variant, who were treated and followed at the Department of Otolaryngology, Head and Neck Surgery of Rabin Medical Center, Israel, in 1992-2009. The medical files were reviewed for background data, clinicopathologic features, treatment, and outcome. RESULTS: The study group included 10 men and 7 women with a mean age of 63 years (range 16-78). Initial treatment was total thyroidectomy, in a single session (n=9) or two sessions (n=8), followed by radioiodine ablation. In addition, five patients received postoperative external beam radiation and one patient received chemotherapy. Nine patients had extrathyroidal extension, seven had vascular invasion, and four had multifocal disease. Distant metastases were present in four patients. Follow-up ranged from 6 months to 12 years. At present, 11 patients are alive and well. Five died of disease, and one died of another cause. CONCLUSION: Insular thyroid carcinoma is aggressive and difficult to treat. Surgery remains the mainstay of treatment, though multimodality therapy is usually required.

Unilateral Choanal Atresia Presenting With Congenital Respiratory Distress and Recurrent Cyanotic Episodes.

Congenital unilateral choanal atresia (CA) is not considered an emergent condition and should not cause respiratory distress in the newborn. Therefore, surgical repair of unilateral CA is usually delayed. This description of a newborn with congenital unilateral CA that caused significant respiratory distress, recurrent cyanotic episodes, and severe feeding difficulties highlights an exception to that rule.

Ultrasonographic Features of Salivary Glands after Radioiodine Therapy in Patients with Thyroid Cancer.

OBJECTIVE: Chronic sialadenitis is the most common complication of radioactive iodine (RAI) treatment. The aim of the study was to ascertain sonographic features of the major salivary glands in patients with papillary thyroid cancer (PTC) treated with RAI. METHODS: The database of a tertiary medical center was retrospectively searched for consecutive patients who underwent total thyroidectomy for PTC in 2011-2020 with ultrasound follow-up after 1 year. Changes in ultrasound features of the major salivary glands were compared between patients treated or not treated with RAI postoperatively. RESULTS: The cohort included 158 patients, of whom 109 (69%) were treated postoperatively with RAI (mean dose, 131 mCi) and 49 were not (control group). Sonographic changes were observed in the major salivary glands in 43% of the study group and 18% of the control group (p = 0.002), including coarse echotexture, decreased echogenicity, fibrosis, and atrophy. Higher RAI doses were significantly correlated with the prevalence and severity of glandular changes (p < 0.0001). CONCLUSION: RAI treatment following thyroidectomy is associated with a dose-response effect and adverse changes in the major salivary glands and should be prescribed carefully. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1271-1275, 2023.

Chondrosarcoma of the larynx.

BACKGROUND: Chondrosarcoma of the larynx is a rare tumor. The most common symptom is hoarseness. Treatment is controversial. OBJECTIVES: To describe six patients with laryngeal chondrosarcoma from a single center. METHODS: The medical records of a major tertiary hospital were reviewed for all patients with laryngeal chondrosarcoma diagnosed and treated from 1959 to 2010. Data on background, clinical treatment and outcome were collected. RESULTS: Six patients, all males with a mean age of 53.3 years, were identified. Partial laryngectomy was performed in three patients, and total laryngectomy, local excision, and partial cricoidectomy in one patient each. Four patients had a permanent tracheostomy after surgery. One patient required postoperative chemotherapy and one radiotherapy. Follow-up time was 12-216 months (mean 102 months). Recurrence developed in two patients 2 and 8 years after initial treatment and was treated by salvage surgery in both patients. One patient died during the follow-up from an unrelated cause. The others are currently alive. CONCLUSIONS: This study supports earlier reports recommending initial treatment with partial or total laryngectomy for laryngeal chondrosarcoma. Long-term follow-up for recurrence is advised. We recommend preserving the larynx, if possible, even if a permanent tracheostomy is necessary.

Endoscopic cauterisation and injection of Voicegel for treatment of congenital pyriform fossa sinus tracts.

OBJECTIVE: To demonstrate our experience in treating pyriform fossa sinus tracts (PFST) using a novel technique of endoscopic cauterisation of the pyriform fossa sinus opening combined with injection of sodium carboxymethylcellulose gel (VoiceGel) lateral to the tract to encourage tight closure. METHODS: Over a 48-month period, we used this technique on 11 patients who were diagnosed with PFST at BC Children's Hospital, a tertiary paediatric centre in Vancouver, BC, Canada. RESULTS: The 11 patients included 8 males and 3 females, and mean age at presentation was 69 months (range 22-108 months). Mean time from beginning of symptoms till diagnosis was 15 months (range 12-22 months). Ten PFST were on the left side of the neck and one on the right. Nine patients presented with recurrent neck infections and two had suppurative thyroiditis. All patients had endoscopic cauterisation of their PFST opening combined with injection of carboxymethylcellulose lateral to the sinus tract to cause tract collapse. Mean follow up was 15.8 months (range 8-24). All patients are asymptomatic without recurrence at the last follow-up visit. No post-operative complications were reported. CONCLUSIONS: Endoscopic management of paediatric PFST combined with the injection of sodium carboxymethylcellulose gel lateral to the sinus tract appears to be a safe and effective treatment option for PFST.

Role of intraoperative recurrent laryngeal nerve monitoring for pediatric thyroid surgery: Comparative analysis.

BACKGROUND: The data on the advantages of intraoperative nerve monitoring (IONM) during pediatric thyroid surgeries are limited. We aimed to study the role of IONM by comparing between children who underwent thyroid surgery with and without IONM. METHODS: A retrospective study of all children who underwent thyroid surgery between 2001 and 2019. RESULTS: The study included 113 patients with 183 recurrent laryngeal nerve (RLN) at risk. Transient paralysis rate was more than 5-fold lower in the IONM group compared to the control group (1.5% vs 8%; P = .114). Permanent paralysis was documented only in the control group (2.5% vs 0%; P = .552). Children <10 years and those who underwent central neck dissection had significantly higher rates of RLN injury. CONCLUSIONS: IONM was associated with decreased rate of RLN injury during pediatric thyroid surgery and should be considered especially in children under 10 years of age and those undergoing concomitant central neck dissection.

Radioiodine therapy induced sialadenitis versus chronic idiopathic sialadenitis-Presentation and outcomes.

BACKGROUND: This study explores the unique characters of high dose radioactive iodine (RAI) induced chronic sialadenitis. METHODS: A retrospective study of patients having received salivary endoscopy and followed in our outpatient clinic. RESULTS: A total of 100 patients met the inclusion criteria, 75 were diagnosed with chronic idiopathic sialoadenitis and 25 with radio-iodine induced sialoadenitis (RIS). The main complaint in both groups was swelling of the parotid gland. Pain, dysphagia, and xerostomia were observed considerably more in the RIS group. During sialo-endoscopy, fibrosis of the Stensen's duct was more common in the RIS group (p = 0.003). RIS patients group generally managed better with interventional endoscopic treatment alone (80% vs. 46%). CONCLUSION: RIS patients have distinct clinical characteristics. There may be a collateral muscular damage to the masticatory muscles. Fibrosis and parenchymal damage are major findings during sialendoscopy. Sialendoscopy is a safe and efficient treatment for RAI induced sialadenitis.

Cochlear implantation via round window or cochleostomy: Effect on hearing in an animal model.

OBJECTIVES/HYPOTHESIS: Cochlear implantation in patients with residual hearing has increased interest in hearing preservation. Two major surgical approaches to implantation have been devised: via the round window membrane and through cochleostomy. However, the advantages of either approach on hearing preservation have not been established. Due to the great inter- and intravariability among implantees, the current study used a normal-hearing animal model to compare the effect of the two methods on hearing. STUDY DESIGN: Animal study. METHODS: Thirteen fat sand rats were studied, in which 13 ears were implanted through cochleostomy and 13 via the round window. Hearing thresholds were determined by auditory brainstem responses to air and bone conduction at low and high auditory stimuli. RESULTS: The results indicated that each stage of the surgery, primarily the opening of the membranous labyrinth, was accompanied by significant deterioration in hearing. Hearing loss was mainly conductive, with no significant differences between the surgical approaches. CONCLUSIONS: Both surgical approaches carry similar risk of hearing loss. LEVEL OF EVIDENCE: NA Laryngoscope, 126:E375-E378, 2016.