The Laryngologist Who Saved the Brooklyn Bridge.

OBJECTIVE: To understand the role of a single laryngologist, Andrew Heermance Smith, in elucidating the mechanisms of Caisson Disease and controlling it effects on bridge workers. DATA SOURCES: Scientific and lay publications, letters and records of the Roebling family, obituaries and internet sources. REVIEW METHODS: Historical review. RESULTS: AH Smith combined physiological observations and experiments in the Brooklyn Bridge caissons with a review of the existing engineering and medical literature to describe the Caisson Disease and to devise strategies to ameliorate its effects. CONCLUSION: Despite an incorrect conclusion about the pathophysiology of decompression sickness, Smith's stringent standards and timely interventions allow completion of the masonry towers of the Brooklyn Bridge. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3044-3048, 2024.

Elective Tympanostomy Tube Removal at 2.5 Years: Results of a Protocol for Retained Tubes.

OBJECTIVES: In 2001, we instituted a protocol for the removal of retained tympanostomy tubes, delaying elective removal until 2.5 years after placement. It was hoped that this would decrease the number of surgeries without increasing the rate of permanent tympanic perforations compared to removal at 2 years. METHODS: Protocol: Fluoroplastic Armstrong beveled grommet tympanostomy tubes were placed by a single surgeon supervising the residents. The children were seen at 6-month intervals after placement. Children with a retained tympanostomy tube(s) at 2 years were seen again at 2.5 years, and the retained tubes were removed under general anesthesia with patch application. All were evaluated 4 weeks after surgery by otoscopy, otomicroscopy, behavioral audiometry, and tympanometry. STUDY: A computerized collection of patient letters and operative reports was queried to identify children treated according to the protocol between 2001 and 2022. Those with examinations at 2 years ± 1 month and 2.5 years ± 1 month and complete follow-up were included. RESULTS: Of the 3552 children with tympanostomy tubes, 497 (14%) underwent tube removal. One-hundred and forty seven children fit the strict inclusion criteria. Among those with retained tubes at 2 years, 67/147 (46%) had lost any remaining tube or tubes at 2.5 years and did not need surgery, 80/147 (54%) required unilateral or bilateral tube removal, 9/147 (6%) had a persistent perforation at 1-year follow-up, and 4/147 children (3%) required tympanic re-intubation after either spontaneous extrusion or removal and patching at 2.5 years. CONCLUSIONS: Delaying tympanostomy tube removal until 2.5 years can cut the need for surgery in half with, an acceptable (6%) incidence of persistent perforations. LEVEL OF EVIDENCE: Four case series-historical control Laryngoscope, 134:439-442, 2024.

Age Distribution of Epistaxis in Outpatient Pediatric Patients.

Objectives: Little is known about the prevalence of epistaxis in children. Existing reports focus on hospitalized children or those presenting to an emergency department. To better understand pediatric epistaxis in clinical practice, we sought out a searchable, representative outpatient database and examined the incidence of epistaxis in children of different ages. Methods: A cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the years 2007 to 2011 was performed. The NHAMCS is a Centers for Disease Control and Prevention-curated national sample of data from visits to non-federally employed office-based physicians and health centers. We queried the NHAMCS to determine the cumulative incidence of epistaxis in children of different age groups. The International Classification of Diseases Ninth Revision code 784.7 was chosen to identify epistaxis. Comparisons of rates were performed using the chi-squared test. A P-value of <.05 was considered statistically significant. Results: In total, 55,435,691 children [27,816,237 (50.2%) males, 55,435,691 (77.2%) white] were included. The overall cumulative incidence rate of epistaxis was 2.4/1000 children. Children in the 3- to 5-year range had the highest cumulative incidence of epistaxis (5.0/1000), followed by those in the 6 to 8 (3.0/1000), 9 to 11 (2.0/1000), 0 to 2 (1.9/1000), 12 to 14 (1.6/1000), and 15 to 17 (0.5/1000) year ranges (P < .001). Conclusion: Pediatric epistaxis is common in the office setting (2.4 per 1000 children)-and well above emergency department estimates (1.7 per 1000 people). Children between the ages of 3 to 5 years have the highest cumulative incidence. Epistaxis is sufficiently unusual in infants and the late teens that alternative causes for nasal bleeding should be included in the differential diagnosis.

Tympanostomy Tube Placement in Children with Autism Spectrum Disorder.

OBJECTIVE: The frequency of tympanostomy tube (TT) placement among United States children with autism spectrum disorder (ASD) is not known. We explored the rate of TT placement in children with ASD in the United States and compared this to children without ASD. We further examined demographic and behavioral factors that might vary between the two groups. METHODS: We utilized data from the National Health Interview Survey (NHIS) administered in 2014. This survey samples a representative population of patients across the United States and includes children under 18 years of age. The 2014 version of the NHIS survey was chosen as it identifies both autism and TT placement among sampled patients. Descriptive statistics and univariable and multivariable logistic regression analyses were performed. RESULTS: In total, 11,730 children (239 [2.0%] with ASD) were included. Overall, 34 (14.2%) children with ASD underwent TT placement versus 987 (8.6%) in children without ASD (p = 0.002) ASD diagnosis was associated with increased odds of TT placement (1.52 OR, 95% CI 1.04-2.22). Male sex, white race, and non-Hispanic ethnicity were also associated with increased odds of TT placement. Age at the time of TT surgery was not different between those with versus without ASD. CONCLUSION: Children with ASD have an increased rate of TT placement compared to children without ASD. The reason(s) for this increased rate might include the following: higher rates of infection in ASD, over-diagnosis of ear infection or hearing disability in a difficult-to-examine population, and/or a predilection toward aggressive treatment in this at-risk group. LEVEL OF EVIDENCE: 3-National database study Laryngoscope, 133:2407-2412, 2023.

Applicability of a sheep model for training in plastic surgery of eyelids and orbit.

OBJECTIVE: To test the applicability of a fresh tissue model for teaching facial plastic techniques and approaches to the eyelids and orbit. DESIGN: Observational animal experiments. SUBJECTS: Ten prepubescent sheep heads harvested following humane euthanasia at the completion of unrelated live animal research. METHODS: Young sheep were saline perfused at the end of an in vivo protocol. Head and neck tissues were harvested and refrigerated for 3-7 days. An experienced oculoplastic surgeon and an otolaryngologist explored the feasibility of common oculoplastic procedures in the ovine model. RESULTS: The model has potential for teaching basic principles in eyelid surgery including upper lid blepharoplasty, aponeurotic ptosis repair, upper lid gold weight lid loading for facial paralysis, lateral canthotomy and inferior limb cantholysis, lower lid tightening, and transconjunctival approach to the orbital floor. Eye muscle advancement, optic nerve sheath fenestration, and enucleation also accurately simulated human surgery. Anatomic variations limit the sheep model for orbital floor reconstruction and lacrimal drainage procedures. CONCLUSIONS: The sheep head and neck provide an inexpensive, safe model for developing skills in several oculoplastic procedures. Formal simulation testing is needed to confirm these expert opinions.

Safety of Ibuprofen in Children With G6PD Deficiency: A Systematic Review.

INTRODUCTION: Ibuprofen is included on websites and frequently referenced lists as medium risk for inducing hemolysis in children with glucose-6-phosphate dehydrogenase (G6PD) deficiency. This presents a challenge for otolaryngologists who perform tonsillectomy and other surgeries in children, as ibuprofen serves as an important alternative to opioids for perioperative pain control. We systematically review published literature and national medication databases to evaluate the risk of hemolytic anemia and related complications when ibuprofen is used in children with G6PD deficiency. METHODS: Systematic literature review using preferred reporting items for systematic reviews and meta-analyses methodology. National drug adverse reaction database inquiry. RESULTS: Our search yielded 774 results for review consideration. Of these, three studies were included in our final analysis (two retrospective case-series, and one nonrandomized prospective study). The prospective study showed no evidence of hemolysis from perioperative exposure to ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs) in children with G6PD deficiency at high risk. Two population studies in the Middle East suggested extremely low incidence of ibuprofen-related hemolysis (approximate 1/100,000 affected children per year). United States Food and Drug Administration (FDA), European Medicine Agency, and Health Canada adverse drug reaction databases reveled reported ibuprofen-related hematologic adverse reactions of approximate 1/100 million affected children per year. CONCLUSIONS: There is scant, low-quality evidence of hemolytic anemia caused by ibuprofen in children with G6PD deficiency. If an association does exist, it is extremely rare. Drug-induced hemolytic anemias are recognizable and reversible following discontinuation of the inciting medication. Given these low risks, ibuprofen should be considered an appropriate choice in the management of perioperative pain in children with G6PD deficiency. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1300-1305, 2022.

Second Sets of Tympanostomy Tubes Extrude Sooner.

INTRODUCTION: Some clinicians believe second sets of tympanostomy tubes extrude more quickly than first sets. STUDY DESIGN: Retrospective case-control series. METHODS: We identified children who were examined 12 months after placement of their second set of tympanostomy tubes and compared them to a similar number of children who were examined 12 months after their first set of tympanostomy tubes. Extrusion was determined by otoscopy, otomicroscopy, and/or tympanometry. RESULTS: One hundred eighteen children had 12-month follow-up data available after their first set of tubes, 54 had 12-month follow-up data available for their second set, and 56 had 12-month follow-up data after their first and second sets. A total of 568 tubes were observed. Looking at each tube, second set tubes were significantly more likely to be extruded at 12 months (48%) compared to first set (28%) (P < .001). Patient age was not associated with extrusion rate. For patients who had 12-month follow-up for both their first and second set of tubes, there was no correlation between extrusion of first and second set tubes. CONCLUSION: Second set tympanostomy tubes are significantly less likely to remain functional 12 months after placement than first sets, independent of patient age at placement and independent of whether the child's first tubes extruded by 12 months. Given the short duration of second tube function, delaying second set placement until the fall might be a better choice for some children. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:222-224, 2022.

A Novel Adenoidectomy Training System.

OBJECTIVES/HYPOTHESIS: Young residents find mirror-guided adenoidectomy difficult. Inexperienced trainees must learn to focus a headlight beam, work upside-down and backward in a small space and thoroughly ablate adenoid tissue-all new skills. We present an adenoidectomy training system that is low-cost, easy to construct, and is focused on these basic adenoidectomy skills. STUDY DESIGN: Prospective experimental study. METHODS: This training suite includes three stations each targeting a different skill. The first employs a mannequin head with exposed nasopharynx. It trains the student to coordinate a headlight and mirror while touching a series of targets with a curved probe. At the second station participants electrodessicate (or microdebride) an anchored piece of veal thymus. The third station combines both sets of skills as participants ablate thymus in a simulated nasopharynx (30 mm rectangular aluminum tube) constrained within a Crow-Davis retractor, using a headlight, mirror, and suction electrosurgical electrode (or microdebrider). To evaluate the training system's efficacy, we assessed the performance of 10 surgically naïve medical student volunteers before and after 15 minutes of practice using a validated rating scale used for adenoidectomy. RESULTS: There was significant improvement in adenoidectomy skill scores after practicing. Overall scores were higher, time taken to touch a series of targets with a headlight and mirror was less and amount of tissue ablated at the final station was greater (P < .05). CONCLUSION: This novel adenoidectomy training system is inexpensive and easy to build. Practice with the model resulted in statistically significant improvement in adenoidectomy skill scores for inexperienced student surgeons. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2056-2062, 2022.

TikTok Tonsils.

There has been a subjective increase in the number of patients presenting for tonsil stones to our pediatric otolaryngology clinic. This may be related to frequent viewing of videos on the social media application, TikTok, pertaining to tonsil stones.

Pilomatrixoma and its Imitators.

Introduction: Pilomatrixomas are benign neoplasms derived from hair follicle matrix cells. They are among the most common soft tissue head and neck tumors of childhood. Pilomatrixomas are typically isolated, slow-growing, firm, nontender masses that are adherent to the epidermis but mobile in the subcutaneous plane. This clinical presentation is so characteristic that many experienced surgeons will excise suspected pilomatrixomas without prior imaging. We reviewed the results of this approach to determine whether physical examination alone differentiates pilomatrixomas from other similar soft tissue lesions of the pediatric head and neck. Methods: Computerized review of all pilomatrixomas over a 20-year period in a single academic pediatric otolaryngology practice. Results: 18 patients presented to our pediatric otolaryngology practice between 2001 and 2021 with historical and physical findings consistent with pilomatrixoma. Of the 18 patients, 7 were male and 11 were female. Ages ranged from 1.5 to 14 years, with a mean of 7.5 years. Most of the lesions (12) were located in the head and face, while the rest (6) were found in the neck. All patients were treated with complete surgical excision. Pathology confirmed pilomatrixoma in 15 patients. The remaining 3 children were found to have an epidermal inclusion cyst, a ruptured trichilemmal cyst, and a giant molluscum contagiosum lesion, respectively. One additional patient presented with a small lesion of the auricular helix that was thought to be a dermoid cyst, but proved to be a pilomatrixoma on histologic examination. Discussion: As pilomatrixomas are common and have a very characteristic presentation, surgical excision without prior diagnostic imaging will lead to correct treatment in the majority of cases. High resolution ultrasonography can help to confirm the diagnosis preoperatively, but is not definitive in large case series. Most of the cystic lesions that imitate pilomatrixoma will ultimately require surgical excision.

Traumatic perforations are associated with previous tympanostomy tube placement.

INTRODUCTION: Recognized late complications of tympanostomy tube placement include persistent tympanic perforation, tympanosclerosis, and focal atrophy. Based on clinical experience, we suspected that atrophy at healed tympanostomy tube sites might predispose to re-perforation following trauma. METHODS: Computerized record review of children seen in an academic pediatric otolaryngology practice from January 2001 to December 2020. RESULTS: 33 children with confirmed traumatic tympanic perforations and complete follow-up were identified. All perforations were unilateral. 19 of 33 (58%) perforations were in children with tympanostomy tube placement in the past and 14/33 (42%) had never had tubes. 17/19 (90%) traumatic perforations in the tube group were due to blunt or barotrauma rather than penetrating trauma as compared with 6/13 (46%) in the non-tube group (p = 0.0147 by Fisher's exact test). One patient in the non-tube group had an unknown mechanism of injury. 15/19 perforations in the tube groups were in the antero-inferior or antero-superior quadrants (old tube sites) compared to 4/14 in the non-tube group (p = 0.0152). Perforations tended to be larger in the non-tube group (non-tube mean perforation size = 27%/tube group mean = 18%) The median time to re-perforation was 8 years (range 3-15 years). Boys predominated in both perforation groups. CONCLUSION: Traumatic perforations in this series occurred more often in the antero-inferior quadrant (old tube site) in children with previous tympanostomy tube placement. These perforations tended to be smaller and less often resulted from penetrating injuries than in children who had never undergone tube placement. LEVEL OF EVIDENCE: 3B - individual case-control study.

Tympanostomy Tubes-A Visual Guide for the Young Otolaryngologist.

OBJECTIVES: To illustrate some of the common dilemmas in tympanostomy tube care and describe time-tested ways to address them. METHODS: Computerized literature review. RESULTS: Issues including the correct diagnosis of recurrent acute otitis media, tympanostomy tube types and techniques for tube placement, management of tube clogging and otorrhea, and methods for tube removal and patching are illustrated. CONCLUSIONS: Tympanostomy tube placement is the most common surgery performed in children requiring general anesthesia. While some elements of tympanostomy tube care have been addressed in clinical studies, much of clinical practice is guided by shared experience.