Anatomical Parameters and Growth of the Pediatric Skull Base: Endonasal Access Implications.

Objectives Endoscopic endonasal anterior skull base surgery has expanding use in the pediatric population, but the anatomy of pediatric patients can lead to limitations. This study aims to characterize the important anatomical implications of the pediatric skull base using computed tomography (CT) scans. Design This study is designed as retrospective analysis. Setting The study setting comprises of tertiary academic medical center. Participants In total, 506 patients aged 0 to 18 who had undergone maxillofacial and or head CTs between 2009 to 2016 were involved. Methods Measurements included piriform aperture width, nare to sella distance (NSD), sphenoid pneumatization, olfactory fossa depth, lateral lamella cribriform plate angles, and intercarotid distances (ICD) at the superior clivus and cavernous sinus. These patients were then subdivided into three age groups adjusting for sex. Analysis of covariance (ANCOVA) models were fit comparing between all age groups and by sex. Results Piriform aperture width, NSD, sphenoid sinus pneumatization as measured using lateral aeration and anterior sellar wall thickness, olfactory fossa depth, and ICD at the cavernous sinus were significantly different among all age groups ( p <0.0001). Our results show that mean piriform aperture width increased with each age group. The mean olfactory fossa depth also had consistent age dependent growth. In addition, ICD at the cavernous sinus showed age dependent changes. When comparing by sexes, females consistently showed smaller measurements. Conclusion The process of skull base development is age and sex dependent. During preoperative evaluation of pediatric patients for skull base surgery piriform aperture width, sphenoid pneumatization in both the anterior posterior and lateral directions, and ICD at the cavernous sinus should be carefully reviewed.

Postoperative Outcomes in Pediatric Septoplasty.

OBJECTIVE: Identify risk factors and perioperative morbidity for pediatric patients undergoing septoplasty. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was retrospectively queried to identify patients who underwent septoplasty (CPT 30520) for a diagnosis of deviated nasal septum (ICD J34.2) from 2018 to 2019. Outcomes analyzed include patient demographics, medical comorbidities, surgical setting, operative characteristics, length of stay, and postoperative outcomes. RESULTS: A total of 729 children were identified. Median age at time of surgery was 15.8 years, with most patients (82.8%) >12 years of age; no significant association was identified between age at time of surgery and adverse surgical outcomes. Overall, postoperative complications were uncommon (0.6%), including readmission (0.4%), septic shock (0.1%), and surgical site infection (0.1%). A history of asthma was found to be a significant risk factor for postoperative complications (P = .035) as well as BMI (P = .028). CONCLUSION: The 30-day postoperative complications following pediatric septoplasty in children reported in the NSQIP-P database are infrequent. Special considerations regarding young age, complex sinonasal anatomy, and surgical technique remain important features in considering corrective surgery for the pediatric nose and certainly warrant further investigation in subsequent studies.

Retrospective Review of Surgical Site Infections after Endoscopic Endonasal Sellar and Parasellar Surgery: Multicenter Quality Data from the North American Skull Base Society.

Introduction Transnasal access to the anterior skull base provides a minimally invasive approach for sellar and parasellar masses compared with its open counterparts. The unique microbiome of the sinonasal mucosa provides distinct challenges not encountered with other cranial approaches. The use of antibiotics in these cases has not been standardized, and data remain scarce regarding infectious outcomes. Methods We conducted a multicenter retrospective analysis of shared quality data points for the endoscopic endonasal approach (EEA) for pituitary adenomas, along with other sellar and parasellar region masses that were included by participating institutions. Patient and operative characteristics, perioperative and postoperative antibiotic regimens and their durations, intraoperative and postoperative cerebrospinal fluid leak, and onset of postoperative meningitis and sinusitis were compared. Results Fifteen institutions participated and provided 6 consecutive months' worth of case data. Five hundred ninety-three cases were included in the study, of which 564 were pituitary adenomectomies. The incidences of postoperative meningitis and sinusitis were low (0.67 and 2.87% for all pathologies, respectively; 0.35% meningitis for pituitary adenomas) and did not correlate with any specific antibiotic regimen. Immunocompromised status posed an increased odds of meningitis in pituitary adenomectomies (28.6, 95% confidence interval [1.72-474.4]). Conclusions The results show no clear benefit to postoperative antimicrobial use in EEA, with further larger studies needed.

Descriptive Analysis of Otolaryngology Program Directors with a Focus on Gender Disparity.

OBJECTIVE: To describe and analyze the demographics and academic backgrounds of United States otolaryngology program directors (PD) and assess gender disparity in the field. METHODS: This was a cross-sectional study in which an online search using publicly available sources was performed to gather information on PDs for 125 United States otolaryngology programs from May 14, 2021, to May 30, 2021. Data collected included PD appointment year, age, gender, resident gender breakdown, degree, as well as training location and graduation year. RESULTS: There were 69.6% programs with a male PD and 30.4% with a female PD. Ninety percent of PDs have an MD degree and 9.6% have a DO degree. The current average age of PDs was 49.9 years old (range 35-79). Males were older than females PD (51.0 vs 47.1 years, P = 0.045) and have served a longer time as PD (7.1 vs 4.8 years, P = 0.019). There was no significant difference in other variables collected. There were 27.3% of program directors that held the position of professor, 44.5% associate professor, and 28.2% assistant professor. The most common subspecialty practiced by otolaryngology PDs was head and neck oncology. CONCLUSION: Disparity in women's representation in otolaryngology still exists, but the program director leadership position demonstrates better parity. There is an equal percent representation when examining female PDs and female otolaryngologists in academic medicine. Continued efforts to encourage women to enter and become leaders in otolaryngology are necessary moving forward.

Can a flexible surgical robot be used in the pediatric population: A feasibility study.

OBJECTIVES: Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population. METHODS: This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale. RESULTS: A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects. CONCLUSIONS: This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.

Pediatric Thyroid Cancer: To Whom Do You Send the Referral?

Pediatric thyroid cancer is rare, but increasing in annual incidence. Differentiated thyroid cancer in pediatric patients is treated surgically. Pediatric thyroidectomies are performed by general surgeons, otolaryngologists, general pediatric surgeons, and pediatric otolaryngologists. In a comprehensive literature review, we discuss the evidence supporting the importance of surgeon subspecialty and surgeon volume on outcomes for pediatric thyroid cancer patients. Pediatric general surgeons and pediatric otolaryngologists perform most pediatric thyroidectomies. Certain subpopulations specifically benefit from a combined approach of a pediatric surgeon and a high-volume thyroid surgeon. The correlation between high-volume surgeons and lower complication rates in adult thyroid surgery applies to the pediatric population; however, the definition of high-volume for pediatric thyroidectomies requires further investigation. The development of dedicated pediatric thyroid malignancy centers and multidisciplinary or dual-surgeon approaches are advantageous.

Outpatient Sistrunk procedure: A retrospective analysis.

OBJECTIVE: The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a Sistrunk procedure via either same day surgery or overnight observation. METHODS: A retrospective review of patients undergoing Sistrunk procedures between January 1, 2008 to January 1, 2019 was performed. 76 cases were identified for review. Bivariate and multivariable analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement. RESULTS: No patients had life-threatening adverse events. There was no difference in complication rates between same day discharge (17%) and overnight observation (23%, p = 0.47). Otolaryngologists were more likely to admit patients overnight (88% vs. 14%, p = 0.042) as well as place a drain (97% vs. 24%, p < 0.001) when compared to pediatric surgeons. Drain placement was associated with overnight observation (73% vs. 3%, p < 0.001). Multivariable logistic regression demonstrated drain placement (OR 21.9, 95%CI (2.5-189.7), p = 0.005) and otolaryngologist as operative surgeon (OR 11.7, 95%CI (2.8-48.2), p < 0.001) as strong predictive variables for overnight observation. There was no association between other investigated variables and adverse events or overnight stay. CONCLUSION: Same day Sistrunk operations are safe in select healthy patients. Overnight observation appears to be driven by drain placement and surgeon practice patterns.

Feasibility of same day surgery for pediatric second branchial cleft anomalies.

OBJECTIVE: The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation. METHODS: A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement. RESULTS: There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay. CONCLUSION: Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

Postoperative Outcomes of Branchial Cleft Cyst Excision in Children and Adults: An NSQIP Analysis.

OBJECTIVE: Identify risk factors and perioperative morbidity for patients undergoing branchial cleft cyst (BCC) excision. STUDY DESIGN: Cross-sectional analysis. SETTING: American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases (NSQIP and NSQIP-P). SUBJECT AND METHODS: Patients who underwent BCC excision (Current Procedural Terminology 42810, 42815) were queried via NSQIP (2005-2016) and NSQIP-P (2012-2016). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of hospital stay, postoperative complications, and readmission. RESULTS: A total of 1775 children and 677 adults were identified. Mean age at time of surgery was 4.6 years for children and 38.6 years for adults. Outpatient procedures were performed in 87.1% of adults and 94.0% of children (P < .001). Postoperative complications were uncommon, occurring in <1% of adults and 3.9% of children (P < .001). Similarly, readmission occurred in 1.2% of adults and 1.1% of children. In adults, smoking status was shown to have a significant effect on postoperative complications (odds ratio, 6.25; P = .037). Age group did not have an effect on the complication rate in the pediatric population. Pediatric otolaryngologists had higher rates of postoperative complications (P = .001), prolonged operative times (P < .001), and fewer outpatient procedures (P < .001). Conversely, in adults, otolaryngologists had fewer postoperative complications. CONCLUSION: Postoperative complications following BCC excision are relatively uncommon, demonstrating procedural safety when performed at any age.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic.

OBJECTIVE: To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic. DATA SOURCES: Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples. METHODS: Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence. CONCLUSIONS: In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety. IMPLICATIONS FOR PRACTICE: The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

Post-tonsillectomy respiratory complications in children with sleep disordered breathing.

OBJECTIVE: A common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population. METHODS: Following Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected. RESULTS: A total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (<95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023). CONCLUSION: A lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring.

Malignant Hyperthermia During Translabyrinthine Acoustic Neuroma Surgery After Previous Uneventful Surgery.

OBJECTIVE: Review current literature and guidelines for malignant hyperthermia in the context of neurotologic surgery. PATIENT: A case of malignant hyperthermia during vestibular schwannoma surgery, in a patient previously exposed to anesthesia. INTERVENTIONS: Excision of vestibular schwannoma, acute management of malignant hyperthermia. MAIN OUTCOME MEASURES: Knowledge of the basic pathophysiology, clinical manifestations, and treatment protocols for malignant hyperthermia. RESULTS: Rapid termination of the procedure and appropriate modifications in surgical technique permitted expeditious treatment of malignant hyperthermia and prevented its lethality. CONCLUSIONS: Malignant hyperthermia is a rare and lethal condition that may arise in neurotologic surgery, even in patients who have previously received general anesthesia. The neurotologic surgeon has a role in early recognition and expeditious termination of surgery to help reduce its mortality.

Primary Papillary Thyroid Cancer of a Thyroglossal Duct Cyst.

Papillary thyroid carcinoma in a thyroglossal duct cyst is very rare. We present the case of a teenage boy with a large thyroglossal duct cyst containing papillary thyroid carcinoma. There was no evidence of carcinoma within the thyroid gland, making this an important case of primary thyroglossal duct cyst carcinoma.

Should Cost Be Formally Incorporated into Clinical Practice Guideline Recommendations?

There is increasing discussion worldwide on explicitly including cost as part of the clinical practice guideline development process. While this could enhance our understanding of value-based care and improve resource utilization, there are many practical challenges for cost inclusion. This commentary explores this issue, examining it from multiple angles and giving pros and cons to inclusion in future guidelines.

The Pursuit of Otolaryngology Subspecialty Fellowships.

OBJECTIVES: To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency training STUDY DESIGN: Cross-sectional study of anonymous online survey data. SETTING: Residents and fellows registered as members-in-training through the American Academy of Otolaryngology-Head and Neck Surgery. SUBJECTS AND METHODS: Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014. RESULTS: Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P < .0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems. CONCLUSIONS: In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

Clinical practice guideline: Allergic rhinitis.

OBJECTIVE: Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options. PURPOSE: The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients. ACTION STATEMENTS: The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Clinical practice guideline: allergic rhinitis executive summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

Section for Residents and Fellows-in-Training Leaders: Where Are They Now?

The purpose of this study was to examine the experiences of prior governing council (GC) members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) and assess the impact of early Academy involvement. A survey was conducted via email on all prior AAO-HNS SRF GC members. The AAO-HNS SRF has elected 52 GC members since its 2003 inception. Each member served an average of 1.5 year-long terms. The mean time since completion of training is 4.1 years. A subspecialty fellowship was pursued in 86%. Fifty-seven percent practice in academic settings, with 3 members advancing to subspecialty division director within their department. More than half (58%) have served on an AAO-HNS committee, and most are frequent attendees of the annual meeting. All prior members felt involvement in the SRF GC was beneficial, enabling them to gain leadership skills and deeper understanding of the specialty.

The Management of Spontaneous Otogenic CSF Leaks: A Presentation of Cases and Review of Literature.

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.

Airway management following pediatric cardiothoracic surgery.

OBJECTIVES: (1) Review airway management in pediatric patients undergoing cardiothoracic surgery (CTS); (2) determine the incidence of airway-related complications of CTS in this population. DESIGN: Case series with chart review. Setting Tertiary care children's hospital. Patients Children undergoing CTS over a 4-year period. METHODS: Patients who underwent CTS at a single, tertiary care, children's hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those <18 years who had open CTS were included. Statistical analysis examined relationships of intubation duration, complications, and need for tracheotomy while comparing patient characteristics, comorbidities, and types of surgery. RESULTS: Eight hundred seventy-five primary surgeries in 745 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days and median 3 days. On univariate analysis, significantly longer postoperative intubation requirements were found in patients younger in age, with congenital comorbidities or prematurity, with preoperative ventilation requirements, and those with early postoperative complications. Multivariate analysis found younger age, presence of congenital comorbidities, preoperative intubation requirements, and early postoperative complications each lengthen ventilation requirements. Four patients developed vocal cord paralysis and 5 developed phrenic nerve palsy. Nineteen patients required tracheotomy. CONCLUSIONS: In this large cohort, CTS in the pediatric population is associated with few long-term or permanent airway-related complications. Patients who are younger in age and those with congenital comorbidities, preoperative ventilation requirements, or early postoperative complications required longer periods of postoperative intubation.